Brunneroma: an infrequent duodenal neoplasm.

An 83-year-old male presented to the Emergency Department with long lasting epigastric discomfort, weight loss and diarrhea. Physical exam and basic laboratory tests showed no remarkable findings. Upper endoscopy revealed a sessile lesion (Paris 0-IIa) in the anterior wall of the duodenal bulb, with smooth surface and slightly ulcerated at the top.

Conversion from Roux-En-Y Gastric Bypass to Single Anastomosis Duodenoileal Bypass (SADI-S) for Weight Regain.

BACKGROUND: Revisional bariatric surgery presents a challenge for bariatric surgeons. This procedure can be considered for patients with inadequate weight loss or weight regain after an initial satisfactory response following bariatric surgery. However, the surgical management of weight regain following RYGB remains controversial. We present a case of successful weight gain management after a single anastomosis duodenoileal bypass with sleeve gastrectomy (SADIS) as a revisional procedure for patients with weight regain after RYGB. METHODS: A 23-year-old female with a body mass index (BMI) of 52 kg/m2 and no comorbidities underwent RYGB. Postoperatively, she reached an excess weight loss of 75% of her initial body weight, with a BMI of 32 kg/m2. Eight years after her RYGB, she started regaining weight, reaching a BMI of 47 kg/m2. The surgical team decided to perform a revisional surgery, a conversion of RYGB to SADIS. RESULTS: There were no intraoperative complications. An upper gastrointestinal series was obtained on the third postoperative day which resulted normal and oral feedings were resumed. The patient was then discharged on fifth postoperative day. There were no complications within the first 30 postoperative days. CONCLUSIONS: We attach a video that illustrates the management and technique used to deal with the weight regain after primary bariatric surgery RYGB. We consider that in patients with super morbid obesity refractory to RYGB, conversion to SADIS is an excellent alternative due to its safety and feasibility.

Spontaneous intramural small-bowel hematoma: a cause of acute abdomen in anticoagulated patients.

Spontaneous intramural small-bowel hematoma (SISBH) is an uncommon cause of acute abdominal pain in anticoagulated patients.

Functional recovery of secondary tropical forests.

One-third of all Neotropical forests are secondary forests that regrow naturally after agricultural use through secondary succession. We need to understand better how and why succession varies across environmental gradients and broad geographic scales. Here, we analyze functional recovery using community data on seven plant characteristics (traits) of 1,016 forest plots from 30 chronosequence sites across the Neotropics. By analyzing communities in terms of their traits, we enhance understanding of the mechanisms of succession, assess ecosystem recovery, and use these insights to propose successful forest restoration strategies. Wet and dry forests diverged markedly for several traits that increase growth rate in wet forests but come at the expense of reduced drought tolerance, delay, or avoidance, which is important in seasonally dry forests. Dry and wet forests showed different successional pathways for several traits. In dry forests, species turnover is driven by drought tolerance traits that are important early in succession and in wet forests by shade tolerance traits that are important later in succession. In both forests, deciduous and compound-leaved trees decreased with forest age, probably because microclimatic conditions became less hot and dry. Our results suggest that climatic water availability drives functional recovery by influencing the start and trajectory of succession, resulting in a convergence of community trait values with forest age when vegetation cover builds up. Within plots, the range in functional trait values increased with age. Based on the observed successional trait changes, we indicate the consequences for carbon and nutrient cycling and propose an ecologically sound strategy to improve forest restoration success.

Creating Health Literate Consumer Resources: Insights from a Professional Development Program.

The Rauemi Atawhai (RA) Program, delivered at Counties Manukau Health by Health Literacy New Zealand (Limited), is a professional development program that aims to develop the capability in health care professionals to recognize and develop health literate, culturally competent health education resources and systems. Local evaluation of this program explored participant learning and barriers to becoming a health literate organization. We found that program participants consolidated their understanding or built a more comprehensive understanding of health literacy. Further, they gained new skills to assist them in developing future consumer resources. However, within the evaluation period, the RA Program had limited influence on the design and refinement of systems for developing, reviewing, disseminating, and evaluating consumer resources for their service, as well as approaches for engaging patients and family in design and review. Significant organizational action is needed to support these changes. Opportunities for leaders and managers to participate in capability building and discussions to create conditions (e.g., resource and authorization) for change in the environments in which staff work are needed. [HLRP: Health Literacy Research and Practice. 2020;4(3):e185-e189.].

