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Thoracic Aortic Aneurysmal Disease: Comprehensive Recommendations for the Primary Care Physician
No full textThoracic aortic aneurysm (TAA) is a commonly encountered disease that is defined as aortic dilation with an increase in diameter of at least 50% greater than the expected age- and sex-adjusted size. Thoracic aortic aneurysms are described by their size, location, morphology, and cause. Primary care clinicians and other noncardiologists are often the first point of contact for patients with TAA. This review is intended to provide them with basic information on the differential diagnosis, diagnostic evaluation, and medical and surgical management of TAAs. Management decisions depend on having as precise a diagnosis as possible. Fortunately, this can often be achieved with a stepwise diagnostic approach that incorporates imaging and targeted genetic testing. Our review includes recommendations. In this review, we discuss these issues at a basic level and include recommendations for patients considering pregnancy
The Rise of the Duodenal Switch: A Narrative Review
Get PDFBackground and Objective: Metabolic and bariatric surgery (MBS) is an excellent therapeutic modality for sustained weight loss management and obesity-related medical conditions resolution. In the current bariatric era, there exists multiple procedures and approaches. Despite sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) being the most commonly performed procedures, the duodenal switch (DS) is a more recent procedure that has shown promising outcomes. DS procedures include the classic biliopancreatic diversion with DS (BPD-DS) and the single anastomosis duodeno-ileostomy with sleeve (SADI-S). DS surgical techniques have been amended multiple times over the last decade in order to obtain optimal patient outcomes. However, bariatric surgeons are still reluctant to offer the DS as a stand-alone procedure primarily due to the perceived long-term complication rates. Therefore, we performed a review article of the available literature to highlight the role and significance of the DS in MBS, emphasizing its multifaceted benefits and the need for continued research to maximize patient outcomes and understand its full potential in the bariatric surgery landscape.
Methods: An extensive literature review (LR) was conducted to define research questions and relevant keywords. Selected databases such as PubMed, ScienceDirect, and Springer Link were searched from inception until 2023 to identify several keywords and locate relevant articles written in English.
Key Content and Findings: Our narrative review demonstrated that DS procedures are associated with favorable weight loss outcomes while also having low morbidity and mortality rates. Additionally, there is an increasing adoption rate within the bariatric field due to the role of technological advancements in overcoming previous technical challenges.
Conclusions: The increased implementation of BPD-DS and SADI-S in the current bariatric era is supported by the favorable safety and efficacy profile compared to other traditional MBS procedures. Further long-term comparative studies are needed to support these findings and reinforce the DS’s role amongst bariatric surgeons
Single-Incision Combined Laparoscopic Right Hemicolectomy and Cholecystectomy: A Case Report
Get PDFMinimally invasive surgery has transformed the management of complex procedures, offering reduced postoperative pain, faster recovery time, and improved cosmetic outcomes. Despite the growing use of minimally invasive techniques, literature specifically addressing single-incision laparoscopic surgery (SILS) for combined hemicolectomy and cholecystectomy is limited. This report seeks to fill this gap by detailing the successful management of a patient case through a single-incision combined laparoscopic right hemicolectomy and cholecystectomy. A 66-year-old female was referred to surgical consultation following a routine screening colonoscopy that identified a greater than 5 cm sessile polyp in the ascending colon. A follow-up computed tomography (CT) scan of the abdomen and pelvis revealed a non-metastatic mass in the ascending colon and gallstones correlating with the patient\u27s reported abdominal discomfort. The decision was made to proceed with a single-incision laparoscopic right hemicolectomy and cholecystectomy. The cholecystectomy and subsequent right hemicolectomy were both performed through a 3 cm umbilical incision using the advanced access platform. Postoperative recovery was uneventful, with the patient passing flatus by day three, starting a clear liquid diet, and being discharged by day four. Pathological analysis of specimens revealed chronic cholecystitis with cholelithiasis and a tubulovillous adenoma of the colon without high-grade dysplasia or metastatic carcinoma. At the 15-day follow-up, the patient reported a full resumption of normal activities and was highly satisfied with the cosmetic results. This case report highlights the benefits of combining SILS right hemicolectomy and cholecystectomy through reducing multiple abdominal procedures, surgical trauma, operating time, and recovery period, all while achieving excellent cosmetic outcomes. Further research and advanced training in SILS combined procedures are needed for broader applicability in more complex cases
Outcomes of Abortion after 26 Weeks by Timing of Mifepristone
No full textIntroduction
The safe and effective use of mifepristone in first- and second-trimester abortion care has been widely documented. Previous literature shows that mifepristone combined with misoprostol for second-trimester induction abortion results in decreased induction times proportional to the length of the mifepristone to misoprostol interval. Mifepristone use in third-trimester abortion is less studied. The DuPont Clinic, an independent all-trimester abortion clinic in Washington, D.C., employs mifepristone for abortion through 31 weeks 6 days, followed by uterine evacuation 1-2 days later, depending on gestational age. We assessed outcomes after 26 weeks by timing of mifepristone administration.
