A diagnostic dilemma: a case report of concomitant duodenal Dieulafoy lesion and gastric ulcer.

Dieulafoy lesions (DL) are an uncommon cause of gastrointestinal bleeding which is often difficult to diagnose due to the rarity of the condition and varying clinical presentations. This case describes an unusual presentation of upper gastrointestinal bleeding in an 85-year-old female with findings on two separate gastroscopies of both a gastric ulcer and duodenal DL. The pathophysiology of DL remains poorly understood and despite shared risk factors, these two pathologies are rarely reported concurrently. The presence of a concomitant gastric ulcer further complicated the diagnosis and treatment of the duodenal DL in this case. This highlights the importance of clinician awareness of this pathology and its presentation and the need for early repeat endoscopy.

Internal Bra: A literature Review and Sub-Classification of Definitions.

BACKGROUND: The term 'internal bra' refers to a range of techniques that aim to stabilise the position of the breast and improve longevity of surgical results. It is increasingly being used to describe techniques in surgical literature and on patient information platforms, including social media. However a lack of consistency in the use of the term is a potential source of confusion and conflicting information. OBJECTIVES: This narrative review aims to improve understanding of what is meant by the term 'internal bra', by providing an overview of the different techniques it refers to and suggesting more specific terminology for use going forward. METHODS: A literature search of the Medline, Embase, and Google Scholar databases was conducted to identify papers in which a surgical technique was described using the term 'internal bra'. RESULTS: 'Internal bra' techniques can be categorised into 5 groups: mesh techniques, acellular dermal matrix techniques, suture techniques, dermal flap techniques, and muscle techniques. Promising results exist for techniques in each group; however, research is generally limited by small studies with short follow up periods, and significant inconsistencies exist in use of the term 'internal bra'. CONCLUSIONS: The titles of the five groups identified in this paper should be used going forward when discussing 'internal bra' techniques, in order to bring greater clarity to both surgical literature and patient information. Further research is also required to establish if 'internal bra' techniques truly improve longevity of surgical results and if one technique, or group of techniques, is superior. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Physician-Targeted Interventions Reduce Surgical Expense and Improve Value-Driven Health Outcomes.

INTRODUCTION: Increasing health-care costs in the United States have not translated to superior outcomes in comparison to other developed countries. The implementation of physician-targeted interventions to reduce costs may improve value-driven health outcomes. This study aimed to evaluate the effectiveness of physician-targeted interventions to reduce surgical expenses and improve care for patients undergoing total thyroidectomies. METHODS: Two separate face-to-face interventions with individual surgeons focusing on surgical expenses associated with thyroidectomy were implemented in two surgical services (endocrine surgery and otolaryngology) by the surgical chair of each service in Jun 2016. The preintervention period was from Dec 2014 to Jun 2016 (19 mo, 352 operations). The postintervention period was from July 2016 to January 2018 (19 mo, 360 operations). Descriptive statistics were utilized, and differences-in-differences were conducted to compare the pre and postintervention outcomes including cost metrics (total costs, fixed costs, and variable costs per thyroidectomy) and clinical outcomes (30-d readmission rate, days to readmission, and total length of stay). RESULTS: Patient demographics and characteristics were comparable across pre- and post-intervention periods. Post-intervention, both costs and clinical outcomes demonstrated improvement or stability. Compared to otolaryngology, endocrine surgery achieved additional savings per surgery post-intervention: mean total costs by $607.84 (SD: 9.76; P < 0.0001), mean fixed costs by $220.21 (SD: 5.64; P < 0.0001), and mean variable costs by $387.82 (SD: 4.75; P < 0.0001). CONCLUSIONS: Physician-targeted interventions can be an effective tool for reducing cost and improving health outcomes. The effectiveness of interventions may differ based on specialty training. Future implementations should standardize these interventions for a critical evaluation of their impact on hospital costs and patient outcomes.

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why.

Background: Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub-Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme. Methods: We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme. Results: N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts. Conclusions: The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006.

The "No bed syndrome" in Ghana - what, how and why? A literature, electronic and print media review.

