Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies.

PURPOSE: Access to health care is a long-standing concern for rural patients; however, administrative measures fail to capture the subjective patient experience of accessing health care. The purpose of this review was to synthesize the qualitative literature on patient and caregiver experiences of accessing health care services for chronic disease management among US residents of rural areas. METHODS: We searched Embase, MEDLINE, PsycInfo, CINAHL, and Scopus to identify qualitative studies published during 2010-2019. A thematic synthesis approach was used to analyze findings from included studies. RESULTS: A total of 62 studies involving 1,354 unique participants were included. The largest share of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%), HIV and AIDS (14.5%), and diabetes (12.9%). We identified 4 primary analytic themes of barriers and facilitators associated with the experience of accessing health care services for chronic disease management in rural areas: (1) navigating the rural environment, (2) navigating the health care system, (3) financing chronic disease management, and (4) rural life (ie, common elements of a distinct "rural" way of thinking and behaving). CONCLUSIONS: In this comprehensive review, we found that important cultural, structural, and individual factors influenced the rural patient's experience of health care access and use, including barriers and facilitators posed by geographic and built environments, and distinct rural mores. Our findings can inform policies and programs that both facilitate structural aspects of access and include culturally appropriate interventions.VISUAL ABSTRACT.

Thyroid cancer overdiagnosis and overtreatment: a cross- sectional study at a thyroid cancer referral center in Ecuador.

BACKGROUND: In contrast to the rapid increase in thyroid cancer incidence, the mortality has remained low and stable over the last decades. In Ecuador, however, thyroid cancer mortality has increased. The objective of this study is to determine possible drivers of high rates of thyroid cancer mortality, through a cross-sectional analysis of all patients attending a thyroid cancer referral center in Ecuador. METHODS: From June 2014 to December 2017, a cross-sectional study was conducted at the Hospital de Especialidades Eugenio Espejo, a regional reference public hospital for endocrine neoplasia in adults in Quito, Ecuador. We identified the mechanism of detection, histopathology and treatment modalities from a patient interview and review of clinical records. RESULTS: Among 452 patients, 74.8% were young adults and 94.2% (426) were female. 13.7% had a family history of thyroid cancer, and patients' median tumor size was 2 cm. The incidental finding was 54.2% whereas 45.8% was non-incidental. Thyroid cancer histology reported that 93.3% had papillary thyroid cancer (PTC), 2.7% follicular, 1.5% Hurtle cells, 1.6% medullary, 0.7% poor differentiated, and 0.2% anaplastic carcinoma. The mean MACIS (metastasis, age, completeness, invasion, and size) score was 4.95 (CI 4.15-5.95) with 76.2% of the thyroid cancer patients having MACIS score less than or equal to 6. The very low and low risk of recurrence was 18.1% (79) and 62% (271) respectively. An analysis of 319 patients with non-metastatic thyroid cancer showed that 10.7% (34) of patients had surgical complications. Moreover, around 62.5% (80 from 128 patients with thyroglobulin laboratory results) of TC patients had a stimulated-thyroglobulin value equal or higher than 2 ng/ml. Overall, a poor surgical outcome was present in 35.1% (112) patients. Out of 436 patients with differentiated thyroid carcinoma, 86% (375) received radioactive iodine. CONCLUSION: Thyroid cancer histological characteristics and method of diagnosis are like those described in other reports without any evidence of the high frequency of aggressive thyroid cancer histology. However, we observed evidence of overtreatment and poor surgical outcomes that demand additional studies to understand their association with thyroid cancer mortality in Ecuador.

Paradigms about the COVID-19 pandemic: knowledge, attitudes and practices from medical students.