Method
We reviewed charts at the DuPont Clinic from January 2018 through June 2020, recording relevant patient characteristics and clinical data. Our protocol begins with intrafetal lidocaine injection to induce fetal asystole followed by two- or three-day processes based on factors including prior mode of delivery. Two-day patients receive mifepristone with dilator placement on day one. Three-day patients receive mifepristone after injection; dilators are placed on day two. On procedure day, all patients receive doses of misoprostol until adequate dilation is achieved, followed by instrumented uterine evacuation. Our primary outcome was induction time. We defined mifepristone time as time from mifepristone administration to induction start, and induction time as time from induction start to the end of evacuation procedure. We used linear regression to estimate the impact on induction time of mifepristone time, gestational age, and prior vaginal deliveries. Ethical review was obtained from Stanford University.
Results We identified 295 patients; 139 (47%), 99 (34%), and 57 (19%) were 26-27, 28-29, and 30-31 weeks gestation (inclusive), respectively, of which 45 (15%) were two-day and 250 (85%) were three-day procedures. Two- and three-day procedure patients had median mifepristone times of 20.8 hours (10-90%ile: 18.7, 39.8) and 41.6 hours (10-90%ile: 37.6, 43.7), respectively. Ten patients (3.4%) had artificial rupture of membranes with dilator placement; twelve (4.1%) had overnight or early morning procedures. Median induction time for two- and three-day procedure patients was 3.3 hours (10-90%ile: 0.3, 7.8) and 2.7 hours (10-90%ile: 0.5, 6.5), respectively. Each additional 6-hours of mifepristone was associated with a 37-minute decrease in induction time (95%CI: 18, 55 minutes, p\u3c0.0001). Each week of gestational age was associated with a 20-minute increase in induction time (95%CI: 6, 35 minutes, p=0.006). Each prior vaginal delivery was associated with a 33-minute decrease in induction time (95%CI: 11, 54 minutes, p=0.004). Prior cesarean delivery and patient age were not associated with a significant change in induction time.
Conclusions
Increased mifepristone time was significantly correlated with clinically relevant decreases in induction time. Increases in prior vaginal deliveries were also significantly correlated with shorter induction times, while increasing gestational age was significantly associated with longer induction time. Induction time was not significantly affected by prior cesarean delivery or patient age. Mifepristone administration one to two days prior to procedure is a safe and effective method for abortion after 26 weeks
Lack of Informed and Affirming Healthcare for Sexual Minority Men: A Call for Patient-Centered Care
Get PDFBackground: Sexual minority men (SMM) face severe health inequities alongside negative experiences that drive avoidance of medical care. Understanding how SMM experience healthcare is paramount to improving this population\u27s health. Patient-centered care, which emphasizes mutual respect and collaboration between patients and providers, may alleviate the disparaging effects of the homophobia that SMM face in healthcare settings.
Objective: To explore how SMM perceive their experiences with healthcare providers and how care can most effectively meet their needs.
Design: Semi-structured qualitative interviews focused on healthcare experiences, pre-exposure prophylaxis (PrEP), and HIV-related beliefs were conducted between July and November 2018.
