tag:theconversation.com,2011:/uk/topics/surgical-risk-20057/articlesSurgical risk – The Conversation2021-06-02T21:23:54Ztag:theconversation.com,2011:article/1604312021-06-02T21:23:54Z2021-06-02T21:23:54ZSimple, fast, wide-awake diagnosis of sleep apnea could enable better surgical care and improve sleep<figure><img src="https://images.theconversation.com/files/403775/original/file-20210601-396-1qerz2p.jpg?ixlib=rb-1.1.0&rect=629%2C253%2C4820%2C3374&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Obstructive sleep apnea is a common sleep disorder that often goes undiagnosed and untreated.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Obstructive sleep apnea (OSA) is a very common sleep disorder, but one that is widely underdiagnosed. Its many symptoms and effects may include <a href="https://doi.org/10.1016/j.amjcard.2008.10.035">cardiovascular disease</a> or <a href="https://dx.doi.org/10.5665%2Fsleep.2374">memory impairment</a>. Fatal accidents can occur when undiagnosed or untreated drivers with OSA <a href="https://doi.org/10.5665/sleep.4486">fall asleep whilst driving</a>.</p>
<p>One reason why there are so many undiagnosed and untreated OSA cases is that accurate diagnosis usually requires an expensive, labour-intensive overnight sleep study called polysomnography (PSG). But new technology <a href="https://bme.eng.umanitoba.ca/bmelab/">developed at the University of Manitoba</a> can tell patients if they have OSA in 30 seconds, just by analysis of their breathing sounds while they are wide awake.</p>
<h2>Obstructive sleep apnea (OSA)</h2>
<p>OSA is the <a href="https://sleepeducation.org/sleep-disorders/sleep-apnea/">temporary cessation of breathing while asleep</a>. An apnea event is a pause in breathing that lasts more than 10 seconds and results in a drop of more than three per cent in the level of oxygen in the blood. Similarly, a reduction in respiratory flow of more than 50 per cent that lasts more than 10 seconds, combined with a drop in blood oxygen level of greater than three per cent, is called a hypopnea event.</p>
<p>The number of apnea and hypopnea events per hour of sleep is called apnea/hypopnea index (AHI), a measure of OSA severity. </p>
<p>A very high AHI, for example 200, means that during one hour of sleep, breathing stops (or is reduced more than 50 per cent) 200 times, each time for more than 10 seconds. Most of these events are accompanied by blood oxygen level decreases that may lead to hypoxia, which may <a href="https://doi.org/10.1016/j.ccm.2019.02.008">trigger the brain to wake up to restore the oxygen level</a>.</p>
<p>A person with a high AHI has a very broken sleep. Indeed, they may never reach a deep sleep. For that reason, they always feel tired and sleepy during the day. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of a man's neck with a band holding a small microphone to his throat" src="https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=472&fit=crop&dpr=1 600w, https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=472&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=472&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=593&fit=crop&dpr=1 754w, https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=593&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/403768/original/file-20210601-19-11vw3f5.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=593&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">AWakeOSA diagnoses sleep apnea by listening to breathing sounds using a microphone connected to the trachea.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>While a full overnight PSG records more than 15 different biological signals, there are many portable PSG devices that can be used by people in their own homes that record three to five signals and give a relatively accurate diagnosis. </p>
<p>However, for sleep apnea cases that need treatment, a full PSG assessment in a sleep lab is needed, during which sleep technicians try different manoeuvres to determine best treatment. For example, for determining the optimal air pressure for a continuous positive airway pressure (CPAP) machine to keep the patient’s airway open during different stages of sleep. </p>
<p>The <a href="https://doi.org/10.1093/sleep/20.9.705">widespread underdiagnosis</a> of sleep apnea becomes crucial for those who need general anesthesia before a surgery, because <a href="https://doi.org/10.1097/ALN.0000000000000053">apneic patients need special care after surgery</a>. Being able to detect OSA within a few minutes when a patient is awake would help ensure these patients receive the care they need. That is what <a href="https://doi.org/10.1038/s41598-019-47998-5">AWakeOSA</a> technology promises.</p>
<h2>Wide-awake identification of obstructive sleep apnea</h2>
<p>AWakeOSA is a smart technology with an app that provides instructions for recording breathing sounds with a small microphone. It records tracheal breathing sounds through five breaths taken while breathing through the nose and another five cycles while breathing through the mouth. The recording is done while the person is awake and lying on their back. </p>
<p>This technology has been under development since 2010. Our rationale for using awake tracheal breathing sounds for detection of OSA is based on the upper airway structure, which is different in people with sleep apnea compared to that of people without apnea, even while awake. Tracheal breathing sounds are affected by a change in the upper airway structure. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/lm6TkjuAUL8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Applications for AWakeOSA technology include fast diagnosis of OSA before surgery, and diagnosis in rural and remote areas where PSG assessment is unavailable.</span></figcaption>
</figure>
<p>These changes in breathing sounds cannot be detected by human ears, but by using advanced signal processing and machine learning techniques we have been able to show that indeed the breathing sounds are reflecting the upper airway pathology. However, showing a high correlation between the OSA and the features of breathing sounds does not guarantee a highly accurate detection of OSA. </p>
<p>Detecting OSA by only breathing sounds analysis is challenging because of the heterogeneity of sleep apnea, which can have different causes resulting in different characteristics of breath sounds. Also, there are many variables including age, gender, height, weight and smoking history that affect breathing sounds’ characteristics. </p>