BACKGROUND: As the disease caused by the novel coronavirus has spread globally, there has been significant economic instability in the healthcare systems. This reality was especially accentuated in Ecuador where, the shortage of healthcare workers combined with cultural and macroeconomic factors has led Ecuador to face the most aggressive outbreak in Latin America. In this context, the participation of final-year medical students on the front line is indispensable. Appropriate training on COVID-19 is an urgent requirement that universities and health systems must guarantee. We aimed to describe the knowledge, attitudes, and practices of Ecuadorian final-year medical students that could potentially guide the design of better medical education curricula regarding COVID-19. METHODS: This was a cross-sectional 33-item online survey conducted between April 6 to April 2020 assessing the knowledge, attitudes, and practices toward the diagnosis, treatment, prevention, and prognosis toward COVID-19 in Ecuadorian final-year medical students. It was sent by email, Facebook, and WhatsApp. RESULTS: A total of 309 students responded to the survey. Out of which 88% of students scored high (≥ 70% correct) for knowledge of the disease. The majority of students were pessimistic about possible government actions, which is reflected in the negative attitude towards the control of COVID-19 and volunteering during the outbreak in Ecuador (77%, and 58% of the students, respectively). Moreover, 91% of students said they did not have adequate protective equipment. The latter finding was significantly associated with negative attitudes. CONCLUSIONS: Although a large number of students displayed negative attitudes, the non-depreciable percentage of students who were willing to volunteer and the coexisting high level of knowledge displayed by students, suggests that Ecuador has a capable upcoming workforce that could benefit from an opportunity to strengthen, improve and advance their training in preparation for COVID-19. Not having personal protective equipment was significantly associated to negative attitudes. Providing the necessary tools and creating a national curriculum may be one of the most effective ways to ensure all students are trained, whilst simultaneously focusing on the students' most pressing concerns. With this additional training, negative attitudes will improve and students will be better qualified.

Management of High Output Enterocutaneous Fistula due to Richter's Hernia After Gastric Bypass: Video Demonstration.

INTRODUCTION: The increase in laparoscopic surgery in patients with obesity increases the incidence of trocar site hernia (TSH). Therefore, TSH represents a risk for the development of Richter's hernia (RH). METHODS: We present the unusual case of a postoperative gastric bypass patient complicated with a high output enterocutaneous fistula through a trocar site wound. RESULTS: The Laparoscopic surgery consists of an RH reduction, enterotomy, and repair of the preperitoneal space. CONCLUSION: RH complicated by high-output enterocutaneous fistula has not been previously reported. It is essential to close the preperitoneal space in bariatric surgery to avoid these complications.

Canal wall up versus canal wall down mastoidectomy techniques in the pediatric population with cholesteatoma: A systematic review and meta-analysis of comparative studies.

IMPORTANCE: The optimal surgical management of cholesteatoma remains controversial. Within pediatric otolaryngology, one of the most vital points of contention is the selection of canal wall-up (CWU) versus canal wall-down (CWD) procedures. Pediatric cholesteatoma has high rates of recurrence (16%-54%). In adults, there is evidence that the selection of surgical techniques affects recurrence rates. This has not been shown in children. OBJECTIVES: 1. To systematically review the literature on recurrent and residual cholesteatoma after CWU and CWD in children and perform a meta-analysis of the data. 2. To assess the rates of recurrent and residual cholesteatoma between CWU and CWD techniques in pediatric patients. 3. To assess hearing outcomes by evaluating postoperative differences in the air-bone gap (ABG) between CWU and CWD techniques. DATA SOURCES: A systematic search of PubMed, Embase, Scopus, and Cochrane Collaboration was performed from inception to May 1st, 2020, to identify studies that compared CWU and CWD procedures for acquired cholesteatoma in children. STUDY SELECTION: Search records were screened in duplicate by four reviewers. Inclusion criteria consisted of comparative randomized clinical trials and observational studies assessing outcomes of CWU and CWD techniques in the pediatric population. Studies involving patients with congenital cholesteatoma were excluded. DATA EXTRACTION AND SYNTHESIS: Four reviewers working independently and in duplicate systematically reviewed and extracted study data. Dichotomous variables were analyzed as risk ratios (RR), while continuous variables were compared using weighted mean differences (MD). The risk of bias was assessed using the CLARITY Scale. PRIMARY OUTCOMES AND MEASURES: The outcomes were recurrence, residual disease, air-bone gap (ABG), and air conductive (AC) thresholds. RESULTS: After screening 1036 publications, 17 retrospective cohort studies were selected. 1333 children were included; the overall mean age was ten years (SD 7.9), and the overall mean follow-up time was 5.9 years (SD 6.6). CWU and CWD techniques were performed in 60% (796) and 40% (537) cases. We did not find differences in cholesteatoma recurrence (RR: 1.50, 95% CI 0.94; 2.40; n = 544; I2 0%; Tau [2]: 0.00), or rates of residual cholesteatoma (RR 1.51, 95% CI 0.96; 2.38, n = 506; I2: 0%; Tau [2]: 0.00) in patients who underwent CWU and CWD mastoidectomy. The mean air-bone gap was lower with CWU than CWD (mean difference: 7.60, 95% CI -10.65; -4.54; n = 242; I2: 71%; Tau [2]: 5.98). CONCLUSION: and relevance: We show similar rates of recurrence and residual disease after either CWU or CWD tympanoplasty. Our results challenge the fundamental principle of CWD surgery as a standard technique, as there is no difference in rates of recurrence and residual disease in CWU and CWD. Moreover, audiometric results support CWU with improved hearing outcomes. TRIAL REGISTRATION: PROSPERO identifier: CRD42020184029.