Neuromodulation of the prefrontal cortex facilitates diet-induced weight loss in midlife women: a randomized, proof-of-concept clinical trial.

BACKGROUND: High body mass index (BMI) is associated with neurocognitive impairments that contribute to overeating and interfere with weight loss efforts. Overweight and obesity at midlife can accelerate neurodegenerative changes and increase the risk of late-life dementia. Noninvasive neuromodulation represents a novel, affordable and scalable approach to improve neurocognitive function in this context. The purpose of this proof-of-concept study was to examine whether transcranial direct current stimulation (tDCS) aimed at enhancing prefrontal cortex activity could enhance weight loss, in combination with a hypocaloric diet, and study underlying mechanisms. METHODS: Overall, 38 women with BMI 25-35 kg/m2 underwent a 4 week randomized, double-blinded, sham-controlled, and parallel-design intervention, during which they received eight sessions of tDCS (n = 18 sham, n = 20 active) in combination with a diet (caloric goal of 20 kcal/kg/day). We evaluated longitudinal changes in body weight, appetite and food craving. In addition, we examined the contribution of cognitive-executive processes via food-modified computerized tasks. RESULTS: We found that the active group had more reduction in body weight than the sham group throughout the study (p = 0.020) and significant weekly weight loss. At 4 weeks, the active group lost 2.32% of initial body weight (sham: 1.29%). Components of subjective appetite and food craving showed a trend toward more reduction in the active group. These changes were paralleled by significant improvements in task performance in the active group, particularly in a dual task that required inhibitory control and working memory (p = 0.007-0.031). Improvement in inhibitory control performance predicted reduction in lack of control overeating, explaining 43.5% of its variance at the end of the study (p = 0.003). No significant adverse effects were observed. CONCLUSIONS: Our results provide proof-of-concept validation of prefrontal-targeted tDCS, combined with a diet, in midlife women with excess body weight, paving the way for larger studies evaluating clinical efficacy and long-term effects of this intervention.

Prevalencia de Fracturas de Pelvis en el Hospital de Especialidades Carlos Andrade Marín, 2017-2018 / Prevalence of Pelvic Fractures at the Carlos Andrade Marin Specialty Hospital, 2017-2018

INTRODUCIÓN. Las fracturas de pelvis se presentan con severidad variable, desde lesiones de baja energía, hasta lesiones secundarias a un traumatismo de alta energía, que llevan a una inestabilidad del anillo pélvico, con lesiones asociadas y altas tasas de morbimortalidad. El manejo inicial se sustenta en la aplicación de protocolos de soporte vital avanzado, disminuir el sangrado pélvico con medidas que reduzcan el volumen de perdida sanguínea en la cavidad pélvica y estabilización de la lesión. Tras la estabilización inicial del paciente el objetivo primordial radica en la restauración anatómica del anillo pélvico predictor de la recuperación funcional. OBJETIVO. Evaluar la prevalencia de pacientes con fracturas de pelvis que ingresaron a la Unidad de Ortopedia de un hospital de tercer nivel. MATERIALES Y MÉTODOS. Se trató de un estudio observacional, descriptivo, de corte transversal, con población 44126, una muestra de 233 pacientes, criterios de inclusión: diagnóstico de fracturas de pelvis, ingresados a la unidad, criterios de exclusión: edad menor a 18 años, registros se encontraban incompletos, el estudio fue en pacientes que ingresaron al Servicio de Ortopedia y Traumatología del Hospital de Especialidades Carlos Andrade Marín, en el período comprendido del 1º de Enero, 2017 al 31 de Diciembre, 2018. Se realizó la revisión de Historia Clínica Única del sistema AS400 del Hospital, se analizó los datos con ayuda de SPSS v22. RESULTADOS. Se reportó una prevalencia anual del 0,255%. En promedio de edad global de 31 +/-5,6 años de edad, con un rango de 18 a 67 años. Afectación del 90,2% en población económicamente activa, la causa más común fueron los accidentes de tránsito 68,6% (160;233), el 81,61% (190;233) fue de sexo masculino, el 18,38% (43;233) femenino. CONCLUSIÓN. Las fracturas de pelvis representaron patologías de morbimortalidad elevada, con una prevalencia anual del 0,2% reportada en el Hospital de Especialidades Carlos Andrade Marín, afectación mayor en población económicamente activa, proporción de 3 a 1 en relación hombre y mujer, los accidentes de tránsito la etiología más prevalente. El tiempo de traslado al hospital de referencia es mayor a los 120 minutos en la mayoría de casos, el manejo quirúrgico en los pacientes que lo requirieron mejoró el pronóstico funcional en los mismos.