<p>To overcome these challenges, we came up with a smart diagnostic scheme that considers the impact of all these confounding variables. With the help of a sophisticated machine learning algorithm (AWakeOSA), <a href="https://bme.eng.umanitoba.ca/research/sleep-apnea/">our team</a> can now reliably and accurately detect the severity of OSA during wakefulness. Validation of the technology in a much larger population is planned.</p>
<h2>Surgical patients</h2>
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<a href="https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Miniature microphone, amp box and cord" src="https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=805&fit=crop&dpr=1 600w, https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=805&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=805&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1012&fit=crop&dpr=1 754w, https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1012&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/403771/original/file-20210601-27-1590bx6.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1012&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A microphone embedded in a specially designed chamber, and a small pre-amp box. The hardware can be connected to an app on phones or a computer to do the recording.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>One important application is for surgical patients with unknown OSA status who are going under general anesthesia. For that application, sensitivity of the test (detecting those who do have sleep apnea) is more important than the specificity (detecting those who do not have sleep apnea). </p>
<p>The beauty of the smart decision-making of the AWakeOSA algorithm is that we can increase its sensitivity at a minor cost to its specificity. That means accurately identifying all patients with sleep apnea is the key priority — as it would be with surgical patients — we can increase OSA detection accuracy with only a minor increase in false positive findings. </p>
<p>Depending on its application, there is some flexibility to adjust the sensitivity/specificity of the test, depending on which one is more important. </p>
<p>The AWakeOSA technology can also <a href="https://doi.org/10.3390/diagnostics11050905">determine those in need of treatment for sleep apnea</a> with greater than 89 per cent accuracy. That means it can be used as an accurate screening tool to reduce the number of people needing full PSG assessment, saving millions of dollars in costs to the health-care system.</p><img src="https://counter.theconversation.com/content/160431/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Zahra Moussavi receives funding from Natural Science Engineering Research Council (NSERC) of Canada and Canadian Institutes of Health Research (CIHR) for relevant topics.</span></em></p>Diagnosing obstructive sleep apnea usually requires a labour-intensive overnight sleep study. But new technology can tell patients if they have OSA in 30 seconds, while they are wide awake.Zahra Moussavi, Professor of Biomedical Engineering, University of ManitobaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1389912020-06-28T06:00:21Z2020-06-28T06:00:21Z‘Prehabilitation’: Training your body for surgery may improve recovery, reduce complications<figure><img src="https://images.theconversation.com/files/343309/original/file-20200622-55009-lsyfn1.jpg?ixlib=rb-1.1.0&rect=429%2C33%2C6610%2C4274&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Exercise training can improve your physical fitness incrementally in as little as two weeks, making it a viable option for people about to undergo a surgical procedure.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>If you’ve had a surgery postponed due to the pandemic, or one is on the horizon, there may be some work you can do right now to prepare and to help improve your postoperative outcome.</p>
<p><a href="https://doi.org/10.12968/hmed.2017.78.12.729">Prehabilitation</a>, a strategy that uses exercise to improve patients’ functional capacity before surgery to help improve outcomes, is increasingly recommended for those facing scheduled surgeries, and it’s improving outcomes and experiences for patients across a wide range of situations. </p>
<p>There’s no guarantee, of course, but it gives patients much greater agency over their own health, and it’s never a bad idea to do what you can to lower your risk of complications following surgery.</p>
<h2>Postoperative risks</h2>
<p>Statistically, dying within a month after an operation accounts for <a href="https://doi.org/10.1016/S0140-6736(18)33139-8">7.7 per cent of deaths globally</a>, which makes it one of the top three factors contributing to global fatalities, trailing only heart attack and stroke. </p>
<p>While death is the most severe outcome, <a href="https://dx.doi.org/10.1016%2Fj.jss.2013.01.032">surgery patients are also susceptible to additional post-operative complications</a> such as intense fatigue, longer hospital stays or hospital re-admittance, anemia and anorexia among a host of others. Those most <a href="https://doi.org/10.1186/s12916-017-0986-2">at risk post-operatively</a> are generally older adults that already live with other chronic diseases, take various medications and have a lower fitness level. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343310/original/file-20200622-55021-1gepvf6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The skill of the surgical team is not the only factor that affects the outcome of surgery.</span>
<span class="attribution"><span class="source">(Unsplash/National Cancer Institute)</span></span>
</figcaption>
</figure>
<p>The success of a surgical procedure depends on more than the skill of the medical staff and the complexity of the operation. It is becoming apparent that the likelihood of the patient returning to a physically and psychologically healthy state is also dependent on <a href="https://www.cfn-nce.ca/impact/get-fit-for-surgery/">what they do in the weeks leading up to the surgery</a>.</p>
<p>Scientists have shown that an effective way of increasing chances of success is to physically train in the time leading up to a surgery. In this time of uncertainty, when many <a href="https://globalnews.ca/news/6948692/covid-19-pandemic-elective-surgeries-canada/">surgeries have been delayed</a>, prehabilitation might be an opportunity to help optimize outcomes. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343758/original/file-20200624-132951-1jvhm6v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Exercise can improve fitness incrementally in as little as two weeks.</span>
<span class="attribution"><span class="source">(Pexels)</span></span>
</figcaption>
</figure>