Participants: The study included a sample of 43 young adult SMM (ages 25-27), representing diverse socioeconomic, racial, and ethnic backgrounds, in New York City.
Approach: Researchers utilized a multiphase, systematic coding method to identify salient themes in the interview transcripts.
Key results: Analyses revealed three main themes: (1) SMM perceived that their clinicians often lack adequate skills and knowledge required to provide care that considers participants\u27 identities and behaviors; (2) SMM desired patient-centered care as a way to regain agency and actively participate in making decisions about their health; and (3) SMM felt that patient-centered care was more common with providers who were LGBTQ-affirming, including many who felt that this was especially true for LGBTQ-identified providers.
Conclusions: SMM expressed a clear and strong desire for patient-centered approaches to care, often informed by experiences with healthcare providers who were unable to adequately meet their needs. However, widespread adoption of patient-centered care will require improving education and training for clinicians, with a focus on LGBTQ-specific clinical care and cultural humility. Through centering patients\u27 preferences and experiences in the construction of care, patient-centered care can reduce health inequities among SMM and empower healthcare utilization in a population burdened by historic and ongoing stigmatization
Whip It Good: A Case of Vitamin B12 Deficiency and Subacute Combined Degeneration of the Spinal Cord
Get PDFA 40-year-old male patient with no significant past history presented to the emergency room with bilateral upper and lower extremity numbness and difficulty walking for three weeks. MRI of the thoracic spine revealed cord signal abnormalities in the dorsal columns consistent with selective degeneration. This was congruent with the patient\u27s presentation and symptoms of myelopathy with dorsal column involvement along with peripheral polyneuropathy. Nitrous oxide inhalation was the culprit, causing acute vitamin B12 deficiency and subsequent myeloneuropathies
Battle of the Sections: Student Outcomes and Course Feedback Support Combined Prosection and Dissection Laboratory Formats to Maximize Student Success
Get PDFGross anatomy laboratories frequently utilize dissection or prosection formats within medical curricula. Practical examination scores are consistent across the formats, yet these examinations assessed larger anatomical structures. In contrast, a single report noted improved scores when prosection was used in the hand and foot regions, areas that are more difficult to dissect. The incorporation of prosected donors within Head and Neck laboratories provided an opportunity to further characterize the impact of prosection in a structurally complex area. Retrospective analysis of 21 Head and Neck practical examination questions was completed to compare scores among cohorts that utilized dissection exclusively or incorporated prosection. Mean scores of practical examination questions were significantly higher in the prosection cohort (84.27% ± 12.69) as compared with the dissection cohort (75.59% ± 12.27) (p \u3c 0.001). Of the 12 questions that performed better in the prosection cohort (88.42% ± 8.21), 10 items mapped to deeper anatomical regions. By comparison, eight of nine questions in the dissection cohort outperformed (88.44% ± 3.34) the prosection cohort (71.74% ± 18.11), and mapped to anatomically superficial regions. Despite the mean score increase with positional location of the questions, this effect was not statically significant across cohorts (p = 1.000), suggesting that structure accessibility in anatomically complex regions impacts performance. Student feedback cited structure preservation (71.5%) and time savings (55.8%) as advantages to prosection; however, dissection was the perceived superior and preferred laboratory format (88.6%). These data support combined prosection and dissection formats for improving student recognition of deeply positioned structures and maximizing student success
Rhabdomyosarcoma in Adults: De Novo or Conversion From Non-seminomas?
Get PDFRhabdomyosarcoma (RMS) is a highly sporadic, very aggressive, and fatal soft tissue tumor in adults. Although more common and treatable in the pediatric population, the occurrence of pleomorphic RMS in adults has a low incidence. Hence, it is not easy to treat. Surgery is the primary definitive treatment, along with radiation therapy, while adjuvant chemotherapy has recently gained popularity. We present an infrequent case of RMS in a patient with a recent history of mixed non-seminomatous germ-cell tumor testicular cancer. Therefore, it was challenging to treat the RMS as a new malignancy or as a recurrence of non-seminomatous testicular cancer. Our patient passed away, unfortunately, but we hope this case can help the minimal data in this regard in order to save more lives in the future