Community perceptions of community health worker effectiveness: Contributions to health behaviour change in an urban health district in South Africa.

BACKGROUND: Community health worker (CHW) programmes contribute towards strengthening adherence support, improving maternal and child health outcomes and providing support for social services. They play a valuable role in health behaviour change in vulnerable communities. Large-scale, comprehensive CHW programmes at health district level are part of a South African (SA) strategy to re-engineer primary healthcare and take health directly into communities and households, contributing to universal health coverage. OBJECTIVE: These CHW programmes across health districts were introduced in SA in 2010 - 11. Their overall purpose is to improve access to healthcare and encourage healthy behaviour in vulnerable communities, through community and family engagements, leading to less disease and better population health. Communities therefore need to accept and support these initiatives. There is, however, inadequate local evidence on community perceptions of the effectiveness of such programmes. METHODS: A cross-sectional descriptive study to determine community perceptions of the role and contributions of the CHW programme was conducted in the Ekurhuleni health district, an urban metropolis in SA. Members from 417 households supported by CHWs were interviewed in May 2019 by retired nurses used as fieldworkers. Frequencies and descriptive analyses were used to report on the main study outcomes of community acceptance and satisfaction. RESULTS: Nearly all the study households were poor and had at least one vulnerable member, either a child under 5, an elderly person, a pregnant woman or someone with a chronic condition. CHWs had supported these households for 2 years or longer. More than 90% of households were extremely satisfied with their CHW; they found it easy to talk to them within the privacy of their homes and to follow the health education and advice given by the CHWs. The community members highly rated care for chronic conditions (82%), indicated that children were healthier (41%) and had safer pregnancies (6%). CONCLUSION: As important stakeholders in CHW programmes, exploring community acceptance, appreciation and support is critical in understanding the drivers of programme performance. Community acceptance of the CHWs in the Ekurhuleni health district was high. The perspective of the community was that the CHWs were quite effective. This was demonstrated when they reported changes in household behaviour with regard to improved access to care through early screening, referrals and improved management of chronic and other conditions.

Generalization of procedural motor sequence learning after a single practice trial.

When humans begin learning new motor skills, they typically display early rapid performance improvements. It is not well understood how knowledge acquired during this early skill learning period generalizes to new, related skills. Here, we addressed this question by investigating factors influencing generalization of early learning from a skill A to a different, but related skill B. Early skill generalization was tested over four experiments (N = 2095). Subjects successively learned two related motor sequence skills (skills A and B) over different practice schedules. Skill A and B sequences shared ordinal (i.e., matching keypress locations), transitional (i.e., ordered keypress pairs), parsing rule (i.e., distinct sequence events like repeated keypresses that can be used as a breakpoint for segmenting the sequence into smaller units) structures, or possessed no structure similarities. Results showed generalization for shared parsing rule structure between skills A and B after only a single 10-second practice trial of skill A. Manipulating the initial practice exposure to skill A (1 to 12 trials) and inter-practice rest interval (0-30 s) between skills A and B had no impact on parsing rule structure generalization. Furthermore, this generalization was not explained by stronger sensorimotor mapping between individual keypress actions and their symbolic representations. In contrast, learning from skill A did not generalize to skill B during early learning when the sequences shared only ordinal or transitional structure features. These results document sequence structure that can be very rapidly generalized during initial learning to facilitate generalization of skill.

Impact of the COVID-19 Pandemic on a Cancer Fast-Track Programme.