<p>Doctors are often concerned with a patients’ risk factors, like high blood pressure, blood lipid status or obesity, many of which are difficult to control. Perhaps physical fitness, something you can change with exercise training and impacts several risk factors, should be added to this list. Exercise training can improve your physical fitness incrementally in <a href="https://pubmed.ncbi.nlm.nih.gov/31827347/">as little as two weeks</a>, making it a viable option for people about to undergo a surgical procedure. </p>
<h2>Prehabilitation</h2>
<p>The concept of prehabilitation is based on the idea that <a href="http://doi.org/10.1249/JSR.0000000000000274">patients with a higher functional capacity, or fitness level</a>, will better tolerate a surgical procedure, have fewer post-operative complications and demonstrate better functional, psychological, social and surgical outcomes. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343330/original/file-20200622-55021-1gong9i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People with higher functional capacity before surgery may have better post-operative outcomes.</span>
<span class="attribution"><span class="source">(Unsplash/Yulissa Tagle)</span></span>
</figcaption>
</figure>
<p>Think of your fitness as a pitcher of water, and each outcome after surgery as a plant. The more water you have at the start somewhat predicts how many plants or outcomes you can care for. Critically, scientific evidence suggests that an <a href="https://doi.org/10.1111/anae.14177">individual’s fitness level may be a stronger predictor of post-operative risk than traditional risk factors</a>, as small improvements in fitness have been associated with substantial improvements in survival.</p>
<p>The great news is that we know that many types of <a href="https://www.exerciseismedicine.org/assets/page_documents/EIM_Rx%20for%20Health_%20Staying%20Active%20During%20Coronavirus%20Pandemic.pdf">exercise training are effective</a>, including brisk walking or jogging, <a href="https://www.vox.com/science-and-health/2019/1/10/18148463/high-intensity-interval-training-hiit-orangetheory">high-intensity interval training</a>, weightlifting, breathing exercises and muscle- or joint-specific training. </p>
<p>The current fitness of the patient is an important factor to consider when prescribing a pre-surgical exercise program, as someone with a higher fitness level will most likely be able to complete a more challenging program, such as high intensity interval training combined with strength training, and will require more activity to see physical gains. By contrast, an older, frail patient undergoing chemotherapy in preparation for a surgical procedure will be more limited in their fitness level, and may only be able to complete deep breathing exercises with a focus on strengthening their inspiratory muscles, which are respiratory muscles used when inhaling, such as the diaphragm. </p>
<h2>Preparing for delayed surgeries</h2>
<p>Regardless of the specific exercise program, it seems that these exercise interventions are safe, and <a href="https://www.ctvnews.ca/health/how-prehab-exercise-could-make-surgery-recovery-easier-1.4457405">may be associated with improved post-operative outcomes</a>.</p>
<p>Like training for a race or sporting event, prehabilitation programs are most effective when combined with nutritional and psychological interventions. Surgery induces a stress response causing an increased need for additional energy sources, which can be relieved with nutritional supplementation, <a href="https://doi.org/10.1111/anae.14506">such as eating a diet higher in protein</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/343331/original/file-20200622-55021-1m4baun.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People whose surgeries have been postponed due to the pandemic have an opportunity to do prehabilitation.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Addressing a patient’s anxiety regarding pain management, and behavioural modifications like quitting smoking and reducing alcohol consumption, have been shown to independently decrease the risk of postoperative complications. The best postoperative results have been observed when a <a href="https://doi.org/10.1111/anae.14505">multi-pronged approach</a>, or a program designed to address all aspects of a patient’s health, has been applied.</p>
<p>In health care, it’s possible to switch gears. If we use prehabilitation and approach surgery like training for a race, we could see better outcomes, fewer deaths and healthier patients. This is even more important now, amid the current pandemic. With so many surgeries delayed, many patients have some extra time for prehabilitation that could improve their outcome.</p><img src="https://counter.theconversation.com/content/138991/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily Dunford receives funding from the Canadian Institutes of Health Research (CIHR). </span></em></p>Physical training before surgery — like breathing exercises or running — boosts the odds of a good outcome. Patients with surgeries postponed during COVID-19 can use the delay for ‘prehabilitation.’Emily C. Dunford, Postdoctoral Fellow in Kinesiology, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/796592017-06-21T20:04:07Z2017-06-21T20:04:07ZSurgeons admit to mistakes in surgery and would use robots if they reduced the risks<figure><img src="https://images.theconversation.com/files/174829/original/file-20170621-26746-1ciui33.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Surgeons admit to unintentional mistakes when performing delicate surgery.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>How good are humans at performing manual surgery? </p>
<p>Major surgical errors must be reported and there has been research into the <a href="http://www.cbsnews.com/news/would-a-surgeon-tell-you-if-something-went-wrong-during-an-operation/">attitudes of surgeons</a> in how they report such errors.</p>
<p>But there is no requirement or legislation in place to report minor unintentional damage, and how that is even defined is a grey area. Very little research exists into the frequency of unintentional surgical damage, the challenges that cause this damage, or understanding of the long-term effects.</p>
<p>We are developing semi-autonomous robotic tools to help surgeons, especially for knee surgery. It’s estimated that around <a href="http://orthoinfo.aaos.org/PDFs/A00299.pdf">4 million</a> knee arthroscopies are performed each year worldwide. </p>
<p>In <a href="http://journals.sagepub.com/doi/10.1177/2309499016684993">our recent study</a>, some surgeons said they found that such knee procedures could be physically challenging and could cause unintentional damage to their patients. </p>