Objectives: "No bed syndrome" has become a familiar phrase in Ghana. Yet, there is very little in medical texts or the peer reviewed literature about it. This review aimed to document what the phrase means in the Ghanaian context, how and why it occurs, and potential solutions. Design: A qualitative desk review using a thematic synthesis of grey and published literature, print and electronic media content covering the period January 2014 to February 2021. Text was coded line by line to identify themes and sub-themes related to the research questions. Analysis was manual and with Microsoft Excel to sort themes. Setting: Ghana. Participants and Intervention: Not applicable. Results: "No bed syndrome" describes the turning away by hospitals and clinics of people seeking walk in or referral emergency care with the stated reasons "no bed available" or "all beds are full". There are reported cases of people dying while going round multiple hospitals seeking help and being repeatedly turned away because there is "no bed". The situation appears to be most acute in the highly urbanized and densely populated Greater Accra region. It is driven by a complex of factors related to context, health system functions, values, and priorities. The solutions that have been tried are fragmented rather than well-coordinated whole system reform. Discussions and recommendations: The "no bed syndrome" describes the challenge of a poorly functioning emergency health care system rather than just the absence of a bed on which to place an emergency case. Many low and middle income countries have similar challenges with their emergency health care systems and this analysis from Ghana is potentially valuable in attracting global attention and thinking about emergency health systems capacity and reform in low and middle income countries. The solution to the "no bed syndrome" in Ghana requires reform of Ghana's emergency healthcare system that takes a whole system and integrated approach. All the components of the health system such as human resource, information systems, financing, equipment tools and supplies, management and leadership need to be examined and addressed together alongside health system values such as accountability, equity or fairness in the formulation, implementation, continuous monitoring and evaluation of policies and programs for system reform to expand and strengthen emergency healthcare system capacity and responsiveness. Despite the temptation to fall back on them as low hanging fruit, piecemeal and ad-hoc solutions cannot solve the problem.

The Colonoscopy Cookbook: Analysis of effect of a recipe resource on quality and experience of bowel preparation in colonoscopy.

Background High-quality bowel preparation for a colonoscopy improves identification of early lesions in the large bowel, decreases procedure time and increases intervals between colonoscopies. Current recommendations advise a low-residue diet in the days leading up to colonoscopy to improve quality of preparation. This study prepared and provided a recipe resource to patients undergoing colonoscopy and assessed the quality of bowel preparation and patient experience. Patients and methods A "Colonoscopy Cookbook" resource of recipes that comply with the preoperative diet recommendations was created and added to routine preoperative information given to patients undergoing elective colonoscopies at a regional Australian hospital over a 12-month period. Endoscopic reports were reviewed for each case and quality of bowel preparation was classified as "adequate'' or "inadequate". Data collected were compared to a representative local cohort from 2019. Results Procedure reports from 96 patients who were provided with the resource were compared with 96 patients who were not. Adequate bowel preparation was nine times as likely when the resource was available (odds ratio 8.54, 95 % confidence interval: 2.85 to 25.60, P  < 0.001) compared to when it was not. The patient experience was assessed using a post-procedure survey, which demonstrated a positive experience in recipe preparation. Most patients would use the resource prior to future colonoscopies. Conclusions Further randomized controlled trials are required to validate this scoping review. Pre-procedure recipe resources may improve quality of bowel preparation in patients undergoing colonoscopy.

A delayed benign anastomotic stricture after anterior resection for sigmoid adenocarcinoma with concomitant collagenous colitis.

Benign anastomotic strictures most commonly occur within 3-12 months after anterior resection (AR) with chronic symptoms amenable to endoscopic treatment. This case describes an acute large bowel obstruction secondary to a severe delayed benign anastomotic stricture in a 74-year-old female who had previously underwent a laparoscopic AR for sigmoid adenocarcinoma 3 years prior. The pathophysiology of benign anastomotic strictures remains poorly understood. This case was likely multifactorial. Potential contributing factors include anastomotic ischaemia and concomitant collagenous colitis, with inflammation leading to fibrosis and stricture development. Surgical techniques to optimize anastomotic vascularity are important to consider, particularly in older patients with multiple co-morbidities.