INTRODUCTION. Pelvic fractures occur with varying severity, from low energy injuries, to secondary injuries to high energy trauma, which lead to pelvic ring instability, with associated injuries and high morbidity and mortality rates. The initial management is based on the application of advanced life support protocols, reducing pelvic bleeding with measures that reduce the volume of blood loss in the pelvic cavity and stabilization of the lesion. After the initial stabilization of the patient, the primary objective lies in the anatomical restoration of the pelvic ring predictive of functional recovery. OBJECTIVE. To assess the prevalence of patients with pelvic fractures admitted to the Orthopedics Unit of a third level hospital. MATERIALS AND METHODS. It was an observational, descriptive, cross-sectional study, with population 44126, a sample of 233 patients, inclusion criteria: diagnosis of pelvic fractures, admitted to the unit, exclusion criteria: age under 18 years, records were were incomplete, the study was in patients who entered the Orthopedics and Traumatology Service of the Carlos Andrade Marín Specialties Hospital, in the period from January 1, 2017 to December 31, 2018. The review of the Unique Clinical History of the AS400 system of the Hospital, the data was analyzed with the help of SPSS v22. RESULTS. An annual prevalence of 0,255% was reported. On average global age 31 +/- 5.6 years old, with a range of 18 to 67 years. Affectation of 90,2% in economically active population, the most common cause was traffic accidents 68,6% (160;233), 81,61% (190;233) was male, 18,38% (43;233) female. CONCLUSION. Pelvic fractures represented pathologies of high morbidity and mortality, with an annual prevalence of 0,2% reported in the Carlos Andrade Marín Specialties Hospital, major affectation in economically active population, ratio of 3 to 1, in relation to men and women, traffic accidents the most prevalent etiology. The transfer time to the reference hospital is greater than 120 minutes in most cases, surgical management in patients who required it improved their functional prognosis.

Wet and dry tropical forests show opposite successional pathways in wood density but converge over time.

Tropical forests are converted at an alarming rate for agricultural use and pastureland, but also regrow naturally through secondary succession. For successful forest restoration, it is essential to understand the mechanisms of secondary succession. These mechanisms may vary across forest types, but analyses across broad spatial scales are lacking. Here, we analyse forest recovery using 1,403 plots that differ in age since agricultural abandonment from 50 sites across the Neotropics. We analyse changes in community composition using species-specific stem wood density (WD), which is a key trait for plant growth, survival and forest carbon storage. In wet forest, succession proceeds from low towards high community WD (acquisitive towards conservative trait values), in line with standard successional theory. However, in dry forest, succession proceeds from high towards low community WD (conservative towards acquisitive trait values), probably because high WD reflects drought tolerance in harsh early successional environments. Dry season intensity drives WD recovery by influencing the start and trajectory of succession, resulting in convergence of the community WD over time as vegetation cover builds up. These ecological insights can be used to improve species selection for reforestation. Reforestation species selected to establish a first protective canopy layer should, among other criteria, ideally have a similar WD to the early successional communities that dominate under the prevailing macroclimatic conditions.

