Bariatric Surgery in Vegetarians: Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) survey of Asian surgeon experience.

PURPOSE: Bariatric and metabolic surgery is increasing in Asia to address the growing obesity epidemic. Literature is scarce regarding this surgery in vegetarian patients. We aim to survey surgeons regarding their practices and experiences with the vegetarian population. MATERIALS AND METHODS: The regional bariatric and metabolic surgery society distributed a multi-national electronic questionnaire to surgeon members. The questionnaire was in the English and Chinese languages. RESULTS: Fifty-six bariatric and metabolic surgeons responded to the questionnaire (response rate 40.6%). Twenty-two respondents (48.9%) have vegetarian patients in their case volume. Patients mostly consume a vegetarian diet for religious (66.7%) and health (66.7%) reasons. More than 60% of surgeons are unsure of micronutrient deficiency status amongst these patients. Over half of the respondents (58.8%) reported that their vegetarian patients do not take multivitamins or vitamin supplements. Significant proportions of respondents (44.4-61.1%) were unsure of the iron, vitamin B12, vitamin D, zinc, and folic acid deficiency status of these patients. Only 38.9% of respondents routinely prescribe multivitamin supplementation. CONCLUSIONS: Vegetarian bariatric patients in East and South-East Asia are an under-recognized patient cohort at risk of micronutrient deficiencies. There is a knowledge gap among regional surgeons in long-term nutritional assessment and management.

COVID-19: Adapting to change, general surgery at a district general hospital in the United Kingdom.

The Coronavirus pandemic has caused major change across the world and in the National Health Service. In order to cope and help limit contagion, numerous institutions recognised the need to adjust clinical practice quickly yet safely. In this paper, we aim to describe the changes implemented in a general surgery department at a district general hospital in the United Kingdom. Across the surgical specialties, frameworks, protocols and guidelines have been established locally and nationally. The aerosol generating procedures involved in general surgery required us to alter our daily activities. Modifications to patient management were necessary to try and reduce viral spread. Staff wellbeing was heavily promoted in order to help maintain the frontline workforce. A holistic approach was required.

The Road to Improving Access to Surgical Specialist Consultations: Ontario's Experience with Wait 1 Wait Time Data.

In 2009, the Ontario Ministry of Health and Long-Term Care engaged Cancer Care Ontario to expand the Wait Time Information System to capture surgical consultation data (Wait 1). Over the years, an increasing number of patient and provider reports have shown that Wait 1 wait times account for a significant portion of the total wait time for surgery. With data published online by the ministry in late summer 2017, patients were given access to consultation wait time information for over 200 types of procedures at 92 surgical facilities in Ontario. This article explains how a highly focused data strategy, strong stakeholder and clinical expert support and a comprehensive communications strategy were critical to driving change for a large-scale provincial initiative, which is helping to drive better access for patients and improve transparency and accountability.

Saskatchewan's Successful Strategy for Surgical Waitlist Reduction.

By 2015, Saskatchewan's surgical wait times, once among Canada's longest, were arguably the nation's shortest. This paper highlights the principal strategies that were implemented to address the exceptionally lengthy surgical wait times in Saskatchewan's SHR. These included the province's funding the establishment of a fair operating room allocation system, a centralized provincial surgery registry, integration of priority scoring tools and creation of the Saskatchewan Surgical Care network. This coordinated backdrop facilitated the integration of Lean principles, hospital service consolidation, private third-party surgical care delivery services and policy direction setting by the provincial government.

Challenges and Opportunities in the Provision of Surgical Care in Vanuatu: A Mixed Methods Analysis.