Pneumomediastinum and pneumothorax: a rare complication of laparoscopic total extraperitoneal inguinal hernia repair.

Increasing utilization of a laparoscopic total extraperitoneal (TEP) approach for inguinal hernia repairs has led to rare complications. We describe a rare case of subcutaneous emphysema, pneumomediastinum and pneumothorax following a laparoscopic TEP inguinal hernia repair in a 29-year-old male. Mechanisms posited include extraperitoneal carbon dioxide migration via the retroperitoneal space and dissection along the fascia transversalis and endothoracic fascia anteriorly to enter the mediastinum. Intra-operatively the patient coughed vigorously, potentially propagating the extent of extraperitoneal gas dissection and exacerbating these complications. Given the potential morbidity, it is important for surgeons and anaesthetists to recognize these complications.

Necrotising fasciitis: a case series set in rural Australia.

Necrotising fasciitis (NF) is a rapidly progressive infection of soft tissue and fascia. Early diagnosis and prompt extensive surgical debridement decrease mortality. This remains a challenge for rural surgeons who have limited experience with the disease, in a setting where patient transfers to tertiary centres are lengthy and often delayed. To assist clinical decision making in this setting, a case series of five NF presentations in a rural Australian hospital were retrospectively analysed for presentation, investigation, treatment and clinical outcomes. Three underwent abdominal wall debridement and two underwent below knee amputation. Results demonstrate early recognition of NF and the extent of surgical intervention prior to acute transfer are key to successful outcomes. Expedient diagnosis and early extensive debridement at the initial contact reduce mortality and should be the goal of management in this setting.

Factors associated with US and Canadian genetic counselors' testing decisions during pregnancy.

Decision-making regarding prenatal screening and diagnostic testing has become more complex as the number of options has increased, with pregnant patients having access to more information about their pregnancies than ever before. Genetic counselors have extensive training in prenatal genetic screening and testing options, but personal decision-making in this well-informed population remains largely unstudied. This study describes the prenatal testing decisions genetic counselors made during their own pregnancies, and the factors identified as important when making those decisions. A web-based, mixed-methods survey was distributed to members of multiple professional societies for genetic counselors. A total of 318 genetic counselors across numerous specialties in the United States and Canada participated in this study. The satisfaction with decision scale was modified and applied to measure participants' decisional satisfaction. In their most recent pregnancies, most genetic counselors pursued carrier screening (77%) and aneuploidy and/or open neural tube defect screening (88%). A minority of genetic counselors (15%) utilized diagnostic testing. Common factors considered when making testing decisions included wanting information that could impact future decisions, test specifics (e.g., accuracy, methodology, and content), and knowledge gained from participants' genetic counseling background. The uptake of diagnostic testing among prenatal genetic counselors was significantly greater (p < 0.05) than the uptake among genetic counselors in other specialties. This informed study population largely self-directed their own prenatal care, leading to high satisfaction with their decisions. Data in this study provide evidence for promoting participation in prenatal screening and testing decision-making to maximize decisional satisfaction.

The Role of the Private Sector in the COVID-19 Pandemic: Experiences From Four Health Systems.

As societies urbanize, their populations have become increasingly dependent on the private sector for essential services. The way the private sector responds to health emergencies such as the COVID-19 pandemic can determine the health and economic wellbeing of urban populations, an effect amplified for poorer communities. Here we present a qualitative document analysis of media reports and policy documents in four low resource settings-Bangladesh, Ghana, Nepal, Nigeria-between January and September 2020. The review focuses on two questions: (i) Who are the private sector actors who have engaged in the COVID-19 first wave response and what was their role?; and (ii) How have national and sub-national governments engaged in, and with, the private sector response and what have been the effects of these engagements? Three main roles of the private sector were identified in the review. (1) Providing resources to support the public health response. (2) Mitigating the financial impact of the pandemic on individuals and businesses. (3) Adjustment of services delivered by the private sector, within and beyond the health sector, to respond to pandemic-related business challenges and opportunities. The findings suggest that a combination of public-private partnerships, contracting, and regulation have been used by governments to influence private sector involvement. Government strategies to engage the private sector developed quickly, reflecting the importance of private services to populations. However, implementation of regulatory responses, especially in the health sector, has often been weak reflecting the difficulty governments have in ensuring affordable, quality private services. Lessons for future pandemics and other health emergencies include the need to ensure that essential non-pandemic health services in the government and non-government sector can continue despite elevated risks, surge capacity to minimize shortages of vital public health supplies is available, and plans are in place to ensure private workplaces remain safe and livelihoods protected.

