Systematic Review of Medium-Term Weight Loss after Bariatric Operations

Background: Although bariatric surgery is known to be effective in the short term, the durability of that effect has not been convincingly demonstrated over the medium term (>3 years) and the long term (>10 years). The authors studied the durability of weight loss after bariatric surgery based on a systematic review of the published literature. Methods: All reports published up to September, 2005 were included if they were full papers in refereed journals published in English, of outcomes after Roux-en-Y gastric bypass (RYGBP), and its hybrid procedures of banded bypass (Banded RYGBP) and longlimb bypass (LL-RYGBP), biliopancreatic diversion with or without duodenal switch (BPD±DS) or laparoscopic adjustable gastric banding (LAGB). All reports that had at least 100 patients at commencement, and provided ≥3 years of follow-up data were included. Results: From a total of 1,703 reports extracted, 43 reports fulfilled the entry criteria (18 RYGBP; 18 LAGB; 7 BPD). Pooled data from all the bariatric operations showed effective and durable weight loss to 10 years. Mean %EWL for standard RYGBP was higher than for LAGB at years 1 and 2 (67 vs 42; 67 vs 53) but not different at 3, 4, 5, 6 or 7 years (62 vs 55; 58 vs 55; 58 vs 55; 53 vs 50; and 55 vs 51). There was 59 %EWL for LAGB at 8 years, and 52 %EWL for RYGBP at 10 years. Both the BPD±DS and the Banded RYGBP appeared to show better weight loss than standard RYGBP and LAGB, but with statistically significant differences present at year 5 alone. The LL-RYGBP was not associated with improved %EWL. Important limitations include lack of data on loss to follow-up, failure to identify numbers of patients measured at each data point and lack of data beyond 10 years. Conclusions: All current bariatric operations lead to major weight loss in the medium term. BPD and Banded RYGBP appear to be more effective than both RYGBP and LAGB which are equal in the medium term.     

Weight Loss and Non-alcoholic Fatty Liver Disease: Falls In Gamma-Glutamyl Transferase Concentrations are Associated with Histologic Improvement

Background: The ability for aminotransferase levels to track histological features of non-alcoholic fatty liver disease (NAFLD) with weight loss has not been examined. Methods: We examined the effect of weight loss following laparoscopic adjustable gastric banding surgery on the histological features of NAFLD and plasma aminotransferase concentrations (AST, ALT and GGT) in 60 (12M, 48F) selected severely obese patients. All 120 paired biopsies were deidentified and scored for lobular steatosis, fibrosis, inflammation, Mallory bodies and NASH. Results: 30 patients (50%) had baseline histological features of non-alcoholic steatohepatitis (NASH). Repeat biopsies were taken at 29.5±10 months after baseline. Mean weight loss was 31.5±18 kg. There were improvements in AST, ALT, GGT, lobular steatosis, inflammation and fibrosis between baseline and follow-up (P<0.001 for all). Only 6 (10%) of repeat biopsies showed NASH. No change in aminotransferase concentrations predicted the change in steatosis, but changes in AST and GGT predicted improved scores for inflammation, fibrosis, Mallory bodies and NASH. The lowering of GGT best predicted the improvements in inflammation, fibrosis and NASH. Conclusion: With weight loss, falls in GGT and, to a lesser extent, in AST, are predictive of improved lobular inflammation and fibrosis, key prognostic features of NAFLD.     

Developing interdisciplinary maternity services policy in Canada. Evaluation of a consensus workshop