<p>But a majority said they would be prepared to use robotic tools if they could be shown to help in the surgery and reduce the risks of injury to patients.</p>
<h2>Unintentional damage in surgery</h2>
<p><a href="https://www.healthdirect.gov.au/osteoarthritis">Osteoarthritis</a> is by far the leading cause of pain in joints, especially knees.</p>
<p>Following X-ray and MRI scans, the first line of minimally invasive diagnostic and treatment procedures is known as <a href="http://orthoinfo.aaos.org/topic.cfm?topic=a00299">knee arthroscopy</a>. It is a procedure in which a surgeon slides a camera and a range of instruments into the joint through small incisions.</p>
<p>This procedure is somewhat controversial as the evidence of its effectiveness for some patients <a href="http://www.abc.net.au/health/features/stories/2015/03/25/4203985.htm">has been questioned</a>. But it is still one of the most common surgical procedures carried out in the world.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=564&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=564&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174347/original/file-20170619-28759-icnp47.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=564&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Knee arthroscopy surgery showing a surgeon holding a patient’s leg.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>With our colleagues, we asked 93 surgeons in Australia with a range of experience how often they observed unintentional damage occurring during a knee arthroscopy. The survey was anonymous and the results were <a href="http://journals.sagepub.com/doi/10.1177/2309499016684993">published earlier this year in the Journal of Orthopaedic Surgery</a>.</p>
<p>Half the surgeons (49.5%) said unintentional damage to articular cartilage, which is the tissue that covers the end of your bones that make up your joints, occurred in at least one in ten procedures.</p>
<p>A third (34.4%) of them said the damage rate was at least one in five procedures. Incredibly, seven of the surgeons (7.5%) said such damage occurred in every procedure carried out.</p>
<p>Damage to cartilage is probably <a href="http://www.arthritis.org/about-arthritis/types/osteoarthritis/causes.php">one of the causes of osteoarthritis</a> and your body does not repair cartilage if damaged, which can then result in knee pain.</p>
<p>So patients who suffer unintentional cartilage damage during an arthroscopy have an additional risk of developing osteoarthritis. This is somewhat ironic, given that the motivation for many arthroscopic procedures is to try to treat osteoarthritis.</p>
<h2>A pain for the surgeon</h2>
<p>Knee arthroscopy is considered straightforward, and a skilled surgeon will make it look easy. But it is actually very difficult and requires considerable <a href="http://bjj.boneandjoint.org.uk/content/97-B/10/1309.short">skill and experience</a>.</p>
<p>During the procedure, the leg must be manipulated to create the space for the camera and the tools. This means that the surgeon has to continually lift and hold the leg, while at the same time hold the camera and the tools and operate by looking at the video on a screen. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174675/original/file-20170620-8734-cbq214.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The view from an arthroscope. Note the metal tool on the left of the image.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>We asked the surgeons whether they found knee arthroscopy to be physically challenging, and whether they had experienced pain themselves after performing this surgery.</p>
<p>Nearly 59% reported they found the procedure to be physically challenging, and more than a fifth (22.6%) said they had experienced physical pain afterwards. It is in the interests of patients that their <a href="https://theconversation.com/you-should-care-about-your-doctors-health-because-it-matters-to-yours-78039">surgeons remain in good health</a>.</p>
<h2>Robots to the rescue</h2>
<p>So how can we reduce the risk of any unintentional damage during knee arthroscopy surgery and make the procedure less challenging for the surgeon?</p>
<p>At the moment there are no robotically assisted technologies used in knee arthroscopy. All the surgery is performed manually. </p>
<p>Our current research focuses on how robots can be used by surgeons to improve patient and surgeon safety, to reduce the need for future medical treatment, and to lower the costs of healthcare.</p>
<p>We are exploring how robots can be used to hold and move the leg during a knee arthroscopy, freeing the surgeon to focus on observing the interior of the knee. </p>
<p>We are also developing new types of flexible robots and tiny stereo cameras to replace the existing arthroscopes and which will feed into <a href="https://theconversation.com/how-do-robots-see-the-world-51205">robotic vision systems</a> to map the 3D structure of the knee. These 3D knee maps will be used by other tool holding robots to avoid colliding with the cartilage. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5HBORi_LyYQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A prototype flexible ‘snake’ robot, designed to move around curved spaces like joints.</span></figcaption>
</figure>
<p>Our aim is to give surgeons semi-autonomous robotic tools so they can concentrate on what they are best at: deciding what is wrong with the patient and how to treat it.</p>
<p>About a third (32.3%) of surgeons<a href="http://journals.sagepub.com/doi/10.1177/2309499016684993"> we surveyed</a> said they were nervous about the introduction of any semi-autonomous arthroscopic systems.</p>
<p>But about three-quarters (76.3%) said they would use a robotic assist system if it improved the efficiency of the procedure, and 86% said they would use a robot if it decreased the rate of unintentional damage to cartilage.</p>
<p>Overall, 47.3% of the surgeons said they saw a future role for semi-autonomous arthroscopic systems.</p>
<p>All surgeons will tell you that surgery carries a risk. As a patient, you must balance the benefits of a given surgery against those risks.</p>
<p>Future upgrades to their toolkit in the form of robotic manipulators, scopes and tools, will hopefully allow surgeons to reduce the risks for both the patients and themselves.</p><img src="https://counter.theconversation.com/content/79659/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anjali Jaiprakash is an Advance Queensland Fellow and receives funding from Australia-India Strategic Research Fund.