Barriers to vasectomy acceptance and uptake in Nigeria: A review of the literature.

There is growing support of male involvement in reproductive health and the integration of voluntary vasectomy services into national family planning programs in lower resource contexts; yet, the prevalence of women of reproductive age who rely on vasectomy in African countries such as Nigeria, is less than 1 percent. This review was conducted to gain a broader understanding of current sociocultural and health systems' conditions that need to be addressed to expand the integration and acceptability of vasectomy as an option for family planning in Nigeria. To explore this, a scoping of existing literature on vasectomy in Nigeria between 2009 to 2021 was conducted. The review focused on qualitative studies and grey literatures. The findings reveal that there is a strong awareness of vasectomy among men in Nigeria. Yet, several factors such as fear and religious and cultural beliefs prevent men from having the same confidence in vasectomy as they have in female biomedical methods. These findings have implications for future family planning policies, strategies and programmes in the country.

Learning curves in minimally invasive esophagectomy: A systematic review and evaluation of benchmarking parameters.

BACKGROUND: Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive esophagectomy is variable and can impact patient outcomes. The aim of this study was to review the current evidence on learning curves in minimally invasive esophagectomy and identify which parameters are used for benchmarking. METHODS: A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used. RESULTS: Twenty-nine studies comprising 3,741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid, and total minimally invasive esophagectomy, 6 studies reported robotic-assisted minimally invasive esophagectomy alone, and 1 study evaluated both robotic-assisted minimally invasive esophagectomy and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity, and blood loss also frequently used. Learning curves were found to plateau at 7 to 60 cases for thoracoscopic esophagectomy, 12 to 175 cases for total and thoracoscopic/hybrid esophagectomy, and 9 to 85 cases for robotic-assisted minimally invasive esophagectomy. CONCLUSION: Multiple parameters are employed to gauge minimally invasive esophagectomy learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be used to ensure best patient outcomes and required length of proctoring.

Strengths, disconnects and lessons in local and central governance of the response to the first wave of COVID-19 in Ghana.

Objectives: To explore governance, coordination and implementation actors, structures and processes, facilitators, and barriers within local government and between central and local government in Ghana's COVID-19 response during the first wave of the outbreak. Design: Cross-sectional single case study. Data collection involved a desk review of media, policy and administrative documents and key informant in-depth interviews. Setting: Two municipalities in the Greater Accra region of Ghana. Participants: Local government decentralised decision makers and officials of decentralised departments. Interventions: None. Main Outcome Measures: None. Results: Coordination between the national and local government involved the provision of directives, guidelines, training, and resources. Most of the emergency response structures at the municipal level were functional except for some Public Health Emergency Management Committees. Inadequate resources challenged all aspects of the response. Coordination between local government and district health directorates in risk communication was poor. During the distribution of relief items, a biased selection process and a lack of a bottom-up approach in planning and implementation were common and undermined the ability to target the most vulnerable beneficiaries. Conclusions: Adequate financing and equipping of frontline health facilities and workers for surveillance, laboratory and case management activities, transparent criteria to ensure effective targeting and monitoring of the distribution of relief items, and a stronger bottom-up approach to the planning and implementation of interventions need to be given high priority in any response to health security threats such as COVID-19. Funding: This work is funded by International Development Research Centre Grant No. 109479, Exploring and learning from evidence, policy and systems responses to COVID-19 in West and Central Africa.