Saving 20 000 Days and Beyond: a realist evaluation of two quality improvement campaigns to manage hospital demand in a New Zealand District Health Board.

Background: The current paper reports on a realist evaluation of two consecutive quality improvement campaigns based on the Institute for Healthcare Improvement's Breakthrough Series. The campaigns were implemented by a District Health Board to manage hospital demand in South Auckland, New Zealand. A realist evaluation design was adopted to investigate what worked in the two campaigns and under what conditions. Methods: A mixed-methods approach was used, involving three phases of data collection. During the first phase, a review of campaign materials and relevant literature, as well as key informant interviews were undertaken to generate an initial logic model of how the campaign was expected to achieve its objective. In phase II, the model was tested against the experiences of participants in the first campaign via a questionnaire to all campaign participants, interviews with campaign sponsors and collaborative team leaders and a review of collaborative team dashboards. In phase III, the refined model was tested further against the experiences of participants in the second campaign through interviews with collaborative team leaders, case studies of four collaborative teams and a review of the overall system-level dashboard. Results: The evaluation identified four key mechanisms through which the campaigns' outcomes were achieved. These were characterised as 'an organisational preparedness to change', 'enlisting the early adopters', 'strong collaborative teams' and 'learning from measurement'. Contextual factors that both enabled and constrained the operation of these mechanisms were also identified. Conclusions: By focusing on the explication of a theory of how the campaigns achieved their outcomes and under what circumstances, the realist evaluation reported in this paper provides some instructive lessons for future evaluations of quality improvement initiatives.

Tratamiento conservador en luxación congénita de rodilla: reporte de un caso y revisión de la literatura / Conservative treatment in congenital knee dislocation: report of a case and review of the literature

Introducción: la luxación congénita de rodilla es una de las alteraciones anatómicas muy poco frecuente, que su diagnóstico se basa en los hallazgos clínicos obtenidos al nacimiento y corroborados con exámenes radiológicos. La evolución y complicaciones que puede acarrear esta patología dependerá del grado de severidad y del momento de la instauración del tratamiento, ya que un tratamiento oportuno conducirá a una movilidad adecuada y un desarrollo sicomotor apropiado. Presentación del caso: presentamos un caso observado en nuestro hospital con seguimiento por cinco meses, en donde se le realizo un cambio paulatino de inmovilizaciones cruropédica y controles radiológicos sucesivos. Se realiza una revisión de caso clínico y revisión bibliográfica. Resultado: el presente caso muestra un manejo conservador en un recién nacido con Luxación Congénita de Rodilla, con el que se obtuvo una adecuada reducción mediante un manejo conservador oportuno. Conclusiones: un diagnóstico apropiado acompañado de un tratamiento oportuno otorgó una recuperación eficaz llevando a una movilidad adecuada, evitando complicaciones serias tanto musculo esqueléticas y sicosociales(AU)

Introduction: congenital knee dislocation is one of the very rare anatomical alterations, whose diagnosis is based on the clinical findings obtained at birth and corroborated with radiological examinations. The evolution and complications that this pathology can bring will depend on the degree of severity and on the time of the initiation of the treatment, since an opportune treatment will lead to an adequate mobility and an appropriate psychomotor development. Case: we present a case observed in our hospital with follow-up for five months, in which a gradual change of cruropic immobilizations and successive radiological controls was made. A clinical case review and bibliographic review is carried out. Result: the present case shows a conservative management in a newborn with Congenital Knee Dislocation, with which an adequate reduction was obtained through opportune conservative management. Conclusions: an appropriate diagnosis accompanied by an opportune treatment granted an effective recovery leading to an adequate mobility, avoiding serious musculoskeletal and psychosocial complications(AU)

Artrotomía versus artroscopia en el tratamiento de artritis séptica en rodilla / Arthrotomy versus arthroscopy in the treatment of septic knee arthritis