</span></em></p><p class="fine-print"><em><span>Jonathan Roberts receives funding from the Australia-India Strategic Research Fund and the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Ross Crawford consults for Stryker Corp. He receives funding from ARC, NHMRC and Australia India Strategic Research fund</span></em></p>Surgeons say minor unintentional damage can happen during surgery, and much of that goes unreported. They say they would be prepared to use robotic tools if they could be shown to help.Anjali Jaiprakash, Advance Queensland Fellow, Medical Robotics, Queensland University of TechnologyJonathan Roberts, Professor in Robotics, Queensland University of TechnologyRoss Crawford, Professor of Orthopaedic Research, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/713402017-01-25T03:24:10Z2017-01-25T03:24:10ZRecent death from resistant bug won’t be the last<figure><img src="https://images.theconversation.com/files/154003/original/image-20170124-8082-9azadi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">According to the World Health Organisation, antimicrobial resistance is now at crisis point. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Reports of the death of effective antibiotics are no longer greatly exaggerated. The US Centers for Disease Control <a href="http://www.wtsp.com/news/health/woman-dies-of-superbug-no-antibiotic-could-treat/386267616">has reported</a> that a woman in her 70s has died of overwhelming sepsis caused by a bacterium that was resistant to all available antibiotics.</p>
<p>The patient had acquired the infection as a complication of treatment for a fractured hip she received in India two years previously. So-called “pan-resistant” bacteria have been <a href="http://jmidonline.org/upload/sayi/18/JMID-00780.pdf">recognised in India</a> and other parts of the developing world for several years and they are <a href="https://www.cdc.gov/drugresistance/index.html">now being identified in the US</a>.</p>
<p>Australia is yet to report a pan-resistant germ, but it is only a matter of time. Local bacteria that are resistant to all but a few antibiotics are now common and, although overseas travel is an important risk factor, <a href="https://www.mja.com.au/journal/2013/198/5/down-drain-carbapenem-resistant-bacteria-intensive-care-unit-patients-and">cases occur in people</a> who have not left the country.</p>
<p>The human race was able to successfully multiply its numbers without the aid of antibiotics up until 1935, the year <a href="https://academic.oup.com/jac/article/17/6/689/734551/Domagk-and-the-development-of-the-sulphonamides">the first antibiotic</a> was released. So how seriously should we take the sometimes apocalyptic warnings that we are approaching the end of the Antibiotic Age? Unfortunately the answer is - very. </p>
<h2>What would happen without antibiotics?</h2>
<p>Infection is one of the commonest causes of death following a bone marrow transplant for leukaemia or lymphoma. It is also a serious risk after heart, lung, kidney and liver transplants. Patients undergoing chemotherapy for breast and lung cancer often develop infections when their white cell counts drop. </p>
<p>Many premature babies, whose immune systems are under-developed, contract bacterial infections in the intensive care unit. Even with effective antibiotics, the death rate from infection in each of these settings is high. With pan-resistant bacteria, the death rate will soar.</p>
<p>People who undergo any of the common abdominal surgical procedures (such as an appendectomy, gallbladder removal and bowel resection) will have a much higher chance of developing infections that, since the 1950s, have hardly even been considered. Infections from common elective surgeries, such as hip and knee replacements, will be commonplace. In a post-antibiotic world, the time may come when the risk of infection outweighs the benefit of elective surgery.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=425&fit=crop&dpr=1 600w, https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=425&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=425&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/154004/original/image-20170124-8075-2du9dy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">In a post-antibiotic age, elective surgeries such as knee replacements may not be worth the risk of infection.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>The common infection of the leg known as cellulitis occasionally requires high-dose antibiotics in hospital, but most cases are treated in the community. With no antibiotics, cellulitis will return to what it was in the early 20th century – a condition that often required surgical drainage of pus from the deep tissues of the leg and, in the most severe cases, amputation. </p>
<p>Urinary tract infections in women will become more than just a nuisance that can be fixed with a short course of oral antibiotics. Women returning from holidays in South-East Asia have a <a href="http://cid.oxfordjournals.org/content/61/11/1766.full">significant chance</a> of picking up resistant bugs in their gastrointestinal tract that may persist for six months or more. These bacteria can cause cystitis (a bladder infection) that is untreatable with any oral antibiotics. </p>
<p>Men returning from an international trip who undergo prostate cancer screening with a transrectal biopsy can end up with an untreatable <a href="http://insidestory.org.au/eleven-grams-of-trouble">bloodstream infection</a>. </p>
<h2>Use them and lose them</h2>
<p>The emergence of resistance to antibiotics is inevitable. When a selection pressure is placed on a bacterium by exposing it to an antibiotic, the “fittest” (resistant) bacteria are not killed and may come to dominate the local population of microorganisms. </p>