INTRODUCTION: The COVID-19 pandemic has disrupted many aspects of clinical practice in oncology, particularly regarding early cancer diagnosis, sparking public health concerns that possible delays could increase the proportion of patients diagnosed at advanced stages. In 2009, a cancer fast-track program (CFP) was implemented at the Clinico-Malvarrosa Health Department in Valencia, Spain with the aim of shortening waiting times between suspected cancer symptoms, diagnosis and therapy initiation. OBJECTIVES: The study aimed to explore the effects of the COVID-19 pandemic on our cancer diagnosis fast-track program. METHODS: The program workflow (patients included and time periods) was analysed from the beginning of the state of alarm on March 16th, 2020 until March 15th, 2021. Data was compared with data from the same period of time from the year before (2019). RESULTS: During the pandemic year, 975 suspected cancer cases were submitted to the CFP. The number of submissions only decreased during times of highest COVID-19 incidence and stricter lockdown, and overall, referrals were slightly higher than in the previous 2 years. Cancer diagnosis was confirmed in 197 (24.1%) cases, among which 33% were urological, 23% breast, 16% gastrointestinal and 9% lung cancer. The median time from referral to specialist appointment was 13 days and diagnosis was reached at a median of 18 days. In confirmed cancer cases, treatment was started at around 30 days from time of diagnosis. In total, 61% of cancer disease was detected at early stage, 20% at locally advanced stage, and 19% at advanced stage, displaying time frames and case proportions similar to pre-pandemic years. CONCLUSIONS: Our program has been able to maintain normal flow and efficacy despite the challenges of the current pandemic, and has proven a reliable tool to help primary care physicians referring suspected cancer patients.

The introduction of competency-based medical education for postgraduate training in South Africa.

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Effectiveness of a large-scale, sustained and comprehensive community health worker program in improving population health: the experience of an urban health district in South Africa.

INTRODUCTION: South Africa is an upper middle-income country with wide wealth inequality. It faces a quadruple burden of disease and poor health outcomes, with access to appropriate and adequate health care a challenge for millions of South Africans. The introduction of large-scale, comprehensive community health worker (CHW) programs in the country, within the context of implementing universal health coverage, was anticipated to improve population health outcomes. However, there is inadequate local (or global) evidence on whether such programs are effective, especially in urban settings. METHODS: This study is part of a multi-method, quasi-experimental intervention study measuring effectiveness of a large-scale CHW program in a health district in an urban province of South Africa, where CHWs now support approximately one million people in 280,000 households. Using interviewer administered questionnaires, a 2019 cross-sectional survey of 417 vulnerable households with long-term CHW support (intervention households) are compared to 417 households with no CHW support (control households). Households were selected from similar vulnerable areas from all sub-levels of the Ekurhuleni health district. RESULTS: The 417 intervention and control households each had good health knowledge. Compared to controls, intervention households with long-term comprehensive CHW support were more likely to access early care, get diagnosed for a chronic condition, be put on treatment and be well controlled on chronic treatment. They were also more likely to receive a social grant, and have a birth certificate or identity document. The differences were statistically significant for social support, health seeking behavior, and health outcomes for maternal, child health and chronic care. CONCLUSION: A large-scale and sustained comprehensive CHW program in an urban setting improved access to social support, chronic and minor acute health services at household and population level through better health-seeking behavior and adherence to treatment. Direct evidence from households illustrated that such community health worker programs are therefore effective and should be part of health systems in low- and middle-income countries.

Ten-year assessment of a cancer fast-track programme to connect primary care with oncology: reducing time from initial symptoms to diagnosis and treatment initiation.

BACKGROUND: Cancer is the second leading cause of mortality worldwide. Integrating different levels of care by implementing screening programmes, extending diagnostic tools and applying therapeutic advances may increase survival. We implemented a cancer fast-track programme (CFP) to shorten the time between suspected cancer symptoms, diagnosis and therapy initiation. PATIENTS AND METHODS: Descriptive data were collected from the 10 years since the CFP was implemented (2009-2019) at the Clinico-Malvarrosa Health Department in Valencia, Spain. General practitioners (GPs), an oncology coordinator and 11 specialists designed guidelines for GP patient referral to the CFP, including criteria for breast, digestive, gynaecological, lung, urological, dermatological, head and neck, and soft tissue cancers. Patients with enlarged lymph nodes and constitutional symptoms were also considered. On identifying patients with suspected cancer, GPs sent a case proposal to the oncology coordinator. If criteria were met, an appointment was quickly made with the patient. We analysed the timeline of each stage of the process. RESULTS: A total of 4493 suspected cancer cases were submitted to the CFP, of whom 4019 were seen by the corresponding specialist. Cancer was confirmed in 1098 (27.3%) patients: breast cancer in 33%, urological cancers in 22%, gastrointestinal cancer in 19% and lung cancer in 15%. The median time from submission to cancer testing was 11 days, and diagnosis was reached in a median of 19 days. Treatment was started at a median of 34 days from diagnosis. CONCLUSIONS: The findings of this study show that the interval from GP patient referral to specialist testing, cancer diagnosis and start of therapy can be reduced. Implementation of the CFP enabled most patients to begin curative intended treatment, and required only minimal resources in our setting.