Strengths, disconnects and lessons in local and central governance of the response to the first wave of COVID-19 in Ghana

Objectives: To explore governance, coordination and implementation actors, structures and processes, facilitators, and barriers within local government and between central and local government in Ghana's COVID-19 response during the first wave of the outbreak. Design: Cross-sectional single case study. Data collection involved a desk review of media, policy and administrative documents and key informant in-depth interviews. Setting: Two municipalities in the Greater Accra region of Ghana Participants: Local government decentralised decision makers and officials of decentralised departments. Interventions: None. Main Outcome Measures: None Results: Coordination between the national and local government involved the provision of directives, guidelines, training, and resources. Most of the emergency response structures at the municipal level were functional except for some Public Health Emergency Management Committees. Inadequate resources challenged all aspects of the response. Coordination between local government and district health directorates in risk communication was poor. During the distribution of relief items, a biased selection process and a lack of a bottom-up approach in planning and implementation were common and undermined the ability to target the most vulnerable beneficiaries. Conclusions: Adequate financing and equipping of frontline health facilities and workers for surveillance, laboratory and case management activities, transparent criteria to ensure effective targeting and monitoring of the distribution of relief items, and a stronger bottom-up approach to the planning and implementation of interventions need to be given high priority in any response to health security threats such as COVID-19.

Prevalence and Correlates of Likely Major Depressive Disorder among the Adult Population in Ghana during the COVID-19 Pandemic.

BACKGROUND: Emerging research suggests that the novel coronavirus disease (COVID-19) pandemic and associated public health restrictions have caused psychological distress in many contexts. In order for public health authorities and policy makers to effectively address the psychological distress associated with the pandemic, it is important to determine the prevalence and correlates of mental disorders, including depression. OBJECTIVES: We aimed to determine the prevalence, and demographic, social, clinical and other COVID-19 related correlates of major depressive disorder symptoms among the general population in Ghana during the COVID-19 pandemic. METHOD: The study was a cross-sectional survey using online data collection methods. The survey assessed demographic, social and clinical variables as well as COVID-19 related variables. Major depressive disorder symptoms were assessed using the Patient Health Questionnaire-9. The survey link was distributed primarily through WhatsApp-based platforms. Data were analyzed using descriptive and inferential statistics. RESULTS: The overall prevalence of likely MDD symptoms among the sample population was 12.3%. Variables such as employment, loss of jobs during the pandemic and rate of exposure to COVID-related news were independently and significantly associated with the likelihood that respondents had likely MDD. Variables such as gender, relationship, housing status and having a family member or friend who was sick from COVID-19 were not independently significantly associated with the likelihood that respondents had likely MDD, when all other factors in the model were controlled. CONCLUSION: This study has identified the prevalence and correlates of depression symptoms in Ghana during the COVID-19 pandemic. There is the urgent need for mental health policy makers and the government of Ghana to have policies in place to alleviate the potential threat to the mental health of the population.

Neighborhood disadvantage and the sales of unhealthy products: alcohol, tobacco and unhealthy snack food.

BACKGROUND: Individuals may use unhealthy coping mechanisms such as alcohol, tobacco, and unhealthy snack consumption. The purpose of this study was to assess how neighborhood disadvantage is associated with sales of alcohol, tobacco, and unhealthy snacks at stores of a discount variety store chain. METHODS: Alcohol, tobacco, and unhealthy snack sales were measured monthly for 20 months, 2017-2018, in 16 discount variety stores in the United States. Mixed effects linear regressions adjusted for population size, with store-specific random effects, to examine the relationship of weekly unit sales with three outcome variables and neighborhood disadvantage, measured using the Area Deprivation Index (ADI). RESULTS: The discount variety stores were located in neighborhoods where the median ADI percentile was 87 [interquartile range 83,89], compared to the median ADI percentile of 50 for all US communities, indicating that the stores were located in substantially disadvantaged neighborhoods. For every 1% increase in ADI, weekly unit sales of unhealthy snack food increased by 43 [95% confidence interval, CI 28-57], and weekly unit sales of tobacco products increased by 11.5 [95% CI 5-18] per store. No significant relationship between neighborhood disadvantage and the weekly unit sales of alcohol products was identified. CONCLUSIONS: The positive relationship between neighborhood disadvantage and the sale of tobacco and snack foods may help explain the pathway between neighborhood disadvantage and poor health outcomes. It would be useful for future research to examine how neighborhood disadvantage influences resident health-related behaviors.