<p>Resistance can be slowed by limiting the use of antibiotics to only those who need them, by using antibiotics with the narrowest possible spectrum of activity, and by using the correct dose for the shortest possible time. The widespread use of antibiotics for non life-threatening infections outside of hospital has been one of the main drivers of resistance. </p>
<p>It is not always easy to differentiate between viral and bacterial infections, and doctors are understandably reluctant to miss a bacterial infection. Unfortunately this anxiety leads to millions of unnecessary prescriptions each year. A wrong antibiotic choice in hospitalised patients with life-threatening infections (such as septicaemia and pneumonia) can be a lethal mistake, so initially these people require powerful, broad-spectrum agents. </p>
<p>It isn’t just a problem of medical prescribing. It’s estimated animals receive <a href="http://livablefutureblog.com/2010/12/new-fda-numbers-reveal-food-animals-consume-lion%E2%80%99s-share-of-antibiotics">80% of the antibiotics used</a> in the US. In animals they are mainly used to boost growth, resulting in resistant bacteria in the human food chain.</p>
<p>Antibiotic resistance is recognised as a <a href="http://www.who.int/antimicrobial-resistance/publications/surveillancereport/en/">global crisis</a> by the World Health Organisation. Its rise can be slowed but not halted. There is an urgent need for new antibiotics, but <a href="http://www.nature.com/nature/journal/v517/n7535/full/nature14098.html">only one new class of agents</a> has been discovered in the past 30 years.</p>
<p>The development in that same period of the extraordinarily effective antiviral drugs for <a href="http://www.hepatitisaustralia.com/hepatitis-b-facts/treatment-for-hep-b">Hepatitis B</a>, <a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">Hepatitis C</a> and <a href="http://emedicine.medscape.com/article/1533218-overview">HIV</a> demonstrate what can be achieved when the mighty resources of the pharmaceutical industry are focused on a problem. </p>
<p>In the meantime, we’ll have to relearn <a href="https://theconversation.com/what-will-it-take-to-reduce-infections-in-the-hospital-62530">lessons about infection control</a> such as hand hygiene, better hospital cleaning and meticulous attention to sterility when performing invasive procedures that were once second nature to health care workers in the pre-antibiotic age.</p><img src="https://counter.theconversation.com/content/71340/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Frank Bowden does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The US Centers for Disease Control has reported a woman in her 70s has died of overwhelming sepsis caused by a bacterium that was resistant to all available antibiotics.Frank Bowden, Professor at ANU Medical School; Senior Staff Specialist Infectious Diseases; General Physician, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/545592016-02-15T01:04:17Z2016-02-15T01:04:17ZCommon surgery for vaginal prolapse can lead to complications, review shows<figure><img src="https://images.theconversation.com/files/111399/original/image-20160214-29185-amzlt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Up to 50% of women who have had children will experience vaginal prolapse.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/66755335@N05/8111915024/in/photolist-dmPFHS-dF56PQ-gegfYd-nVU3jH-dEW4MZ-87xcdG-b37PjH-bDdZ8Y-cj65y7-5QHiz8-d3EWjC-9TBQjo-p2M6nW-dmJoDR-bUcf6T-nmnsC1-anMwLJ-ayFGbU-ekhPNB-95DjwF-28WN7t-gYaUsz-awHapT-7BMHff-b75wx2-oAhMcz-oKggBK-bufSMv-q21rjM-64sk4i-iR91VW-65dbY9-mbgzEP-524rqU-9eQyGf-bwJwYr-cUDD1J-7tvqAy-jU42nb-66GvKg-cEjFPY-8qaDwD-8skPjh-czgKM1-czgJPN-bXuYXA-74oKyv-6qm1AL-6CGC4k-c14Z8b"> Geneva Vanderzeil apairandasparediy.com/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>A common surgery to treat vaginal prolapse using an artificially grafted mesh has more problems than benefits, <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012079/abstract">our Cochrane review</a> has found. Women who underwent the operation had high rates of needing repeat surgery due to mesh exposure, bladder injury and urinary incontinence.</p>
<p>A vaginal prolapse occurs when the walls of the vagina become weak and collapse inwards. Women can feel a lump or bulge low in their vagina, which is exacerbated at times of physical activity. The debilitating condition <a href="http://www.oxfordgynaecology.com/Conditions/Uterine-Prolapse.aspx">affects up to 50%</a> of women who have had children. </p>
<p>We evaluated the safety and success of inserting mesh through the vagina (transvaginal) with that of traditional surgery that repairs damaged tissue. The aim was to provide clarity in a long-standing controversy over vaginal prolapse treatment.</p>
<p>Complications following transvaginal mesh surgery have led to <a href="http://www.drugwatch.com/transvaginal-mesh/verdict-settlement/">lawsuits in the United States</a> and to Scotland’s health minister temporarily <a href="http://www.bbc.com/news/uk-scotland-scotland-politics-27884794">suspending the technique</a> in 2014 pending safety investigations.</p>
<p>We analysed evidence from 37 randomised trials in 4,032 women and found 12% of those who had mesh inserted suffered from the mesh being exposed in the vagina. This can cause vaginal bleeding, pain, painful intercourse and penile scratching or bleeding in the male partner. </p>
<p>While 7% more women who had transvaginal mesh surgery compared to a native tissue repair reported successful resolution of prolapse, one in 12 of these needed repeat surgery for mesh exposure.</p>
<p>Newer transvaginal mesh products available in Australia haven’t been rigorously evaluated despite being on the market for at least five years. We advise clinicians ensure women understand this uncertainty, as well as the proven complications, before undergoing the interventions. </p>
<h2>Pelvic organ prolapse</h2>
<p>Overweight women, those with a family history of the condition or who chronically strain, by coughing, constipation or heavy lifting, are at increased risk of vaginal prolapse.</p>