Identification of KIT and BRAF mutations in thyroid tissue using next-generation sequencing in an Ecuadorian patient: A case report.

Background: The incidence of thyroid cancer has increased worldwide. Ecuador presents the highest incidence among Latin American countries and the second around the world. Genetic alteration is the driving force for thyroid tumorigenesis and progression. The change from valine (V) to glutamic acid (E) at codon 600 of the BRAF gene (BRAFVal600Glu) is the most commonly reported mutation in thyroid cancer. Moreover, the BRAF mutation is not the only mutation that has been correlated with TC. For instance, mutations and overexpression of the KIT gene has been associated with different types of cancer, including lung and colon cancer, and neuroblastoma. Case presentation: A woman in her early fifties, self-identified as mestizo, from Otavalo, Imbabura-Ecuador had no systemic diseases and denied allergies, but she had a family history of a benign thyroid nodule. Physical examination revealed a thyroid gland enlargement. The fine-needle aspiration biopsy indicated papillary thyroid cancer. The patient underwent a successful total thyroidectomy with an excellent recovery and no additional treatments after surgery. Using Next-Generation sequencing a heterozygous mutation in the BRAF gene, causing an amino acid change Val600Glu was identified. Similarly, in the KIT gene, a heterozygous mutation resulting in an amino acid change Leu678Phe was detected. Moreover, an ancestry analysis was performed, and the results showed 3.1% African, 20.9% European, and 76% Native American ancestry. Conclusions: This report represents the genetic characteristics of papillary thyroid cancer in an Ecuadorian woman with a mainly Native American ethnic component. Further studies of pathological variants are needed to determine if the combined demographic and molecular profiles are useful to develop targeted treatments focused on the Ecuadorian population.

Robotic Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis.

The introduction of robotics in living donor liver transplantation has been revolutionary. We aimed to examine the safety of robotic living donor right hepatectomy (RLDRH) compared to open (ODRH) and laparoscopic (LADRH) approaches. A systematic review was carried out in Medline and six additional databases following PRISMA guidelines. Data on morbidity, postoperative liver function, and pain in donors and recipients were extracted from studies comparing RLDRH, ODRH, and LADRH published up to September 2020; PROSPERO (CRD42020214313). Dichotomous variables were pooled as risk ratios and continuous variables as weighted mean differences. Four studies with a total of 517 patients were included. In living donors, the postoperative total bilirubin level (MD: −0.7 95%CI −1.0, −0.4), length of hospital stay (MD: −0.8 95%CI −1.4, −0.3), Clavien−Dindo complications I−II (RR: 0.5 95%CI 0.2, 0.9), and pain score at day > 3 (MD: −0.6 95%CI −1.6, 0.4) were lower following RLDRH compared to ODRH. Furthermore, the pain score at day > 3 (MD: −0.4 95%CI −0.8, −0.09) was lower after RLDRH when compared to LADRH. In recipients, the postoperative AST level was lower (MD: −0.5 95%CI −0.9, −0.1) following RLDRH compared to ODRH. Moreover, the length of stay (MD: −6.4 95%CI −11.3, −1.5) was lower after RLDRH when compared to LADRH. In summary, we identified low- to unclear-quality evidence that RLDRH seems to be safe and feasible for adult living donor liver transplantation compared to the conventional approaches. No postoperative deaths were reported.

