1
|
Ramalingam N, Coury J, Barnes C, Kenzie ES, Petrik AF, Mummadi RR, Coronado G, Davis MM. Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity. J Rural Health 2024; 40:272-281. [PMID: 37676061 PMCID: PMC10918036 DOI: 10.1111/jrh.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/07/2023] [Accepted: 08/26/2023] [Indexed: 09/08/2023]
Abstract
PURPOSE Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion. METHODS We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes. FINDINGS We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift. CONCLUSIONS These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.
Collapse
Affiliation(s)
- NithyaPriya Ramalingam
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3030 S Moody Avenue, Suite 160, Portland, OR 97201
| | - Jennifer Coury
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3030 S Moody Avenue, Suite 160, Portland, OR 97201
| | - Chrystal Barnes
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3030 S Moody Avenue, Suite 160, Portland, OR 97201
| | - Erin S. Kenzie
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3030 S Moody Avenue, Suite 160, Portland, OR 97201
- Department of Family Medicine & School of Public Health, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098
| | - Amanda F. Petrik
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227
| | - Rajasekhara R Mummadi
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227
| | - Gloria Coronado
- Kaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227
| | - Melinda M. Davis
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3030 S Moody Avenue, Suite 160, Portland, OR 97201
- Department of Family Medicine & School of Public Health, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098
| |
Collapse
|
2
|
Kolber MR, Miles PJ, Shaw MD, Goosen H, Mok DCM. Evaluation of the quality of colonoscopies performed by Alberta North Zone surgeons, family physicians and internists: a quality improvement initiative. CMAJ Open 2023; 11:E654-E661. [PMID: 37527900 PMCID: PMC10400082 DOI: 10.9778/cmajo.20210237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND In Canada, endoscopy is primarily performed by gastroenterologists and surgeons, and some studies report that colonoscopies performed by nongastroenterologists have more complications and higher rates of future colorectal cancer. Our objective was to determine whether rural-based nongastroenterologist endoscopists are achieving quality benchmarks in colonoscopy. METHODS This quality improvement initiative prospectively evaluated 6 key performance indicators (KPIs) (cecal intubations, polyp detection [males and females; for first-time colonoscopies on patients aged ≥ 50 yr], bowel preparations, patient comfort and withdrawal times) on consecutive colonoscopies performed by participating Alberta North Zone endoscopists. The study period was June 2018 to March 2020. Overall and individual endoscopist's KPIs were compared with standard benchmarks. Additional performance indicators included mean number of polyps per colonoscopy and an exploration of study-defined sedation-related level of consciousness. RESULTS Data were collected on 6212 colonoscopies performed by 16 endoscopists (9 surgeons, 5 family physicians and 2 internists) in 6 hospitals. All 6 KPI benchmarks were achieved when results were pooled over all endoscopists in the study. Overall, cecal intubation occurred in 6006 of 6209 (96.7%, 95% confidence interval 94.5%-99.0%) cases. Polyp detection was 65.9% (592/898) and 49.8% (348/699) for male and female patients, respectively, aged 50 years or older. Variability in individual endoscopist results existed, especially for the mean number of polyps per 100 colonoscopies and sedation-related level of consciousness. INTERPRETATION Overall, Alberta North Zone endoscopists are performing high-quality colonoscopies, collectively achieving all 6 KPIs. To understand endoscopic performance and encourage individual and group reflection on endoscopic practices, Canadian endoscopists are encouraged to participate in similar colonoscopy quality initiative studies.
Collapse
Affiliation(s)
- Michael R Kolber
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta.
| | - Peter J Miles
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| | - Marcus D Shaw
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| | - Hilgard Goosen
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| | - Dereck C M Mok
- Department of Family Medicine (Kolber, Goosen); Division of General Surgery (Shaw, Mok, Miles), Department of Surgery, University of Alberta, Edmonton, Alta
| |
Collapse
|
5
|
Schroeder T, Sheppard C, Wilson D, Champion C, DiMillo S, Kirkpatrick R, Hiscock S, Friesen R, Smithson L, Miles P. General surgery in Canada: current scope of practice and future needs. Can J Surg 2020. [PMID: 33009899 DOI: 10.1503/cjs.004419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The scope of practice of general surgeons in Canada is highly variable. The objective of this study was to examine the demographic characteristics of general surgeons in Canada and compare surgical procedures performed across community sizes and specialties. METHODS Data from the Canadian Institute for Health Information's National Physician Database were used to analyze fee-for-service (FFS) care provided by general surgeons and other providers across Canada in 2015/16. RESULTS Across 8 Canadian provinces, 1669 general surgeons provided FFS care. The majority of the surgeons worked in communities with more than 100 000 residents (71%), were male (78%), were aged 35-54 years (56%) and were Canadian medical graduates (76%). Only 7% of general surgeons practised in rural areas and 14% in communities with between 10 000 and 50 000 residents. Rural communities were significantly more likely to have surgeons who were international medical graduates or who were older than 65 years. The surgical procedures most commonly performed by general surgeons were hernia repairs, gallbladder and biliary tree surgery, excision of skin tumours, colon and intestine resections and breast surgery. Many general surgeons performed procedures not listed in their Royal College of Physicians and Surgeons of Canada training objectives. CONCLUSION Canadian general surgeons provide a wide array of surgical services, and practice patterns vary by community size. Surgeons practising in rural and small communities require proficiency in skills not routinely taught in general surgery residency. Opportunities to acquire these skills should be available in training to prepare surgeons to meet the care needs of Canadians.
