An Impact Assessment of the Armed Violence Reduction Project in North Western Kenya

The current report will discuss an impact assessment of the AVR project. The impact assessment was made possible via the administration of the Pre & Post-Impact Assessments (PIA) survey. The PIA survey was designed for two purposes. Firstly, it was designed to establish a baseline on; i) the levels of community knowledge regarding small arms and SGBV, ii) the perceived prevalence of armed violence in the targeted regions, iii) the safety perceptions within the targeted communities, and iv) the knowledge within the targeted communities of appropriate reporting and security structures. The second function of the PIA was to act as an impact assessment tool of the five-month AVR project. The first publication produced from the results of the PIA, titled ‘Armed Violence Reduction in North Western Kenya: Results of the Pre Impact Assessment’ focused predominantly on acquiring operational knowledge regarding the prevalence, use and misuse of small arms, as well as the level of community knowledge of security agents, and SGBV. The current publication will focus entirely on the impact assessment of the AVR project and the development of recommendations for future implementation phases

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis

Introduction: The World Health Organization's (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees. Methods and analysis: Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. Ethics and dissemination: Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals

Scalable psychological interventions for Syrian refugees in Europe and the Middle East: STRENGTHS study protocol for a prospective individual participant data meta-analysis

Introduction The World Health Organization’s (WHO) scalable psychological interventions, such as Problem Management Plus (PM+) and Step-by-Step (SbS) are designed to be cost-effective non-specialist delivered interventions to reduce symptoms of common mental disorders, such as anxiety, depression and post-traumatic stress disorder (PTSD). The STRENGTHS consortium aims to evaluate the effectiveness, cost-effectiveness and implementation of the individual format of PM+ and its group version (gPM+), as well as of the digital SbS intervention among Syrian refugees in seven countries in Europe and the Middle East. This is a study protocol for a prospective individual participant data (IPD) meta-analysis to evaluate (1) overall effectiveness and cost-effectiveness and (2) treatment moderators of PM+, gPM+ and SbS with Syrian refugees. Methods and analysis Five pilot randomised controlled trials (RCTs) and seven fully powered RCTs conducted within STRENGTHS will be combined into one IPD meta-analytic dataset. The RCTs include Syrian refugees of 18 years and above with elevated psychological distress (Kessler Psychological Distress Scale (K10>15)) and impaired daily functioning (WHO Disability Assessment Schedule 2.0 (WHODAS 2.0>16)). Participants are randomised into the intervention or care as usual control group, and complete follow-up assessments at 1-week, 3-month and 12-month follow-up. Primary outcomes are symptoms of depression and anxiety (25-item Hopkins Symptom Checklist). Secondary outcomes include daily functioning (WHODAS 2.0), PTSD symptoms (PTSD Checklist for DSM-5) and self-identified problems (PSYCHLOPS). We will conduct a one-stage IPD meta-analysis using linear mixed models. Quality of evidence will be assessed using the GRADE approach, and the economic evaluation approach will be assessed using the CHEC-list. Ethics and dissemination Local ethical approval has been obtained for each RCT. This IPD meta-analysis does not require ethical approval. The results of this study will be published in international peer-reviewed journals