An analysis of the services provided by community health workers within an urban district in South Africa: a key contribution towards universal access to care.

INTRODUCTION: Community health worker teams are potential game-changers in ensuring access to care in vulnerable communities. Who are they? What do they actually do? Can they help South Africa realize universal health coverage? As the proactive arm of the health services, community health workers teams provide household and community education, early screening, tracing and referrals for a range of health and social services. There is little local or global evidence on the household services provided by such teams, beyond specific disease-oriented activities such as for HIV and TB. This paper seeks to address this gap. METHODS: Descriptive secondary data analysis of community health worker team activities in the Ekurhuleni health district, South Africa covering approximately 280,000 households with 1 million people. RESULTS: Study findings illustrated that community health workers in these teams provided early screening and referrals for pregnant women and children under five. They distributed condoms and chronic medication to homes. They screened and referred for hypertension, diabetes mellitus, HIV and TB. The teams also undertook defaulter and contact tracing, the majority of which was for HIV and TB clients. Psychosocial support provided was in the form of access to social grants, access to child and gender-based violence protection services, food parcels and other services. CONCLUSION: Community health workers form the core of these teams and perform several health and psychosocial services in households and poor communities in South Africa, in addition to general health education. The teams studied provided a range of activities across many health conditions (mother and child related, HIV and TB, non-communicable diseases), as well as social services. These teams provided comprehensive care in a large-scale urban setting and can improve access to care.

Phase II trial with letrozole to maximum response as primary systemic therapy in postmenopausal patients with ER/PgR[+] operable breast cancer

PURPOSE: Letrozole is superior to tamoxifen in terms of response and breast preservation rates as primary systemic therapy (PST) in postmenopausal women with ER-positive early breast cancer. However, the optimum duration of endocrine PST remains uncertain. METHODS: A phase 2 multicentre, open-label trial was conducted to evaluate the efficacy of letrozole over a preoperative period of 4 months to 1 year. Seventy postmenopausal patients (over 65 years) were recruited in four centers. The primary endpoint was to establish the optimal duration of treatment defined as the time required to attain the maximum response by clinical palpation. RESULTS: The median age of the group was 79 years (66-91) and the median tumour size 35 mm (range 25-100 mm). No severe adverse events were reported. Fifty-six patients were evaluable for the primary objective. A total of 43 patients (76.8%) achieved an objective response; 29 (51.8%) being partial and 14 (25.0%) complete. The median time to objective response was 3.9 months (95% CI, 3.3-4.5) and the median time to maximum response was 4.2 months (95% CI, 4.0-4.5), although 20 (37.1%) patients achieved the maximal response within 6-12 months. CONCLUSIONS: Letrozole shows a high activity and excellent tolerability as neoadjuvant therapy in elderly patients with endocrine-dependent breast cancer. Four to six months of letrozole as PST is an optimum duration with modest benefits thereafter (AU)

Epicardial catheter ablation of atrial fibrillation.

Catheter ablation for atrial fibrillation, while superior to medical therapy alone, carries significant risk of complications and limited efficacy. Surgical therapy for atrial fibrillation, including the maze procedure, seems to be more effective but is also more invasive than percutaneous approaches. In this review, we outline the rationale for a percutaneous catheter-based epicardial ablation strategy. Operators considering such a procedure should have a detailed understanding of the anatomy of the pericardial space, which is reviewed in this manuscript. Also, technology used in epicardial ablation and special challenges of epicardial ablation are discussed. Finally, some preliminary work on epicardial ablation of atrial fibrillation is reviewed before concluding with some possibilities for future research in the area.