Collapse
Affiliation(s)
- Travis Schroeder
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Caroline Sheppard
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Dawn Wilson
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Caitlin Champion
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Shanna DiMillo
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Roy Kirkpatrick
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Stephen Hiscock
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Randall Friesen
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Lauren Smithson
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| | - Peter Miles
- From the Division of General Surgery, McMaster University, Hamilton, Ont. (Schroeder); the Cumming School of Medicine, University of Calgary, Calgary, Alta. (Sheppard); the Canadian Association of General Surgeons, Ottawa, Ont. (Wilson); the Division of General Surgery, University of Ottawa, Ottawa, Ont. (Champion); the Royal College of Physicians and Surgeons of Canada, Ottawa, Ont. (DiMillo); the Northern Ontario School of Medicine, Huntsville District Memorial Hospital, Huntsville, Ont. (Kirkpatrick); the University of British Columbia, Shuswap Lake General Hospital, Salmon Arm, B.C. (Hiscock); the Department of Surgery, University of Saskatchewan, Victoria Hospital, Prince Albert, Sask. (Friesen); the Department of Surgery, Charles S. Curtis Memorial Hospital, Labrador-Grenfell Health, St. Anthony, Nfld. (Smithson); and the Department of Surgery, University of Alberta, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles)
| |
Collapse
|
6
|
Wilk P, Stranges S, Maltby A. Geographic variation in short and long sleep duration and poor sleep quality: a multilevel analysis using the 2015-2018 Canadian community health survey. Sleep Health 2020; 6:676-683. [PMID: 32335041 DOI: 10.1016/j.sleh.2020.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/06/2020] [Accepted: 02/28/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND There is a dearth of evidence on geographic variation in sleep duration and quality, and about the effect of geographic location or "place" on sleep. The objective was to assess the magnitude of geographic variation in sleep duration and sleep quality in Canada, while controlling for individual-level factors. METHODS Data from the 2015-2018 cycles of the Canadian Community Health Survey were used. The sample consisted of 96,484 respondents from 6 provinces. Multilevel logistic regression techniques were used to assess the magnitude of geographic variation in self-reported measures of short and long sleep duration and 3 indicators of sleep quality (difficulty initiating and maintaining sleep, daytime sleepiness, and finding sleep refreshing) across geographic areas, defined by the boundaries of Forward Sortation Areas. RESULTS Overall, 45.31% of respondents reported short sleep, 2.31% reported long sleep, 46.97% had difficulty initiating and maintaining sleep, 29.50% had daytime sleepiness, and 39.11% did not find their sleep refreshing. After controlling for individual-level factors, geographic variation accounted for 4.00% and 13.67% of overall variance in short and long sleep duration, respectively; the corresponding estimates for difficulty initiating and maintaining sleep, daytime sleepiness, and finding sleep refreshing were 3.04%, 3.80%, and 5,08%, respectively. CONCLUSIONS There is a significant level of geographic variation in short and long sleep duration and sleep quality and this variation cannot be accounted for by differential distribution of individual characteristics across geographic areas. Future research is warranted to examine specific contextual factors that can account for this variation.
Collapse
Affiliation(s)
- Piotr Wilk
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Kresge Building, Room K201, 1151 Richmond Street, London, Ontario N6A 5C1, Canada; Department of Paediatrics, 800 Commissioners Road East, London, Ontario N6C 2V5, Canada; Child Health Research Institute, 800 Commissioners Road East, London, Ontario N6C 2V5, Canada.
| | - Saverio Stranges
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Kresge Building, Room K201, 1151 Richmond Street, London, Ontario N6A 5C1, Canada; Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, Western Centre for Public Health and Family Medicine, 1465 Richmond St, London, Ontario N6G 2M1, Canada; Epidemiology and Public Health Research Unit, Department of Population Health, Luxembourg Institute of Health, 1A-B rue Thomas Edison, Strassen L-1445, Luxembourg
| | - Alana Maltby
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Kresge Building, Room K201, 1151 Richmond Street, London, Ontario N6A 5C1, Canada
| |
Collapse
|
8
|
Akhtar-Danesh GG, Doumouras AG, Flageole H, Hong D. Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study. J Pediatr Surg 2019; 54:1804-1808. [PMID: 30482382 DOI: 10.1016/j.jpedsurg.2018.10.065] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/10/2018] [Accepted: 10/16/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND/PURPOSE Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. METHODS Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. RESULTS Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. CONCLUSIONS In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. LEVEL OF EVIDENCE Prognosis study, level II.
Collapse
Affiliation(s)
- Gileh-Gol Akhtar-Danesh
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Aristithes G Doumouras
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
| | - Helene Flageole
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of Pediatric Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.
| | - Dennis Hong
- Department of Surgery, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada; Division of General Surgery, St. Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario, L8N 4A6, Canada.
| |
Collapse
|