BACKGROUND: The Pacific island nation of Vanuatu faces a number of challenges in delivering surgical care to its population. We aimed to understand and document the barriers, opportunities and required actions to improve surgical care in the country using a mixed methods analysis which incorporated the perspectives of local health stakeholders. METHODS: A baseline quantitative assessment of surgical capacity in Vanuatu was carried out using the WHO situational analysis tool. Twenty semi-structured interviews were then conducted on the two main islands (Efate and Espiritu Santo) with surgeons, allied health staff, health managers, policy-makers and other key stakeholders, using a grounded theory qualitative case study methodology. Initial informants were identified by purposive sampling followed by snowball sampling until theoretical saturation was reached. Interviews were open and axially coded with subsequent thematic analysis. RESULTS: Vanuatu faces deficits in surgical infrastructure, equipment and human resources, especially in the rural provinces. Geographic isolation, poverty and culture-including the use of traditional medicine and low health literacy-all act as barriers to patients accessing timely surgical care. Issues with governance, human resourcing and perioperative care were commonly identified by stakeholders as key challenges facing surgical services. Increasing outreach clinics, developing efficient referral systems, building provincial surgical capacity and undertaking locally led research were identified as key actions that can improve surgical care. CONCLUSION: Documenting locally identified challenges and opportunities for surgical care in Vanuatu is an important first step towards developing formal strategies for improving surgical services at the country level.

An integrated approach to surgery and primary care systems strengthening in low- and middle-income countries: building a platform to deliver across the spectrum of disease.

BACKGROUND: Surgical services in low- and middle income countries (LMICs) must be considered within the context of a coordinated strategy for building primary care systems. Weak front-line primary care systems lead to delayed presentation and poor follow-up of patients with surgical illness, increasing the risk of poor outcomes. METHODS: Here we propose a framework to integrating surgery and primary care, organized around basic primary care principles of access, longitudinal care, coordination, integration and equity. RESULTS: Making surgical care accessible will require frontline provider capacity to screen for and recognize common surgical conditions, as well as to deliver certain basic surgical services themselves. Making this care effective will require strengthening the capacity of interdisciplinary teams to provide longitudinal care, involving coordinated networks for referral, communication with and mentorship by more specialized providers, and postoperative follow-up. Innovative approaches to information and communication technology can help to overcome the transportation and infrastructure barriers that jeopardize both access and effectiveness. Explicit integration of surgical and primary care programs at the managerial and administrative levels, as well as at the point-of-care, will also be critical. Taking a pro-equity approach can ensure that populations with the greatest unmet needs are effectively reached. CONCLUSION: Utilizing the pillars of effective primary care as a guiding framework to design, implement, and scale surgical programs in LMICs offers an opportunity for strengthening and enhancing the quality of health systems as a whole.

Surgical Care and Health Systems.

BACKGROUND: While surgical care impacts a wide variety of diseases and conditions with non-operative and operative services, both preventive and curative, there has been little discussion concerning how surgery might be integrated within the health system of a low and middle-income country (LMIC), nor how strengthening surgical services may improve health systems and population health. METHODS: We reviewed reports from several meetings of the working group on health systems strengthening of the Global Initiative for Emergency and Essential Surgical Care, and also performed a review of the literature including the search terms "surgery," "health system," "developing country," "health systems strengthening," "health information system," "financing," "governance," and "integration." RESULTS: The literature search revealed no reports which focused on the integration of surgical services within a health system or as a component of health system strengthening. A conceptual model of how surgical care might be integrated within a health system is proposed, based on the discussions of our working group, combined with sources from the medical literature, and utilizing the World Health Organization's conceptual model of a health system. CONCLUSIONS: Strengthening the delivery of surgical services in LMICs will require inputs at multiple levels within a health system, and this effort will require the coalescence of committed individuals and organizations, supported by civil society.

How do you give information?

BEING A PATIENT in the NHS is like being a stranger in a foreign country. It has its own food, language and customs, clans and chiefs. It can be frightening, confusing and alienating for adults, let alone children visiting a hospital or GP's surgery.

[Formation of centers in general and abdominal surgery -- necessity or trend?]. / Zentrenbildung in der Allgemein- und Viszeralchirurgie - Notwendigkeit oder Trend?

The introduction of the DRG (diagnosis-related groups) system as basis for reimbursement in the German health-care system has led to a mentality of quality orientation and verification of therapeutic results. An immediate result was the formation of medical "centres" on rather different levels and consequently the inauguration of institutions, authorities, and organisations to review these centres. Finally, a range of certifications was installed in order to stratify the rather diverse aims of different centres. This review critically evaluates the current situation in the field of general and abdominal surgery in Germany.