Neumoperitoneo por pneumatosis quística intestinal / Pneumoperitoneum due to pneumatosis cystoides intestinalis

La presencia de neumoperitoneo en el estudio radiológico hace pensar habitualmente en una perforación de víscera hueca. Sin embargo, ante un neumoperitoneo acompañado de poca clínica hay que sospechar otras posibles causas. La pneumatosis quística intestinal (PQI) se caracteriza por la presencia de quistes de gas en la pared intestinal. Su diagnóstico suele ser difícil, se llega hasta él mediante estudio radiológico o en el propio acto quirúrgico y se confirma con el estudio anatomopatológico. Nosotros presentamos una paciente que se diagnosticó de perforación de víscera hueca en puertas de urgencia, siendo posteriormente diagnosticada de PQI en el acto quirúrgico (AU)

Metástasis de carcinoma ductal infiltrante de mama simulando un cáncer de colon obstructivo primario / Metastases from infiltrating ductal carcinoma of the breast mimicking primary obstructive colon cancer

Las metástasis gastrointestinales extrahepáticas del cáncer de mama son poco frecuentes. Presentamos, por su rareza, un caso de metástasis de carcinoma ductal infiltrante de mama simulando un cáncer de colon obstructivo primario. Debe realizarse un correcto diagnóstico diferencial en pacientes con cáncer de mama que tienen síntomas o hallazgos radiológicos de cáncer de colon para evitar el tratamiento quirúrgico innecesario de la lesión metastásica como si fuese un segundo primario (AU)

Utilidad de la ecografía anorrectal en la enfermedad de Crohn perianal / Utility of anorectal echography in perianal Crohn's disease

Introducción. La ecografía anorrectal (EAR) es una exploración sencilla, cuyo valor en el diagnóstico de la patología anorrectal está altamente contrastado en la bibliografía. El propósito de este estudio ha sido examinar la utilidad de la EAR en pacientes con enfermedad de Crohn (EC) intestinal que presentan algún tipo de manifestación perianal de su enfermedad. Material y métodos. Entre octubre de 1996 y febrero de 1999 se han realizado un total de 18 EAR en 16 pacientes diagnosticados de EC intestinal y con sospecha clínica de presentar algún proceso anorrectal. Utilizamos un ecógrafo B&K Medical con un transductor rotatorio de 360°. El motivo más frecuente de petición de EAR fue la valoración de proctalgia de etiología incierta (5 casos, 28 por ciento). Otros motivos fueron: fístulas anales (4 casos, 22 por ciento), sospecha de absceso anal (3 casos, 17 por ciento), control evolutivo (3 casos, 17 por ciento), incontinencia fecal (2 casos, 11 por ciento) y sepsis perianal (un caso, 6 por ciento). Resultados. La orientación diagnóstica del clínico coincidió con los hallazgos ecográficos en 12 casos (67 por ciento). Una imagen compatible con absceso fue reconocida en 10 casos (55 por ciento), dos de ellos ya sospechados clínicamente y los otros ocho fueron hallazgos asociados fundamentalmente a fístulas y proctalgias de etiología no filiada. Se detectaron defectos esfinterianos en los 2 casos de incontinencia fecal y en otros 2 pacientes fue un hallazgo casual. En el caso de las fístulas anorrectales la EAR permitió conocer de modo más preciso la relación de las mismas con los esfínteres. Conclusiones. La EAR es de gran utilidad en la EC perianal ya que es capaz de detectar con precisión los defectos esfinterianos y los abscesos anales, motivo por el que resulta de gran valor en el caso de proctalgias o abscesos no sospechados clínicamente. Creemos que la EAR debe ser realizada después del examen rectal, la rectoscopia o la colonoscopia en estos enfermos (AU)

Estudio cooperativo nacional sobre la utilización de aspiración nasogástrica y alimentación precoz en cirugía colorrectal / Nationwide cooperative study on the utilization of nasogastric aspiration and early feeding in colorectal surgery