INTRODUCCIÓN. La artritis séptica aguda de rodilla puede provocar daño grave en las articulaciones o sepsis, si no se logra un diagnóstico y tratamiento precoz, lo que incluye drenaje de la articulación, cobertura adecuada de antibióticos y reposo de rodilla. Clásicamente, el drenaje de la rodilla se realiza con múltiples artrocentesis o con artrotomía. El abordaje artroscópico es cada vez más aceptado, pues permite el drenaje adecuado del material purulento y el desbridamiento con la sinovectomía parcial o total de la articulación. OBJETIVO. Evaluar las diferencias entre la artroscopia y la artrotomía en los resultados clínicos y la tasa de recurrencia en pacientes con artritis séptica de la articulación de rodilla. MATERIALES Y MÉTODOS. Revisión de 20 artículos científicos de los últimos 5 años de publicación. Además se analizó los artículos seleccionados para este estudio, como criterios de inclusión se revisaron los que contenían recomendaciones acerca de artrotomía vs artroscopia en el tratamiento de la artritis séptica aguda, excluyendo otro tipo de procedimientos quirúrgicos. RESULTADOS. Se hizo una selección aleatoria de artículos científicos. No existió diferencia en la efectividad del tratamiento en ambos grupos. El dolor fue más alto en los sometidos a tratamiento por artrotomía a los 7 y 14 días postoperatorios. El regreso a las actividades de la vida diaria tomó un promedio de 5,7 días para ambos grupos: 7,1 días para el grupo de artrotomía y 4,3 días para el grupo de artroscopia. CONCLUSIÓN. Esta revisión recolectó información sin evidencia concluyente que demuestre que la artroscopia es más efectiva en el manejo de la artritis séptica. La artrotomía se mantiene como terapéutica estándar en el tratamiento de la artritis séptica de rodilla.

INTRODUCTION. Acute knee septic arthritis can cause serious joint damage or sepsis if early diagnosis and treatment is not achieved, including drainage of the joint, adequate antibiotic coverage and knee rest. Classically, the knee is drained with multiple arthrocentesis or arthrotomy. The arthroscopic approach is increasingly accepted, since it allows adequate drainage of purulent material and debridement with partial or total synovectomy of the joint. OBJECTIVE. To assess the differences between arthroscopy and arthrotomy in clinical outcomes and the recurrence rate in patients with septic arthritis of the knee joint. MATERIALS AND METHODS. Review of 20 scientific articles of the last 5 years of publication. In addition, the articles selected for this study were analyzed, as inclusion criteria were reviewed, which included recommendations about arthrotomy vs arthroscopy in the treatment of acute septic arthritis, excluding other types of surgical procedures. RESULTS A random selection of scientific articles was made. There was no difference in the effectiveness of the treatment in both groups. The pain was highest in those undergoing arthrotomy treatment at 7 and 14 days postoperatively. The return to activities of daily life took an average of 5,7 days for both groups: 7,1 days for the arthrotomy group and 4,3 days for the arthroscopy group. CONCLUSION. This review collected information without conclusive evidence demonstrating that arthroscopy is more effective in the management of septic arthritis. Arthrotomy remains the standard therapy in the treatment of septic knee arthritis.

What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study.

PURPOSE: The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented. DESIGN/METHODOLOGY/APPROACH: A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments. FINDINGS: The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people. RESEARCH LIMITATIONS/IMPLICATIONS: Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input. PRACTICAL IMPLICATIONS: The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems. ORIGINALITY/VALUE: This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

Estimated reduction in expenditure on hospital-acquired pressure injuries after an intervention for early identification and treatment.

AIM: An intervention designed to reduce numbers of hospital-acquired pressure injuries was delivered in Counties Manukau Health hospitals. An audit of a sample of patients was carried out to estimate the cost savings that would have been acquired across the district health board (DHB) due to a reduction in pressure injuries. METHOD: The pressure injury intervention was delivered from 2011 to 2015. A monthly prospective audit of patients with stages 1, 2, 3 and 4 pressure injuries was carried out. This involved a random sample of five patients per ward in all hospitals in Counties Manukau DHB. RESULTS: It was found that the annual estimated cost of treating pressure injuries in hospital patients was NZ$12,290,484 less in 2015 than in 2011. CONCLUSION: Implementation of strategies for managing hospital-acquired pressure injuries can lead to potentially large financial savings for hospitals, as well as reducing the burden of managing this difficult condition for patients and staff.