Perceiving integration of a complementary medicine service within a general surgery department through documentation of consultations: a thematic analysis.

OBJECTIVE: This study aims to examine the meaning and practical implications of integration of a complementary medicine-based surgery service in a hospital setting (CISS--Complementary/Integrative Surgery Service) through analysis of consultation reports associated with this service. METHODS: Thematic analysis was used to evaluate CISS consultation reports in a hospital electronic consultant charting system during the first half year of the service's activity. RESULTS: 304 consultation reports were analyzed. Nurses initiated significantly more consultations than physicians (55% vs 7%). Consultation requests were gradually more focused on specific symptoms, possibly manifesting a better understanding of the scope of complementary medicine in the surgery setting. CISS practitioners responded in more biomedical language over time, albeit offering a more holistic perspective regarding patients' needs as well as clarifications regarding the nature of the treatment they provided. CONCLUSIONS: Diverse communication patterns in consultations evolved over time representing dynamics in multiple levels of integration of the CISS. PRACTICE IMPLICATIONS: Documented communication through consultations can provide a window to the process of integration of complementary medicine-based services in health systems.

A comprehensive simulation for wait time reduction and capacity planning applied in general surgery.

This paper describes the use of operational research techniques to analyze the wait list for the Division of General Surgery at the Capital District Health Authority in Halifax, Nova Scotia, Canada. A discrete event simulation model was developed to aid capacity planning decisions and to analyze the performance of the division. The analysis examined the consequences of redistributing beds between sites, and achieving standard patient lengths of stay, while contrasting them to current and additional resource options. From the results, multiple independent and combined options for stabilizing and decreasing waits for elective procedures were proposed.

The pivotal role of critical care and surgical efficiencies in supporting Ontario's Wait Time Strategy: Part 3.

As part of its Wait Time Strategy, the Ontario Ministry of Health and Long-Term Care provided significant amounts of money to perform more cases with the understanding that improving access by reducing wait times is not just a matter of increasing funding. Rather, fundamental system and practice change is required to sustain improvements in the long term.

Academic practice groups: strategy for survival.

BACKGROUND: The mission of public academic health centers (puAHC) and their affiliated practice groups (APG) focuses on teaching, research, and the clinical care of at-risk populations. Resources to accomplish this mission, however, are becoming scarce. For puAHC to survive and remain competitive, innovative strategies will need to be developed by the APG. We hypothesized that the integration of a surgical academic practice of the APG with a nonacademic integrated health care delivery system (NAIDS) in a managed care environment would benefit all involved. METHODS: A surgical academic practice was integrated with a NAIDS in a 95% managed care market. Faculty alone provided care the first year, and third-year residents were added the following year. To assess outcome, we collected benefit and cost data for the 1-year period before integration and compared them with the two, 1-year periods after integration. RESULTS: In the second year of integration, revenues from the NAIDS referrals to the puAHC and APG increased 89% and 150%, respectively. The NAIDS' general surgical and endoscopy caseload increased by 25%. Additionally, there was a 92% reduction in operating room technician cost with no increase in operating time per case. Finally, the third-year resident experienced a caseload increase of 163%. CONCLUSIONS: In an environment where resources are diminishing and managed care consists of many large NAIDS that drive referrals and revenue, the integration of a surgical academic practice with a NAIDS benefits all shareholders. Academic practice groups that develop strategies that leverage their competitive advantage will have the best chance of surviving in today's turbulent health care market.

Surgery in Spain.

The Iberian Peninsula-the southwestern point of Europe, between the Mediterranean Sea and the Atlantic Ocean-was visited and settled in ancient times by a variety of peoples. Phoenicians, Carthaginians, Celts, Greeks, Romans, Visigoths, and Arabs all left their mark on the peninsula, and their cultures blended together to found, among other things, a rich tradition in medicine and surgery. During the Renaissance, the fluid exchange of technical skills and knowledge with the rest of Europe and the emergence of universities ensured the development of a high level of medical expertise. Today, surgery in Spain is at the forefront of innovations in the field.