Introducción. El objetivo de este estudio fue evaluar la seguridad y eficacia de la sonda nasogástrica y la alimentación oral precoz en cirugía colorrectal. Pacientes y métodos. Hemos realizado un estudio multicéntrico, prospectivo y no aleatorizado que incluía a pacientes sometidos a cirugía colorrectal electiva. Los grupos de estudio fueron: grupo 1: sonda nasogástrica postoperatoria; grupo 2: sin sonda nasogástrica y dieta oral progresiva habitual, y grupo 3: sin sonda nasogástrica y alimentación oral precoz. Las variables analizadas fueron: presencia de náuseas y vómitos, necesidad de colocación de la sonda nasogástrica, tolerancia a la dieta oral, día de comienzo de peristalsis audible, inicio de tránsito para gases y heces, uso de fármacos antieméticos, grado subjetivo de bienestar postoperatorio y aparición de complicaciones. Resultados. Al final del estudio se recibieron 406 encuestas. La distribución ha sido: grupo 1: 200 pacientes (49,3 por ciento), grupo 2: 152 pacientes (37,4 por ciento) y grupo 3: 54 pacientes (13,3 por ciento). La aparición de peristaltismo audible, el inicio de tránsito a gases y heces, así como la tolerancia a la alimentación oral, fueron más precoces en los grupos 2 y 3 (sin sonda nasogástrica) que en el grupo 1, con diferencias estadísticamente significativas (p < 0,05). El grado de comodidad postoperatoria fue mayor en los grupos sin sonda nasogástrica. Las complicaciones aparecieron de forma similar en todos los grupos. Conclusiones. La alimentación oral precoz y la restricción del uso de sonda nasogástrica en cirugía colorrectal electiva son seguras y sin desventajas en relación con el uso sistemático de SNG y dieta oral progresiva (AU)

Anorectal function in patients with complete rectal prolapse. Differences between continent and incontinent individuals.

AIMS: A study is made of the alterations in anorectal physiology among rectal prolapse patients, evaluating the differences between fecal continent and incontinent individuals. PATIENTS AND METHODS: Eighteen patients with complete rectal prolapse were divided into two groups: Group A (8 continent individuals) and Group B (10 incontinent women), while 22 healthy women were used as controls (Group C). Clinical exploration and perineal level measurements were performed, along with anorectal manometry, electrophysiology, and anorectal sensitivity to electrical stimuli. RESULTS: The main antecedents of the continent subjects were excess straining efforts, while the incontinent women presented excess straining and complex deliveries. Pathological perineal descent was a frequent finding in both groups, with a hypotonic anal canal at rest (p < 0.001 vs controls) and at voluntary squeezing (p < 0.001 vs controls). In turn, the incontinent patients exhibited a significantly lower anal canal pressure at rest than the continent women (p < 0.05). There were no significant differences between Groups A and C in terms of pudendal motor latency, though latency was significantly longer in Group B than in the controls (p < 0.01). Moreover, pudendal neuropathy was more common, severe and often bilateral in Group B. There were no differences in rectal sensation to distention or in terms of the volumes required to relax the internal anal sphincter. In turn, both prolapse groups exhibited diminished anal canal and rectal sensitivity to electrical stimuli. CONCLUSIONS: Patients with rectal prolapse exhibit a hypotonic anal canal at rest, regardless of whether they are continent to feces or not. Continent patients have less pudendal neuropathy and therefore less pressure alterations at voluntary sphincter squeeze than incontinent individuals.

Can digital examination substitute anorectal manometry for the evaluation of anal canal pressures?