Inappropriate use of thyroid ultrasound: a systematic review and meta-analysis.

PURPOSE: Nearly half the cases of thyroid cancer, a malignancy rapidly rising in incidence within the United States, are attributable to small and asymptomatic papillary thyroid cancers that will not increase mortality. A primary driver of thyroid cancer overdiagnosis is ultrasound use. It is therefore valuable to understand how inappropriate use of thyroid ultrasound is defined, analyze the current evidence for its frequency, and identify interventions to lessen misuse. METHODS: Ovid MEDLINE(R), Ovid EMBASE, and Scopus databases were searched from inception to June 2020 for studies assessing inappropriate use of thyroid ultrasound. Reviewers, working independently and in duplicate, evaluated studies for inclusion, extracted data, and graded risk of bias. We used a random-effects model with a generalized linear mixed approach to calculate the mean overall proportion estimates of inappropriate use. RESULTS: Seven studies (total n = 1573) met the inclusion criteria with moderate to high risk of bias. Inappropriate thyroid ultrasound use was described variably, using published practice guidelines, third-party expert reviewers, or author interpretations of the literature. The overall frequency of inappropriate thyroid ultrasound use was 46% (95% CI 15-82%; n = 388) and 34% (95% CI 16-57%; n = 190) among studies using guideline based definitions. The pooled frequency of iUS due to thyroid dysfunction (either hypothyroidism or thyrotoxicosis) was 17% (95% CI 7-37%; n = 191) and the frequency of iUS due to nonspecific symptoms without a palpable mass was 11% (95% CI 5-22%; n = 124). No study examined interventions to address inappropriate use. CONCLUSIONS: Low quality evidence suggests that inappropriate use of thyroid ultrasound is common. Interventional studies aiming to decrease the inappropriate use of thyroid ultrasound are urgently needed.

Impact of the Surgical Approach to Thymectomy Upon Complete Stable Remission Rates in Myasthenia Gravis: A Meta-analysis.

OBJECTIVES: To determine whether the available operative techniques for thymectomy in myasthenia gravis (MG) confer variable chances for achieving complete stable remission (CSR), we performed a meta-analysis of comparative studies of surgical approaches to thymectomy. METHODS: Meta-analysis was done of all studies providing comparative data on thymectomy approaches, with CSR reported and minimum 3-year mean follow-up. RESULTS: Twelve cohort studies and 1 randomized clinical trial, containing 1,598 patients, met entry criteria. At 3 years, CSR from MG was similar after video-assisted thoracoscopic (VATS) extended vs both basic (relative risk [RR] 1.00, p = 1.00, 95% confidence interval [CI] 0.39-2.58) and extended (RR 0.96, p = 0.74, 95% CI 0.72-1.27) transsternal approaches. CSR at 3 years was also similar after extended transsternal vs combined transcervical-subxiphoid (RR 1.08, p = 0.62, 95% CI 0.8-1.44) approaches. VATS extended approaches remained statistically equivalent to extended transsternal approaches through 9 years of follow-up (RR 1.51, p = 0.05, 95% CI 0.99-2.30). The only significant difference in CSR rate between a traditional open and a minimally invasive approach was seen at 10 years when the now-abandoned basic (non-sternum-lifting) transcervical approach was compared to the extended transsternal approach (RR 0.4, p = 0.01, 95% CI 0.2-0.8). CONCLUSIONS: A significant difference in the rate of CSR among various surgical approaches for thymectomy in MG was identified only at long-term follow-up and only between what might be considered the most aggressive approach (extended transsternal thymectomy) and the least aggressive approach (basic transcervical thymectomy). Extended minimally invasive approaches appear to have CSR rates equivalent to those of extended transsternal approaches and are therefore appropriate in the hands of experienced surgeons.

Safety of laparoscopic cholecystectomy in patients older than 90 years in a private hospital in Ecuador: A case series.

