Assessing Knowledge and Perceptions of Colorectal Cancer Screening in Armenia.

BACKGROUND: Armenia has a high incidence of and mortality from colorectal cancer (CRC). No organized screening programs for CRC exist in Armenia. This study seeks to evaluate knowledge of and attitudes toward CRC and screening programs in Armenia. METHODS: Adults aged 40-64 y were administered a survey using convenience sampling throughout polyclinics in Yerevan city. Survey questions were based on the Health Belief Model and were translated and modified for local relevance. RESULTS: A total of 368 surveys were completed. Eighty-four percent had knowledge of CRC, 91% believed that early detection leads to improved outcomes, but only 22% had knowledge of screening. Women were more likely to have knowledge of CRC (odds ratio 2.19, P < 0.05). Although 19% have personally worried about having CRC, only 7% admitted to discussing their worries with a provider and 76% were willing to undergo screening if recommended by their doctor. Seventy-eight percent of respondents would only undergo screening if free or less than ~$20 USD. CONCLUSIONS: Self-reported knowledge of CRC is high, whereas knowledge of screening remains low in Armenia. There is a willingness to undergo screening if recommended by a health care professional; however, this willingness is cost-sensitive. Interventions aimed at (1) increasing awareness of the disease and screening tests, (2) improving physician counseling, and (3) reducing financial barriers to screening should be considered along with the implementation of a national screening program in Armenia.

Statewide Impact of the COVID Pandemic on Pediatric Appendicitis in California: A Multicenter Study.

BACKGROUND: The COVID-19 pandemic has resulted in delays in presentation for other urgent medical conditions, including pediatric appendicitis. Several single-center studies have reported worse outcomes, but no state-level data is available. We aimed to determine the statewide effect of the COVID-19 pandemic on the presentation and management of pediatric appendicitis patients. MATERIALS AND METHODS: Patients < 18 years old with acute appendicitis at four tertiary pediatric hospitals in California between March 19, 2020 to September 19, 2020 (COVID-era) were compared to a pre-COVID cohort (March 19, 2019 to September 19, 2019). The primary outcome was the rate of perforated appendicitis. Secondary outcomes were symptom duration prior to presentation, and rates of non-operative management. RESULTS: Rates of perforated appendicitis were unchanged (40.4% of 592 patients pre-COVID versus 42.1% of 606 patients COVID-era, P = 0.17). The median symptom duration was 2 days in both cohorts (P = 0.90). Computed tomography (CT) use rose from 39.8% pre-COVID to 49.4% during COVID (P = 0.002). Non-operative management increased during the pandemic (8.8% pre-COVID versus 16.2% COVID-era, P < 0.0001). Hospital length of stay (LOS) was longer (2 days pre-COVID versus 3 days during COVID, P < 0.0001). CONCLUSIONS: Pediatric perforated appendicitis rates did not rise during the first six months of the COVID-19 pandemic in California in this multicenter study, and there were no delays in presentation noted. There was a higher rate of CT scans, non-operative management, and longer hospital lengths of stay.

The Heterogeneity of Global Pediatric Surgery: Defining Needs and Opportunities Around the World.

BACKGROUND: The global burden of pediatric surgical conditions continues to remain inadequately addressed, particularly in low- and middle-income countries. Among the many factors contributing to this gap are a lack of access to care secondary to resource shortages and inequitable distribution, underfinancing of healthcare systems, poor quality of care, and contextual challenges such as natural disasters and conflict. The relative contribution of these and other factors varies widely by region and even with countries of a region. METHODS: This review seeks to discuss the heterogeneity of global pediatric surgery and offer recommendations for addressing the barriers to high-quality pediatric surgical care throughout the world. RESULTS: There is significant heterogeneity in pediatric surgical challenges, both between regions and among countries in the same region, although data are limited. This heterogeneity can reflect differences in demographics, epidemiology, geography, income level, health spending, historical health policies, and cultural practices, among others. CONCLUSION: Country-level research and stakeholder engagement are needed to better understand the heterogeneity of local needs and drive policy changes that contribute to sustainable reforms. Key to these efforts will be improved financing, access to and quality of pediatric surgical care.

Feasibility and scalability of spring parameters in distraction enterogenesis in a murine model.