INTRODUCTION: Anorectal manometry provides objective information on the sphincter function of the anal canal. However, in many centers sphincter function is evaluated by digital examination, due to the unavailability of manometry. OBJECTIVE: A study is made to correlate the sensitivity and specificity of a quantitative digital examination in the analysis of sphincter tone with the pressures recorded by manometry, and to examine the capacity of both techniques to discriminate continent subjects and incontinent patients. PATIENTS AND METHODS: A total of 191 patients were divided into three groups: control (C), obstructive defecation (OD) and fecal incontinence (FI). Subjective quantitative digital evaluation of anal tone was performed on a scale of 0 to 5 points at rest, and 0 to 10 points at squeeze. A correlation analysis was performed, and the sensitivity and specificity of each fecal incontinence diagnostic test was determined. RESULTS: Digital examination found rectal tone to be diminished in elderly patients. A significant correlation was established between the digital and manometric tone readings, both at rest and at squeeze. Both techniques showed a low anal sphincter pressure in the FI group versus the C and OD groups. Differences in tone were recorded between the C and OD groups with manometry, but not with digital examination. The latter was in turn found to be more sensitive but less specific than manometry in differentiating between fecal continence and incontinence. CONCLUSIONS: Although digital examination does not substitute anorectal manometry, a good correlation exists between the two techniques. In this sense, digital examination may afford an approximate clinical evaluation of some fecal continence mechanisms in those centers where manometry is not available.

Prevalence of pudendal neuropathy in fecal incontinence. Results of a prospective study.

PURPOSE: A prospective study was made of the prevalence and associations of pudendal neuropathy in 96 patients with fecal incontinence (72 females and 24 males). METHODS: Clinical exploration, perineal level measurement, anorectal manometry, and electrophysiologic evaluations (pudendal nerve terminal motor latency (PNTML) and external sphincter fiber density (FD)) were performed. RESULTS: Pudendal neuropathy (defined as PNTML > 2.2 ms or FD > 1.65) was found in 67 patients (69.8 percent) and was more common in females (75 percent) than in males (50 percent; P = 0.05). Pudendal neuropathy was also more frequent in patients with pathologic perineal descent (85 percent vs. 55 percent; P < 0.01) or exhibiting risk factors such as difficult labor or excessive defecatory straining (P < 0.01). Perineal level at staining correlated inversely with both PNTML and FD (P < 0.01). Manometric findings suggested greater external anal sphincter damage in patients with pudendal neuropathy than in those suffering fecal incontinence but no neuropathy (P < 0.05). Pressure caused by the striated anal sphincter was also inversely correlated to PNTML. Pudendal neuropathy was encountered in 37 of 33 (58.7 percent) patients with sphincter injury vs. in 31 of 33 (93.9 percent) patients with idiopathic fecal incontinence (P < 0.01). CONCLUSIONS: Pudendal neuropathy is an etiologic or associated factor often present in patients with fecal incontinence. In this sense, clinical, perineometric, and manometric findings correlate with pudendal neuropathy, though such explorations do not suffice to detect it.

Transmucosal potential difference in experimental colitis in rats.

Colon transmucosal potential difference (TPD), macro- and microscopic lesions, myeloperoxidase activity, and leukotriene levels were studied after the induction of experimental colitis in the rat. Forty-three male Wistar rats were subjected to the instillation of 200 mg/ml 2,4,6-trinitrobenzenesulfonic acid (TNB) solution through a rectal cannula. TPD measurements were made at different distances from the anus before and 24 h and one, two, three, and four weeks after lesion induction. Leukotriene B4 levels were assayed by intracolonic dialysis 24 h and one, two, three and four weeks after lesion induction. Macro- and microscopic evaluations were made of the bowel lesions, and myeloperoxidase activity was assayed. The mean basal TPD was -46.06 mV at 1 cm from the anus, and +10.86 mV in the proximal colon. Twenty-four hours after lesion induction the values proved markedly positive. This was correlated with an abrupt increase in LTB4 levels and myeloperoxidase activity. After one week the TPD values exhibited a greater electronegativity, returning to basal values by the fourth week after lesion induction. This coincided with an improved macroscopic lesion index, LTB4 levels, and myeloperoxidase activity. In conclusion, TPD is a useful indicator of acute colonic lesions and correlates well with LTB4 and myeloperoxidase assays. Moreover, the parameter is able to delimit lesion evolution, reflecting possible ad integrum restoration of the bowel mucosa.