ANTECEDENTES: La tasa de litiasis biliar y sus complicaciones son mayores en los ancianos. Algunos autores describen la edad como un factor principal que aumenta significativamente la morbilidad y la mortalidad de los pacientes sometidos a colecistectomía. OBJETIVO: Describir la seguridad de la colecistectomía laparoscópica centrándose en su tasa de complicaciones y de conversión en pacientes mayores de 90 años, en un hospital privado de un país en desarrollo. MÉTODO: Esta serie de casos incluyó pacientes mayores de 90 años diagnosticados de colecistitis aguda según los criterios Tokio 2013. Todos fueron sometidos a colecistectomía laparoscópica entre enero de 2010 y diciembre de 2016 en el Hospital Vozandes Quito (Ecuador). Se informaron las frecuencias y los porcentajes, y la media, para las variables categóricas y numéricas, respectivamente. RESULTADOS: Se incluyeron 15 pacientes con edades comprendidas entre los 90 y 96 años. Hubo tres complicaciones posoperatorias, dos casos de shock hipovolémico secundario a sangrado que remitieron sin reoperación (13%) y uno de delirio (7%). Se realizó conversión quirúrgica en dos pacientes (13%) debido a la imposibilidad de visualizar las estructuras anatómicas y lograr una visión crítica adecuada de seguridad por flemón vesicular. CONCLUSIÓN: La colecistectomía laparoscópica parece ser un enfoque seguro, con unas tasas de conversión y de complicaciones relativamente bajas, en los pacientes mayores de 90 años. BACKGROUND: The rate of biliary lithiasis and its complications are higher in the elderly. Some authors describe age as the main factor that significantly increases the morbidity and mortality of patients undergoing cholecystectomy. OBJECTIVE: The objective of this study was to describe the safety of laparoscopic cholecystectomy, focusing on complication and conversion rates in patients older than 90 years, in a private hospital of a developing country. MATERIALS AND METHODS: This case-series enrolled patients older than 90 years diagnosed with acute cholecystitis using the Tokyo 2013 criteria. All included patients underwent laparoscopic cholecystectomy from January 2010 to December 2016 at Vozandes Hospital Quito-Ecuador. Frequencies and percentages and mean were reported for categorical and numerical variables, respectively. RESULTS: We included 15 patients aged between 90 and 96 years. There were three post-operative complications, two cases of hypovolemic shock secondary to bleeding that stop without reoperation (13%) and 1 of delirium (7%). Conversion was performed in two patients (13%) due to the impossibility of visualizing the anatomical structures and obtain an adequate critical view of safety due to gallbladder phlegmon. CONCLUSION: Laparoscopic cholecystectomy seems to be a safe approach, with relatively low complication and conversion rates in patients older than 90 years.

Triggers of thyroid cancer diagnosis: a systematic review and meta-analysis.

PURPOSE: Understanding the method of thyroid cancer detection has potential implications on interpreting incidence rates, the diagnosis and management of thyroid cancer. We conducted a systematic review of studies reporting methods of thyroid cancer detection to estimate the frequency of incidentally found cancers and classify triggers of incidental thyroid cancer diagnosis. METHODS: We searched multiple bibliographic databases from inception to June 2020. A pair of reviewers, working independently and in duplicate selected studies for inclusion, extracted data, and evaluated each trial's risk of bias. Studies enrolling patients older than 18 years with thyroid cancer confirmed histologically were included. RESULTS: In total, 17 cohorts and 1 cross-sectional study, conducted between 1991 and 2018, enrolling 4668 patients with thyroid cancer were included: 88% had papillary thyroid cancer and 23% had papillary thyroid microcarcinoma. The proportion of patients with non-incidental and incidental thyroid cancer was similar: 49% [95% confidence interval (CI): 40-58%]. Subgroup analysis showed that most patients with incidental thyroid cancers had tumor size <10 mm (76%; 95% CI: 56-92%), age >45 (61%; 95% CI: 56-67%), and were detected through imaging (35%; 95% CI: 26-45%), of which ultrasound was the most common modality (27%; 95% CI: 14-43%). The heterogeneity for all the effect sizes was large and significant. CONCLUSIONS: About half of thyroid cancers were found incidentally through the use of imaging studies, in particular neck ultrasound. These incidentally found cancers were mostly small papillary thyroid cancer. These results highlight opportunities for interventions aimed at reducing drivers of overdiagnosis.

Surgical multicenter collaborative studies: ¿What happen in Latin America?