Pseudotumoral Endometriotic Nodule

peer reviewedStudy Objective: To demonstrate a rare case of a pediculated endometriotic nodule that was initially diagnosed as a solid adnexal mass. Design: We present a stepwise narrated demonstration of our laparoscopic technique. Setting: We present a case report of a patient aged 44 years, gravida 2 para 2, who was diagnosed with a solid (adnexal) mass during a gynecologic examination. She presented symptoms of dyspareunia. During a bimanual examination, 2 fixed nodules were palpated in both the uterosacral ligaments, and a mobile solid mass of 5 cm could be palpated on the right adnex. A transvaginal ultrasound showed a solid (adnexal) mass of 50 mm in diameter. The tumor marker cancer antigen 125 was normal, and after application of the International Ovarian Tumor Analysis score, the risk of malignancy was up to 39%. A complementary magnetic resonance image showed a heterogeneous solid mass of 47 × 47 × 29 mm with a differential diagnosis of a pediculated fibroma in (myxoid) degeneration vs an adnexal solid mass. A laparoscopic unilateral adnexectomy was scheduled, and the patient was informed about the risk of malignancy. The laparoscopy revealed bilateral normal adnexa, the presence of a solid pediculated mass originating from the right uterosacral ligament and 2 endometriotic nodules originating from the left and right uterosacral ligaments. The rectovaginal space was dissected, and a third deep infiltrating endometriotic nodule was revealed. The operation proceeded by the sectioning of the left uterosacral ligament below the endometriotic nodule. The posterior vaginal wall was separated from the endometriotic nodule, and after further dissection of the rectovaginal space, we arrived in a disease-free area. After opening of the right medial division of the pararectal space, the right hypogastric nerve was dissected and preserved. The solid mass was separated from the uterus, the right uterosacral ligament was excised at a distance from the nodule, and the pediculated mass was removed intact en block with the right ligament. The patient was discharged 24 hours after surgery. The postoperative period was uneventful. The definitive histology report confirmed the presence of endometriotic nodules and a solid tumor classified as a pseudotumoral endometriotic mass. This was justified by the presence of conjunctival vascular stroma including multiple endometriotic foci, the presence of cytogenic stroma of variable abundance including glands lined with a columnar epithelium, and, most important, the fact that the epithelium had no cytologic atypias. Interventions: Laparoscopic excision of the pseudotumoral endometriotic nodule en block with the right and left uterosacral ligaments. Conclusion: Endometriosis is a complex multifactorial pathology in which several factors are involved: genetics, environmental factors, immunologic reactions, hormonal effects, and anatomic anomalies. All these factors may contribute to the creation of an inflammatory response related to immune cells, adhesion molecules, extracellular matrix metalloproteinase, and proinflammatory cytokines enhancing the formation of fibrotic tissue [1,2]. These changes may sometimes have an unusual presentation, as we are showing in this case report of a pseudotumoral endometriotic mass. This rare case should be included in the differential diagnosis of solid tumors before surgery for symptomatic patients and those who have a medical history of endometriosis

Laparoscopic approach for a cesarean scar pregnancy.

peer reviewed[en] OBJECTIVE: To describe a surgical technique of laparoscopic resection of a cesarean scar pregnancy (CSP) with an immediate myometrial reconstruction. The advantage of such a technique is that it is a minimally-invasive procedure that can treat the ectopic pregnancy and the defected scar at the same time with good postoperative results. DESIGN: Video article with the description of a surgical minimally-invasive technique. SETTING: Academic medical center. PATIENT(S): A 34-year-old patient, Gravida 6 Para 4 Abortus 1, with a history of 4 previous cesarean sections presented to the emergency department with abdominal pain and vaginal bleeding. The patient was hemodynamically stable. An endovaginal ultrasound revealed a viable pregnancy of 8 weeks implanted in the cesarean scar, with a residual myometrium of <1 mm. Because of increasing abdominal pain, vaginal bleeding, and a desire to preserve future fertility, an emergent laparoscopy was performed. INTERVENTION(S): Laparoscopy was performed using a CO2 AcuPulse laser device (Lumenis Inc. Salt Lake City, Utah). A continuous wave mode was used, with a power of 30 Watt and a round-shaped beam of 1.5 mm in diameter. The laser was connected to a 10-mm Hopkins endoscope 0° (Karl Storz, Tuttlingen, Germany). A complete adhesiolysis was performed, and the urinary bladder was detached from the anterior abdominal wall. The vesicouterine fold was opened to expose the isthmic part of the uterus where the ectopic pregnancy was implanted. The defected scar was resected en bloc with the pregnancy, using the laser. The limits of the resection depended on the residual myometrial thickness. We considered a myometrial thickness of >8 mm as healthy tissue. A metallic probe was introduced vaginally into the endocervix to differentiate the anterior part from the posterior part of the uterus. This probe facilitates the manipulation of the cervix and, thus, the laparoscopic intracorporeal suturing during the myometrial reconstruction. A 2-layered suturing was performed. The first layer of the suture consisted of 3 interrupted figure-of-8 sutures using a monofilament absorbable suture (Monocryl 0, ETHICON-Johnson and Johnson medical devices New Brunswick, New Jersey). A second superficial layer consisted of a continuous nonlocking suture using the same type of thread. MAIN OUTCOME MEASURE(S): Laparoscopic excision of the CSP and immediate repair of the scar defect without any postoperative complications. RESULT(S): An emergent laparoscopy was performed, with excision of the CSP and immediate reconstruction of the residual myometrium. No complications occurred, the blood loss was estimated at 200 mL, and no blood transfusion was necessary. The patient was discharged 24 hours after the intervention. Six months after surgery, the remaining myometrial thickness was between 7 mm and 9.3 mm, and no residual cesarean scar defect (isthmocele) was visualized by ultrasound. CONCLUSION(S): Cesarean scar pregnancy is a rare form of ectopic pregnancy. The incidence, however, is increasing as a consequence of the rising cesarean section rate. Different surgical and nonsurgical techniques have been described in the literature. Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction. The cesarean scar defect diminishes, and this potentially could improve the future fertility of the patient and decrease the probability of abnormal uterine bleeding and chronic pelvic pain