<p>Women with the condition can experience incomplete emptying of their bladder or bowel and feel very negatively about their body, which impacts sexual function. </p>
<p>As many as 10% to 20% of women with vaginal prolapse <a href="http://www.ncbi.nlm.nih.gov/pubmed/24807341">will need surgery</a>. </p>
<p>Until the early 2000s, surgeons used different techniques to treat prolapse involving stitching the damaged tissues surrounding the vagina. These remain relatively successful, but <a href="http://www.ncbi.nlm.nih.gov/pubmed/9083302">rates of recurrent prolapse</a> of up to 30% have been reported. </p>
<p>Following successes incontinence surgeons have had <a href="http://www.ncbi.nlm.nih.gov/pubmed/12114234">using tapes</a> to support the urethra like a sling and others using mesh in hernia repair, gynaecology surgeons adopted the use of the net-like mesh to support the vagina. </p>
<p>The technique took off and in 2010, transvaginal mesh operations <a href="http://www.ajog.org/article/S0002-9378(15)00153-2/abstract">accounted for nearly 25%</a> of prolapse interventions in some countries.</p>
<h2>The controversy</h2>
<p>In the last few years, <a href="https://www.researchgate.net/publication/227343100_Vaginal_invagination_Definition_clinical_presentation_and_surgical_management">increasing complaints from women</a> who had undergone transvaginal mesh surgery have raised questions about the safety of the procedure. The problems included vaginal pain, painful intercourse and vaginal bleeding, secondary to the mesh rubbing or becoming exposed in the vagina. </p>
<p>Although there has been insufficient evidence as to the frequency of the complications, as well as no consensus on the best approach to treat the condition, regulatory authorities in several countries took some action. </p>
<p>In 2012, the United States Food and Drug Administration (FDA) <a href="http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM271769.pdf">reclassified transvaginal mesh</a> as a high-risk device that demands a higher level of evaluation of new products. Existing mesh devices were also required to report greater comparative data to determine their efficacy and safety. To date, these evaluations have not been published.</p>
<p>The Medicines and Healthcare products Regulatory Authority (MHRA) in Britain <a href="https://www.gov.uk/government/publications/vaginal-mesh-working-group-interim-report">recently reported</a> “a strong disparity between the types of experience patients are reporting and the published evidence” relating to transvaginal mesh. The MHRA recommended regulatory changes including improvements to the informed consent process. </p>
<p>A <a href="https://www.gov.uk/government/publications/vaginal-mesh-working-group-interim-report">Scottish report</a> stated they “remained concerned regarding the safety and efficacy of the transvaginal meshes”. </p>
<p>In Australia, the Therapeutic Goods Administration (TGA) formed the <a href="https://www.tga.gov.au/behind-news/review-urogynaecological-surgical-mesh-implants">Urogynaecological Devices Working Group</a> to advise on this issue. Due to concerns over the lack of definitive data, the group is reassessing clinical evidence for each transvaginal mesh product to ensure it complies with the TGA’s requirements for safety and performance. These evaluations are ongoing. </p>
<p>It is concerning also that many of the mesh products already evaluated were voluntarily withdrawn from use in 2011 to be replaced with newer, lightweight transvaginal permanent meshes. These have yet to be evaluated but remain in use. </p>
<h2>What we found</h2>
<p>Our research aimed to offer women and health professionals the evidence to make better informed choices about surgical treatment. </p>
<p>We found transvaginal mesh surgery had benefits. It reduced the risk that women would be aware of the vaginal bulge from 18% in those who had traditional repairs to 12% in those who had mesh repairs, one to three years following the surgery. </p>
<p>The rate of repeat operations for prolapse following transvaginal permanent mesh repair (1-3%) was also lower compared to traditional repairs (3%). </p>
<p>But some problems were reported with transvaginal mesh. The average rate for repeat operations for prolapse, urinary incontinence, or mesh exposure after mesh repair, was 11% compared with around 5% in women who had a traditional tissue repair. </p>
<p>Permanent mesh surgery was also associated with higher rates of bladder injury than traditional tissue repair and higher rates of urinary incontinence with activity after the surgery.</p>
<p>And, as already mentioned, one in 12 women experienced unpleasant symptoms from mesh complications.</p>
<p>Clinicians and women should be aware that the benefits of transvaginal mesh as compared to traditional repairs should be carefully weighed against the complications. </p>
<p>Gynaecologists should be wary of adopting innovations that have not been fully evaluated by clinical trials. Our patients deserve better studies and, in the absence of evidence, better advice.</p><img src="https://counter.theconversation.com/content/54559/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Maher is Chair of the Urogynaecological Society of Australasia . </span></em></p>A common operation to treat vaginal prolapse using an artificially grafted mesh has women needing repeat surgery due to mesh exposure, and suffering from bladder injury and urinary incontinence.Christopher Maher, Associate Professor, Urogynaecology Royal Brisbane and Women's and Wesley Hospitals Brisbane , The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/470082015-09-04T04:45:22Z2015-09-04T04:45:22ZWhy you shouldn’t be popping herbal medicines before you go for surgery<figure><img src="https://images.theconversation.com/files/93795/original/image-20150903-8791-1icavuz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Using herbal medicines in the two weeks before surgery could be dangerous. </span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Herbal therapies, taken for medicinal and health reasons, are becoming increasingly popular and are often regarded as innately safe. But their interaction with other medicines is less well known – and could be dangerous.</p>
