A culturally informed model to enhance breast, cervical, and colorectal cancer screenings: perspectives of American Indian adults and healthcare providers in rural New Mexico.

PURPOSE: American Indian/Alaska Native (AI/AN) populations have some of the lowest cancer screening rates compared to other racial/ethnic populations. Using community-based participatory research methods, we sought to characterize knowledge, attitudes, beliefs, and approaches to enhance breast, colorectal, and cervical cancer screening. METHODS: We conducted 12 focus groups between October 2018 and September 2019 with 96 eligible AI adults and healthcare providers, recruited using non-probability purposive sampling methods from the Zuni Pueblo in rural New Mexico. We used the Multi-level Health Outcomes Framework (MHOF) to conduct a qualitative content analysis identifying mutable systems- and individual- level constructs important for behavior change that we crosslinked with the Community Preventive Services Task Force (CPSTF) recommended evidence-based interventions (EBIs) or approaches. RESULTS: Salient systems-level factors that limited uptake of cancer screenings included inflexible clinic hours, transportation barriers, no on-demand service and reminder systems, and brief doctor-patient encounters. Individual-level barriers included variable cancer-specific knowledge that translated into fatalistic beliefs, fear, and denial. Interventions to enhance community demand and access for screening should include one-on-one and group education, small media, mailed screening tests, and home visitations by public health nurses. Interventions to enhance provider delivery of screening services should include translation and case management services. CONCLUSIONS: The MHOF constructs crosslinked with CPSTF recommended EBIs or approaches provided a unique perspective to frame barriers and promoters of screening utilization and insights for intervention development. Findings inform the development of culturally tailored, theoretically informed, multi-component interventions concordant with CPSTF recommended EBIs or approaches aimed at improving cancer screening.

Health Literacy, Health Numeracy, and Cancer Screening Patterns in the Zuni Pueblo: Insights from and Limitations of "Standard" Questions.

American Indians experience disparities in cancer screening, stage at disease diagnoses, and 5-year cancer survival. This study investigates how health literacy and health numeracy may be linked to cancer screening behaviors of Zuni Pueblo members using a survey exploring screening behaviors related to breast, cervical, and colorectal cancers. As part of a larger community-based cancer prevention and control project, Zuni Health Initiative staff conducted surveys from October 2020 through April 2021 of 281 participants (men ages 50-75 and women ages 21-75) from the Zuni Pueblo. Bivariate and multivariable analyses investigated associations between health literacy/numeracy measures and cancer screening behaviors. Bivariate analyses showed some associations between distinct measures of health literacy/numeracy and colorectal cancer (CRC) screening, including both colonoscopy (health literacy) and fecal occult blood testing (FOBT) (health numeracy), as well as cervical cancer screening (health literacy). There were no statistically significant associations between health literacy/numeracy measures and mammogram screening for breast cancer. In multivariable analyses, there were no consistent patterns between health literacy/numeracy and screening for any cancer. There are some individual findings worth noting, such as statistically significant findings for health numeracy and FOBT (those reporting lower health numeracy were less likely to report FOBT). An important finding of this study is that questions used to assess health literacy/numeracy did not identify associations aligned with previous research. We reflect on the ways the "standard" questions may not be sufficiently tailored to the Zuni experience and may contribute to health equity barriers.

Management of spontaneous intracranial hypotension: a series of 31 cases over 15-years with a challenging outlier.

Spontaneous intracranial hypotension (SIH) has been classified as a triad of postural headache, low CSF opening pressure (below 60mmH20) and diffuse pachymeningeal gadolinium enhancement on MRI. SIH is due to a non-iatrogenic defect in the dura somewhere along the neuraxis (usually in the spine). The resultant leak depressurizes the system and undermines the buoyancy-providing quality of CSF. In many cases the site of leak is not identified. Epidural blood patch (EBP) is a well-established treatment of SIH but is not always effective. We retrospectively analysed thirty-one cases of SIH who required at least one EBP. They were managed over a fifteen-year period at a single institution. EBP resulted in a significant improvement in headache for 77% of patients. We report in more detail on a particularly challenging outlier where severe SIH resulted in coma. Serial epidural blood patches, burr hole evacuation of chronic subdural haematomata, and infusion of 0.9% NaCl via an intradural spinal catheter were all required to enable long-term recovery.