My Home is My Marae: Kaupapa Maori evaluation of an approach to injury prevention.

OBJECTIVE: The objective of this study was to evaluate the New Zealand Accident Compensation Corporation's (ACC) 'My Home is My Marae' approach to injury prevention for whanau (families). SETTING: Over an 18 month period from November 2013 to June 2014, 14 'My Home is My Marae' trials were conducted across the South Auckland and Far North regions of New Zealand. ACC engaged with local Maori providers of healthcare, education and social services to deliver the home safety intervention. PARTICIPANTS: Participants of this evaluation were a purposive sample of 14 staff from six provider organisations in South Auckland and the Far North regions of New Zealand. METHODS: Kaupapa Maori theory-based evaluation and appreciative inquiry methodologies underpinned the evaluation. Interview participants led discussions about strengths and weaknesses of the approach, and partnerships with ACC and other organisations. The evaluation was also supported by pre-existing information available in project documentation, and quantitative data collected by Maori providers. RESULTS: Five key critical success factors of 'My Home is My Marae' were found from interviews: mana tangata (reputation, respect and credibility); manakitanga (showing care for people); kanohi-ki-te-kanohi (face-to-face approach); capacity building for kaimahi, whanau and providers and 'low or no cost' solutions to hazards in the home. Data collected for the Far North area showed that 76% of the hazards identified could be resolved through 'low or no cost' solutions. Unfortunately, similar data were not available for South Auckland. CONCLUSIONS: Injury prevention or health promotion approaches that seek to engage with whanau and/or Maori communities would benefit from applying critical success factors of 'My Home is My Marae'.

A literature review for large-scale health information system project planning, implementation and evaluation.

Information technology is perceived as a potential panacea for healthcare organisations to manage pressure to improve services in the face of increased demand. However, the implementation and evaluation of health information systems (HIS) is plagued with problems and implementation shortcomings and failures are rife. HIS implementation is complex and relies on organisational, structural, technological, and human factors to be successful. It also requires reflective, nuanced, multidimensional evaluation to provide ongoing feedback to ensure success. This article provides a comprehensive review of the literature about evaluating and implementing HIS, detailing the challenges and recommendations for both evaluators and healthcare organisations. The factors that inhibit or promote successful HIS implementation are identified and effective evaluation strategies are described with the goal of informing teams evaluating complex HIS.

TRPA1 polymorphisms in chronic and complete spinal cord injury patients with neuropathic pain: a pilot study.

STUDY DESIGN: Pilot study. OBJECTIVES: Single-nucleotide polymorphisms (SNPs) in TRPA1 gene are related to the etiology of chronic pain. The study is a pilot study with the primary objective of analyzing these SNPs in Spanish patients with chronic and complete spinal cord injury (SCI) and neuropathic pain (NPP). SETTING: Asepeyo Hospital Department of Chronic and Complete SCI. METHODS: Twelve patients with chronic and complete SCI and NPP, and 12 patients with chronic and complete SCI with no pain were reviewed. International Spinal Cord Injury Pain Classification (LANSS) and visual analog score (VAS) were chosen to classify pain syndrome. SNPs were identified by melting analysis after DNA amplification with real-time fluorescence PCR. RESULTS: There were differences in rs11988795 variant: GG homozygous (p = 0.01) and G allele (p = 0.001) were more frequent in SCI patients with no pain. There were differences in rs13255063 variant: TT homozygous were prevalent (p = 0.03) in patients with NPP. CONCLUSIONS: Until now this is the first study to show a description of TRPA1 SNPs in Spanish patients with chronic and complete SCI and NPP. These results suggest that GG genotype in rs11988795 variant and G allele could be protective factors against NPP. TT genotype in rs13255063 variant could be a risk factor for NPP. Neuropathic pain after spinal cord injuries may have genetic contributions.