BACKGROUND: Distraction enterogenesis has been investigated as a novel treatment for short bowel syndrome (SBS). With variable intestinal sizes, it is critical to determine safe, translatable spring characteristics in differently sized animal models before clinical use. Nitinol springs have been shown to lengthen intestines in rats and pigs. Here, we show spring-mediated intestinal lengthening is scalable and feasible in a murine model. MATERIALS AND METHODS: A 10-mm nitinol spring was compressed to 3 mm and placed in a 5-mm intestinal segment isolated from continuity in mice. A noncompressed spring placed in a similar fashion served as a control. Spring parameters were proportionally extrapolated from previous spring parameters to accommodate the smaller size of murine intestines. After 2-3 wk, the intestinal segments were examined for size and histology. RESULTS: Experimental group with spring constants, k = 0.2-1.4 N/m, showed intestinal lengthening from 5.0 ± 0.6 mm to 9.5 ± 0.8 mm (P < 0.0001), whereas control segments lengthened from 5.3 ± 0.5 mm to 6.4 ± 1.0 mm (P < 0.02). Diameter increased similarly in both groups. Isolated segment perforation was noted when k ≥ 0.8 N/m. Histologically, lengthened segments had increased muscularis thickness and crypt depth in comparison to normal intestine. CONCLUSIONS: Nitinol springs with k ≤ 0.4 N/m can safely yield nearly 2-fold distraction enterogenesis in length and diameter in a scalable mouse model. Not only does this study derive the safe ranges and translatable spring characteristics in a scalable murine model for patients with short bowel syndrome, it also demonstrates the feasibility of spring-mediated intestinal lengthening in a mouse, which can be used to study underlying mechanisms in the future.

Breast Cancer Awareness and Screening Perceptions of Women in Yerevan, Armenia.

Objectives: Breast cancer is the leading cause of female cancer mortality in Armenia. The government is considering covering breast cancer screening, but prevailing attitudes towards it are unknown. This cross-sectional study assessed Armenian women's awareness and perceptions of breast cancer screening. Methods: We administered a validated telephone survey to women ages 35-65 registered in Yerevan's polyclinic system between 2019-2021, assessing sociodemographic characteristics, breast cancer exposure and screening attitudes, using an adapted Champion's Health Belief Model Scale (CHBMS). We analyzed the association, unadjusted and adjusted, between sociodemographic characteristics, screening exposure, and CHBMS scores. Results: 170 women completed surveys. Most (82.9%) were aware of screening, 48.5% knew someone with breast cancer, but only 42.5% had undergone screening, predominantly without their physician's recommendation (63.2%). Despite elevated awareness, 76.2% had never discussed screening with their provider. Barriers included cost and mistreatment concerns. Education consistently predicted prior screening and most CHBMS scores. Conclusion: Armenian women are highly exposed to breast cancer, but knowledge and prior screening primarily emanate from non-physician sources. Results highlighted the influence of education, patient-provider relationships, and healthcare costs, underscoring the importance of multi-level interventions.

Non-Operative Management of Uncomplicated Appendicitis in Children: Can Patients Be Discharged From the Emergency Department?

INTRODUCTION: Non-operative management of uncomplicated appendicitis in children is a safe alternative to laparoscopic appendectomy. The purpose of this study is to determine the feasibility of nonoperative outpatient management of uncomplicated appendicitis in pediatric patients. METHODS: A standardized pathway for non-operative outpatient management of uncomplicated appendicitis in children (NOMA-C) was implemented in a university pediatric surgery practice starting October 2021. Those who met criteria would be considered for discharge from the emergency department (ED) with oral antibiotics and close followup over the following year. A quality improvement project started concurrently to monitor patients for recurrent symptoms of appendicitis. RESULTS: A total of 121 patients were diagnosed with acute appendicitis during the study period (October 2021 to April 2023). Forty-five children (38%) met criteria for the NOMA-C protocol, and 11 patients/families chose appendectomy. Of the 34 patients who pursued nonoperative management, 14 patients were admitted to the hospital and 20 patients were discharged from the ED. Total time in the ED/hospital was significantly shorter for patients discharged from the ED (7 hours versus 23 hours; p<0.001). At one year follow up only 4 (12%) had undergone appendectomy. There were no adverse events for patients who underwent nonoperative management. CONCLUSION: A protocol offering non-operative management of appendicitis with an option for outpatient management was feasible and safe. Outpatient management was associated with shorter ED/hospital stays than those admitted. Future studies should evaluate whether this protocol can be adopted by EDs without pediatric surgery services to avoid the need for transfer.

Six Years of Quality Improvement in Pectus Excavatum Repair: Implementation of Intercostal Nerve Cryoablation and ERAS Protocols for Patients Undergoing Nuss Procedure.

BACKGROUND: The Nuss procedure for pectus excavatum is associated with prolonged hospitalizations due to pain. We evaluated implementation of intercostal nerve cryoablation and enhanced recovery after surgery (ERAS) protocols on outcomes of Nuss procedures performed over six years at a single institution. METHODS: This retrospective cohort study included patients who underwent Nuss procedure from 10/2017 to 09/2023. Patients received epidurals prior to 06/2019, cryoablation from 06/2019 to 07/2021, and ERAS with cryoablation and intraoperative methadone administration after 07/2021. We used multivariable linear regression to evaluate length of stay (LOS), inpatient morphine milligram equivalents (MMEs), and discharge opioids. We assessed the balancing measures of operative time, postoperative pain scores, and complications. RESULTS: We identified 62 patients; 15 who received epidurals, 18 cryoablation, and 29 cryoablation with ERAS. Cryoablation was associated with a 62.3% (p < 0.001) decrease in length of stay, an 86.6% (p < 0.001) decrease in inpatient MMEs, and a 72.9% (p < 0.001) decrease in discharge opioids. Cryoablation was additionally associated with 24.5% (p = 0.02) longer operative times and 46.4% (p = 0.04) higher postoperative day one pain scores. Subsequent implementation of an ERAS protocol was associated with a further 82.8% (p = 0.04) decrease in discharge opioids and a 25.0% (p = 0.04) decrease in postoperative day one pain scores. CONCLUSIONS: Over six years of quality improvement efforts, we found the implementation of cryoablation and ERAS protocols to be associated with a significant decrease in length of stay and opioid exposures. Protocolized pain management and cryoablation may work synergistically to improve outcomes without compromising patient experience. LEVEL OF EVIDENCE: Level III - Retrospective comparative study.