Paradoxical cardiac and cerebral arterial gas embolus during percutaneous lead extraction in a patient with a patent foramen ovale.

A 42 year-old man presented for elective percutaneous lead extraction for pacemaker redundancy. The procedure was performed supine under general anaesthesia via the right femoral vein and was complicated by acute inferior ST elevation and hypotension. Urgent transoesophageal echocardiogram showed inferior left ventricular hypokinesis, right ventricular impairment, a patent foramen ovale and air in the left ventricle. Coronary angiography demonstrated normal coronary arteries, the ST changes resolved and the leads were subsequently removed intact. Post-operatively the patient displayed nystagmus, was managed with hyperbaric oxygen therapy, and had complete resolution of his symptoms. An MRI brain confirmed an acute left cerebellar infarction, and a diagnosis of paradoxical air embolus to the coronary and cerebral circulations was made. This case illustrates the risks associated with paradoxical embolism in patients with PFOs undertaking percutaneous lead extractions. It also highlights the need for further consideration into techniques to avoid this complication in all high-risk percutaneous procedures.

Morphology of ileal and jejunal pouches used as rectal substitutes.

PURPOSE: Our aim was to determine whether the mucosa of a canine jejunal pouch used as a rectal substitute after proctocolectomy retains its morphologic features better than the mucosa of a canine ileal pouch so used. METHODS: Among ten dogs that underwent proctocolectomy, five had a jejunal pouch-distal rectal anastomosis and five an ileal pouch-distal rectal anastomosis. After six months, the animals were killed, the intestinal pouches and portions of unaltered distal ileum were removed, and a blinded, mucosal morphometric analysis was performed. RESULTS: The mucosa of the jejunal pouches had an overall thickness (mean +/- standard deviation, anterior and posterior walls, 1,300 +/- 140 microm), villous height (286 +/- 46 microm), and crypt depth (790 +/- 77 microm) greater than that of the ileal pouches (920 +/- 170, 208 +/- 47, and 530 +/- 130 microm, respectively; P < 0.05). Moreover, the mucosal thickness of the jejunal pouches was similar to that of the distal ileum proximal to the pouch (1,200 +/- 200 microm; P > 0.05), whereas the mucosal thickness of the ileal pouch was thinner (P < 0.05). CONCLUSIONS: The jejunal mucosa retains its major morphometric features when the jejunum is used as a rectal substitute after proctocolectomy. In contrast, the ileal mucosa atrophies when the ileum is so used.

The spectrum of pneumatosis intestinalis.

HYPOTHESIS: A review of the spectrum of illness associated with pneumatosis intestinalis enables us to identify the probable causes of, the best diagnostic approaches to, and the most appropriate treatments for this condition. DATA SOURCES: A review of all published material in the English language regarding pneumatosis intestinalis was conducted using the PubMed and MEDLINE databases. Any relevant work referenced in those articles and not previously found or published before the limit of the search engine was also retrieved and reviewed. STUDY SELECTION: There were no exclusion criteria for published information relevant to the topic. All of the studies cited in the present review make a point that contributes to the portrayal of this condition. In circumstances in which the same point was made in several different studies, not all were cited herein. DATA EXTRACTION: All published material on pneumatosis intestinalis was considered. Information was extracted for preferentially selected ideas and theories supported in multiple studies. DATA SYNTHESIS: The collected information was organized by theory. CONCLUSIONS: Mucosal integrity, intraluminal pressure, bacterial flora, and intraluminal gas all interact in the formation of pneumatosis intestinalis. Radiography and computed tomography are the best diagnostic tests. Nonoperative management should be pursued in most patients, and underlying illnesses should be treated. When acute complications appear, such as perforation, peritonitis, and necrotic bowel, surgery is indicated.