Context Four maternity/obstetrical care organizations, representing women, midwives, obstetricians and family doctors conducted interdisciplinary policy research under auspices of four key stakeholder groups. These projects teams and key stakeholders subsequently collaborated to develop consensus on strategies for improved maternity services in Ontario. Objectives The objective of this study is to evaluate a 2‐day research synthesis and consensus building conference to answer policy questions in relation to new models of interdisciplinary maternity care organizations in different settings in Ontario. Methods The evaluation consisted of a scan of individual project activities and findings as were presented to an invited audience of key stakeholders at the consensus conference. This involved: participant observation with key informant consultation; a survey of attendees; pattern processing and sense making of project materials, consensus statements derived at the conference in the light of participant observation and survey material as pertaining to a complex system. The development of a systems framework for maternity care policy in Ontario was based on secondary analysis of the material. Findings Conference participants were united on the importance of investment in maternity care for Ontario and the impending workforce crisis if adaptation of the workforce did not take place. The conference participants proposed reforming the current system that was seen as too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. However, not one model of interdisciplinary maternity/obstetrical care was endorsed. Consistency and coherence of models (rather than central standardization) through self‐organization based on local needs was strongly endorsed. An understanding of primary maternity care models as subsystems of networked providers in complex health organizations and a wider social system emerged. The patterns identified were incorporated into a complexity framework to assist sense making to inform policy. Discussion Coherence around core values, holism and synthesis with responsiveness to local needs and key stakeholders were themes that emerged consistent with complex adaptive systems principles. Respecting historical provider relationships and local history provided a background for change recognizing that systems evolve in part from where they have been. The building of functioning relationships was central through education and improved communication with ongoing feedback loops (positive and negative). Information systems and a flexible improved central and local organization of maternity services was endorsed. Education and improved communication through ongoing feedback loops (positive and negative) were central to building functioning relationships. Also, coordinated central organization with a flexible and adaptive local organization of maternity services was endorsed by participants. Conclusions This evaluation used an approach comprising scoping, pattern processing and sense making. While the projects produced considerable typical research evidence, the key policy questions could not be addressed by this alone, and a process of synthesis and consensus building with stakeholder engagement was applied. An adaptive system with local needs driving a relationship based network of interdisciplinary groupings or teams with both bottom up and central leadership. A complexity framework enhanced sense making for the system approaches and understandings that emerged.     

What principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review

Visiting health services are a feature of health care delivery in rural and remote contexts. These services are often described as ‘fly‐in fly‐out’ or ‘drive‐in drive‐out’. Posing the question ‘What are the different types of visiting models of primary health care being used in rural and remote communities?’, the objective of this article was to describe a typology of models of health services that visit remote communities. A systematic review of peer‐reviewed literature from established databases was undertaken. Data were extracted from 20 papers (16 peer‐reviewed papers and four from other sources), which met the inclusion criteria. From the available evidence, it was difficult to develop a typology of services. The central feature of service providers visiting rural and remote districts on a regular basis was consistent, although the service provider's geographical base varied and the extent to which the same service provider should be providing the service was not consistently endorsed. While a clear typology did not emerge from the systematic review, it became apparent that a set of guiding principles might be more helpful to service providers and planners. Focusing policy and decision‐making on important principles of visiting services, rather than their typological features, is likely to be of ultimately more benefit to the health outcomes of people who live in rural and remote communities.     

Improving the effectiveness of interpreted consultations: Australian interpreter,general practitioner and patient perspectives

Healthcare consultations with patients lacking English proficiency are challenging for all parties, even in Australian primary care where the engagement of interpreters is encouraged and fully subsidised. Our objective was to understand these challenges from the perspectives of interpreters, patients and general practitioners in order to improve the effectiveness of interpreted consultations. Our investigator team approached the interpreted consultation as an interprofessional collaboration. A convenience sample of seven general practitioners, eight health interpreters and six representatives from culturally and linguistically diverse communities (representing the patient perspective) participated in three separate focus group discussions, lasting 60–90 min each, exploring participant experiences with healthcare consultations in which interpreters were present. Two semistructured interviews were undertaken subsequently with three additional community representatives purposively recruited to increase participant diversity. Data were collected in 2016 and analysed inductively using a method of constant comparison to identify, and reach consensus on, key emerging themes. All participant groups emphasised the importance of working with trained interpreters, rather than relying on family interpreters or a doctor's own second language skills. Although participants reported experiences of effective interpreted consultations, other reports suggested that some doctors are unaware of, or have difficulty following, accepted guidelines about speech, gaze and turn‐taking. Challenges identified in relation to interpreted consultations fell into the five themes of contextual constraints, consultation complexity, communication difficulties, the interpreter role and collaboration. Some general practitioner participants appeared to be unsure and anxious about the etiquette of interpreted consultations, and there was some confusion between and within participant groups about interpreter roles and professional codes. A briefing session prior to the consultation, clarifying the roles of all parties, including any family or bicultural workers present, may help to establish respectful, flexible and effective interprofessional collaborations and to encourage participants to directly address any problems during the consultation.