<p>One fifth of patients on prescription medication also use herbal remedies, high dose dietary supplements or both, according to the South African <a href="http://www.sajaa.co.za/index.php/sajaa/article/viewFile/1421/1509">Journal</a> of Anaesthesia and Analgesia. When herbal medicines sold by traditional healers are included, that figure shoots up to 80%.</p>
<p>Herbal therapies are plant-derived products. They have been part of human existence since the beginning of time and span the spectrum from home-brewed teas prepared from collected leaves and herbs to products with official approved status granted by drug-regulating authorities.</p>
<p>The danger of herbal medicines lies in the widespread perception that because they are “natural”, they are safe. This perception is ill informed. The manufacture of herbal medicine is poorly regulated in <a href="http://dx.doi.org/10.1097/MJT.0b013e31825891a0">South Africa</a>. This means the true content of different preparations vary greatly between manufacturers. Some tend to under-report or omit the side effects of their therapies and overemphasise the positive effects.</p>
<h2>How it can be bad for you</h2>
<p>How herbal medicines and conventional drugs interact is not fully understood. For patients who fail to disclose using herbal medicines before they go into surgery, the side effects can be dire. Among the most dangerous adverse effects are increased bleeding and resultant blood loss throughout the surgery.</p>
<p><a href="http://dx.doi.org/10.1056/NEJM199301283280406">Research</a> from the New England Journal of Medicine shows that 70% of patients don’t tell the doctors and physicians treating them that they are using any of these drugs.</p>
<p>A survey looking at the increased surgical risk from herbal products found up to 51% of surgical patients used herbal medicine in the two weeks before a procedure. Of the drugs patients used, 27% altered clotting, 30% had a direct influence on heart rhythm, rate and blood pressure and 20% increased sedation. </p>
<p>These are the three most high risk problems during operations and could result in complications - or even death. </p>
<p>Common herbal medicines include ginger, garlic, <a href="http://www.webmd.com/vitamins-supplements/ingredientmono-872-kava.aspx?activeingredientid=872&activeingredientname=kava">kava</a>, <a href="https://www.nlm.nih.gov/medlineplus/druginfo/natural/333.html">gingko</a> and evening primrose oil – which, on the face of it, are innocuous or even beneficial to consume.</p>
<p>Numerous research publications have shown that these could have serious implications if they are used with other medication. </p>
<p>For instance, when used in clinically effective doses, garlic’s interaction with oral contraceptives may result in contraceptive failure. Ginger can cause decreased blood pressure, exaggerating the effects of blood pressure medication and interfering with blood pressure therapy. </p>
<p>And although wounds are often treated with kava, its side effects include anxiety, insomnia, restlessness, muscle pain and headaches, drowsiness and depression of motor reflexes. This may be the result of kava interacting with the central nervous system depressants such as sedatives and tranquilisers or alcohol. </p>
<p>When evening primrose oil interacts with anaesthetics, it could increase the risk of seizures during or after an operation. And when ginger, evening primrose oil or gingko interact with medicine to prevent the blood from clotting these interactions could increase the risk of bleeding.</p>
<p>At the South African Society of Anaesthesiologists, we have anecdotal evidence of patients not disclosing their use of herbal medicines such as omega oils, arnica tablets, evening primrose oil and St. John’s wort. In most instances it meant the physicians had to return to theatre because their patients’ excessive bleeding.</p>
<h2>The science behind it</h2>
<p>Some physicians may not be familiar with all the clinical effects of the herbal medication or the action of a specific herb and would therefore underestimate the risk it poses to their patient. </p>
<p>The bioactive components contained in a single herb may contribute, in varying degrees, to the observed effect and interaction, leading to difficulties in predicting and explaining herb-drug interactions. </p>
<p>Other herbal medicines compete for the same cytochrome pathway as anaesthetic agents commonly used, which may slow down the clearance of the anaesthetic drug administered, predisposing patients to toxic effect as a result of higher plasma concentration. The net effect of such interactions is pharmacological chaos and unexpected drug toxicity.</p>
<p>Most medical authorities agree that the use of herbal supplements and medicines should be stopped at least two weeks before surgery.</p>
<p>Perhaps you, like many others, take herbal medicines because you believe it’s the smart thing to do. In some cases it may well be so. But to tell your healthcare practitioner that you use such therapies, especially in run-up to and after a surgical procedure, may be one of the smartest things you ever do.</p><img src="https://counter.theconversation.com/content/47008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tinus Dippenaar does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Herbal medicines can be detrimental if they are used with conventional medicine - especially if you don’t tell your doctors about them.Tinus Dippenaar, Principal Specialist. Clinical Head: Anaesthesiology, Department Maxillo-Facial-Oral-Surgery, Oral and Dental Hospital, University of PretoriaLicensed as Creative Commons – attribution, no derivatives.