Managing Patients With COVID-19 in Armenia Using a Remote Monitoring System: Descriptive Study.

BACKGROUND: The COVID-19 pandemic has imposed immense stress on global health care systems, especially in low- and middle-income countries (LMICs). Armenia, a middle-income country in the Caucasus region, contended with the pandemic and a concurrent war, resulting in significant demand on its already strained health care infrastructure. The COVID@home program was a multi-institution, international collaboration to address critical hospital bed shortages by implementing a home-based oxygen therapy and remote monitoring program. OBJECTIVE: The objective of this study was to describe the program protocol and clinical outcomes of implementing an early discharge program in Armenia through a collaboration of partner institutions, which can inform the future implementation of COVID-19 remote home monitoring programs, particularly in LMICs or low-resource settings. METHODS: Seven hospitals in Yerevan participated in the COVID@home program. A web app based on OpenMRS was developed to facilitate data capture and care coordination. Patients meeting eligibility criteria were enrolled during hospitalization and monitored daily while on oxygen at home. Program evaluation relied on data extraction from (1) eligibility and enrollment forms, (2) daily monitoring forms, and (3) discharge forms. RESULTS: Over 11 months, 439 patients were screened, and 221 patients were managed and discharged. Around 94% (n=208) of participants safely discontinued oxygen therapy at home, with a median home monitoring duration of 26 (IQR 15-45 days; mean 32.33, SD 25.29) days. Women (median 28.5, mean 35.25 days) had similar length of stay to men (median 26, mean 32.21 days; P=.75). Despite challenges in data collection and entry, the program demonstrated feasibility and safety, with a mortality rate below 1% and low re-admission rate. Opportunities for operational and data quality improvements were identified. CONCLUSIONS: This study contributes practical evidence on the implementation and outcomes of a remote monitoring program in Armenia, offering insights into managing patients with COVID-19 in resource-constrained settings. The COVID@home program's success provides a model for remote patient care, potentially alleviating strain on health care resources in LMICs. Policymakers can draw from these findings to inform the development of adaptable health care solutions during public health crises, emphasizing the need for innovative approaches in resource-limited environments.

Colorectal Cancer: A Systematic Review of the Current Situation and Screening in North and Central Asian Countries.

The prevalence of colorectal cancer (CRC) is increasing in the past few decades. A significant proportion of this increase is from low to middle income countries (LMIC). CRC prevalence is also increasing in North and Central Asian Countries (NCAC). Screening for colorectal cancer has decreased CRC mortality but data regarding screening practices in NCAC is limited.  A literature search was conducted in PubMed/Medline, Embase and Cochrane for current colorectal cancer screening practices in NCAC. Incidence and mortality rates were derived from public health agency websites to calculate age-standardized CRC mortality-to-incidence ratios. Web-based online break-point testing defined as statistical major changes in CRC mortality trends was completed. Among the 677 screened studies, 37 studies met the criteria for inclusion for review. CRC screening in NCAC is not organized, although most countries have cancer registries. The data availability is scarce, and most data is prior to 2017. Most studies are observational. There is minimal data about colonoscopy preparations, adenoma detection and complications rates. The polyp detection rates (PDRs) and adenoma detection rates (ADRs) seem low to optimal in this region. Commonly measured outcomes include participation rate, fecal immunochemical tests (FIT) positivity rate and cost-benefit measures. Lower mortality-to-incidence ratios is seen in countries with screening programs. Kazakhstan and Lithuania with screening programs have achieved breakpoint suggesting major changes in CRC mortality trends. Data about CRC screening varies widely within NCAC. High human developmental index (HDI) countries like Lithuania and Estonia have higher incidence of CRC and mortality. Seven NCAC have CRC screening programs with most utilizing non-invasive methods for screening. Data collection is regional and not organized. The ADR and PDR are low to optimal in this region and cancer detection rates are comparable to other high-income countries (HIC). CRC detection rate is 0.05% for screening in Kazakhstan and 0.2% for screening in Lithuania. Very limited information is available on the actual cost and logistics of implementing a CRC screening program. All NCAC have a cancer registry, with some having a high-quality registry showing national coverage with good validity and completeness. Establishing guideline-based registries and increasing screening efficacy could improve CRC outcomes in NCAC.