BACKGROUND: GlobalSurg is an international group of researchers whose purpose is to conduct and disseminate robust collaborative, international and multicenter studies. OBJECTIVE: To expose the necessary strategies and the barriers crossed in conducting massive multicenter studies in surgery. METHOD: During the second semester of 2020, the study Surg-Week Prospective International Cohort Study was carried out. Surg-Week has been the largest international study in the field of surgery to date, with 141,582 patients included. A total of 4975 mini-teams, of between 1 and 5 members, collected data from 116 countries on all continents. RESULTS: The creation of an official website for the study, reports with relevant information via email or groups via WhatsApp, formation of a Dissemination Committee of the protocol, delivery of webinars on recent team publications, appointment of leaders at the national and international level, and outreach through partnerships, were the strategies used for the development of the research. However, the barriers turned out to involve different aspects. CONCLUSIONS: Collaborative work allows establishing networks between different professionals with the goal of improving the quality of management, health policies and care of our patients in a timely manner of constant change.

ANTECEDENTES: GlobalSurg es un grupo internacional de investigadores que tiene como propósito la conducción y la diseminación de robustos estudios colaborativos, internacionales y multicéntricos. OBJETIVO: Exponer las estrategias necesarias y las barreras encontradas en la conducción de estudios multicéntricos masivos en cirugía. MÉTODO: Durante el segundo semestre del año 2020 se llevó a cabo el estudio Surg-Week Prospective International Cohort Study, hasta la fecha el estudio internacional más grande en el campo de la cirugía, con 141,582 pacientes incluidos. Un total de 4975 miniequipos, de uno a cinco integrantes, recopilaron datos de 116 países de todos los continentes. RESULTADOS: La creación de un sitio web oficial del estudio, reportes con información relevante vía e-mail o grupos vía WhatsApp, conformación de un comité de diseminación del protocolo, dictado de webinars sobre publicaciones recientes del equipo, designación de líderes nacionales e internacionales, y la divulgación por medio de sociedades, fueron las estrategias utilizadas para el desarrollo de la investigación. Sin embargo, las barreras detectadas para llevar a cabo el estudio multicéntrico fueron variadas. CONCLUSIONES: Los trabajos colaborativos permiten establecer redes entre diferentes profesionales con el fin de mejorar la calidad de la gestión, las políticas sanitarias y la atención a los pacientes en tiempos de constante cambio.

Major complications after tongue-tie release: A case report and systematic review.

INTRODUCTION: The diagnosis of ankyloglossia, or tongue-tie, and the number of frenotomies performed has increased over 10-fold from 1997 to 2012 in the United States. The sharpest increase has been in neonates. For parents considering frenotomy for their breastfeeding newborn, there is controversy surrounding the evaluation of tongue-tie and the benefit of a frenotomy. Complications from tongue-tie procedures are thought to be low, though it is not well reported nor studied. OBJECTIVES: The aim of this study is to describe a case of a sublingual mucocele after laser frenotomy in a neonate with tongue-tie and to investigate major complications reported after tongue-tie release in pediatric patients through a systematic review of the literature. CASE REPORT: We present a 6-week-old female who underwent a laser frenotomy procedure performed by a dentist who presented with a new cyst under her tongue. MATERIAL AND METHODS: A systematic literature search of articles published from 1965 to April 2020 was conducted in Ovid MEDLINE(R), Ovid EMBASE, and Scopus. Citations were uploaded into a systematic review software program (DistillerSR, Ottawa, ON, Canada), followed by full text screening. RESULTS: 47 major complications were reported in 34 patients, including our patient. Most of the cases were located in the United States and Europe. The most frequent indications for the procedure were breastfeeding problems (n = 18) and speech impediment (n = 4). The procedure was performed by dentists (n = 6), lactation consultants (n = 5), and otolaryngologists (n = 4). The bulk of the major complications after frenotomy included poor feeding (n = 7), hypovolemic shock (n = 4), apnea (n = 4), acute airway obstruction (n = 4), and Ludwig angina (n = 2). CONCLUSIONS: Reporting of complications after frenotomy is lacking. Risks to neonates may be different than risks to older children and adults. Practitioners across different specialties should be monitoring and studying this more rigorously to better guide patients and families on the risks and benefits of this procedure.