Reoperation on the abdomen encased in adhesions.

PURPOSE: To determine outcome after lysis of intestinal adhesions, relief of obstruction, closure of fistulas and drainage of abscesses in patients with an abdominal cavity obliterated by chronic postoperative adhesions. METHODS: Among 40 patients with an abdomen encased in dense adhesions after a mean of 5 previous operations, 31 patients also had intestinal obstruction, 25 enteric fistulas and 20 abdominal abscesses. Reoperation was done and outcome assessed from the medical records and by a mailed questionnaire. RESULTS: Only 1 postoperative death occurred, but 24 early complications appeared. At hospital discharge, obstruction, fistula and abscess were completely resolved in all but 3 patients (P <0.001). Only 2 of 16 patients on parenteral nutrition before operation (TPN) still required it (P = 0.004). At late follow-up (mean, 4.6 years) the patients' quality of life (mean score +/- SD, 8.6 +/- 2.1) was similar to that of a healthy control population (9.2 +/- 1.2, P = 0.17). CONCLUSIONS: Reoperation on the abdomen encased in adhesions restores most patients to good health and an excellent long-term quality of life.

Spontaneous intramural small-bowel hematoma: clinical presentation and long-term outcome.

HYPOTHESIS: To review our experience with the treatment of patients with nontraumatic spontaneous intramural small-bowel hematoma. Our hypothesis was that this condition resolves spontaneously in most patients. DESIGN: A retrospective review of the records of 13 patients with nontraumatic spontaneous intramural small-bowel hematoma who presented to Mayo Clinic (Rochester, Minn; Scottsdale, Ariz; and Jacksonville, Fla) between January 1, 1983, and December 31, 2000. SETTING: A tertiary care medical institution. PATIENTS: Mean age at presentation was 64 years (8 men, 5 women). Patients presented with abdominal pain (13 patients), intestinal obstruction (11 patients), and biliary obstruction (1 patient). Mean duration of symptoms was 4 days. Eight patients were receiving anticoagulant therapy (mean international normalized ratio, 11.6). Only 1 patient was anemic at presentation, but 11 patients became anemic during hospitalization. Computed tomography established the diagnosis in all patients. MAIN OUTCOME MEASURES: Short- and long-term outcomes obtained from clinical records and telephone interviews. RESULTS: Single and multiple hematomas were present in 11 patients and 2 patients, respectively. Two patients had an exploratory operation, but no bowel resection was performed. The other 11 patients were managed with bowel rest. Two patients died of sepsis related to their coexisting medical conditions, and 11 patients left the hospital without short-term complications. At follow-up (mean, 35 months), 4 patients had died of unrelated causes, and 7 were alive; none had recurrence of bowel hematoma or intestinal obstruction. CONCLUSION: Nonoperative treatment of spontaneous small-bowel hematoma has a good outcome in most patients.

Use of a colonic pouch as a rectal substitute after rectal excision

Mid or distal rectal resection with straight coloanal anastomosis effectively treats distal rectal cancer and avoids a permanent stoma. However, the straight colonic segment is a poor reservoir for stools, and patients usually experience varying degrees of impaired rectal function after operation, including frequent bowel movements, incontinence, tenesmus, and soiling. In contrast a J-shaped colonic pouch provides an adequate neorectal reservoir after operation. Patients with a colonic pouch-anal canal anastomosis have bowell movements per day than patients with straight colorectal or coloanal anastomosis. Furthermore, the morbility of the colonic pouch is not greater than that of the straight coloanal anastomosis. An important technical aspect of the colonic pouch procedure is that the limbs used to form the pouch must be no longer than 5 to 6 cm. Patients with larger pouches experience emptying difficulties. Also, the level of the anastomosis between the pouch and the anal canal must be no more than 4 cm from the anal verge, again to avoid problems with defecation. With these caveats, the operation should be considered in patients who require excision of the mid and distal rectum for cancer.