Spontaneous rupture of a mycotic splenic artery pseudoaneurysm secondary to histoplasmosis: a case report.

BACKGROUND: A splenic artery pseudoaneurysm is a rare pathology that occurs mainly secondary to pancreatitis, abdominal trauma, peptic ulcers, pancreatic and gastric cancers, and infections. It is best diagnosed using computed tomography angiography and typically treated using endovascular embolization and, in some cases, open or laparoscopic surgery. In this report, we present a case of a ruptured mycotic splenic artery pseudoaneurysm containing Histoplasma capsulatum, which to our knowledge is the first case to report a mycotic splenic artery pseudoaneurysm of this nature. CASE PRESENTATION: We report a case of a 42-year-old white male with past medical history of Hepatitis C and IV drug abuse who presented to the Emergency Department with a 24-h history of severe diffuse abdominal pain. He was tachycardic and peritonitic on exam. Work-up demonstrated leukocytosis and lactic acidosis. Computed tomography of the abdomen and pelvis with intravenous contrast showed hemoperitoneum and active extravasation of contrast from the splenic artery into the splenic hilum, associated with a surrounding hematoma measuring 5.3 × 5.0 cm, concerning for ruptured splenic artery pseudoaneurysm. The patient was taken emergently for exploratory laparotomy, where a large intraperitoneal hematoma was evacuated. A ruptured splenic artery pseudoaneurysm was identified, isolated, and controlled, followed by completion splenectomy. Final pathology demonstrated a 3.0 × 1.3 × 0.3 cm pseudoaneurysm wall and a 14 × 9.5 × 5.5 cm spleen containing multiple necrotizing granulomata positive for the presence of Histoplasmosis species. The patient recovered appropriately and was discharged on post-operative day five. CONCLUSIONS: This case demonstrates a successful approach to a ruptured mycotic splenic artery pseudoaneurysm resulting in a positive outcome. It is a unique case as it highlights, to our knowledge, the first report of splenic artery aneurysm secondary to Histoplasma capsulatum infection. This report helps further the understanding of the pathophysiology as well as the natural history of mycotic splenic pseudoaneurysms.

Colorectal Sarcomatoid Carcinoma: 30-Year Experience.

Background: Primary colorectal sarcomatoid carcinoma is a rare and aggressive malignant neoplasm that displays mixed epithelial and mesenchymal differentiation, with uncertain histogenesis. First described in 1986, there is a paucity of literature related to this condition and there are no evidence-based treatment guidelines. The aim of our study is to present our 30-year experience with primary colorectal sarcomatoid carcinoma. Methods: Retrospective single-center analysis of all patients treated for primary colorectal sarcomatoid carcinoma from 1992 to 2022. The primary outcome was response to treatment strategy and overall survival. Results: A total of six cases met eligibility criteria. Three were male (50%) with a mean age at diagnosis of 59 years (range, 49-72). Four neoplasms were located in the rectum (66%) and two in the colon. Mean tumor size at diagnosis was 4.8 cm (range, 2.8-7.0). Three patients were treated endoscopically and three underwent oncologic surgical resection. Five experienced recurrence and one expired from other comorbidities. The mean survival among those with colonic and rectal sarcomatoid carcinoma was 7 months (range, 3-11) and 39 months (range, 9-60), respectively. Discussion: Primary colorectal sarcomatoid carcinoma is a rare malignant tumor with poor prognosis. Treatment modalities have not been standardized and despite multimodal therapy, disease recurrence and/or metastasis is likely to occur. Further studies are necessary to determine optimal treatment to improve outcomes.

Outcomes in robotic-assisted compared to laparoscopic-assisted colorectal surgery in a newly established colorectal tertiary center: a retrospective comparative cohort study.

The robotic platform matches or surpasses laparoscopic surgery in postoperative results. However, limited date and slow adoption are noticed in the middle east. We aimed to report outcomes of robotic and laparoscopic colorectal surgery performed by fellowship-trained robotic colorectal surgeons and compare it to larger more experienced centers. Retrospective review of prospectively collected data between 2021 and 2023 of 107 patients who had robotic-assisted or laparoscopic-assisted colorectal surgery was included in the study. The outcomes were overall morbidity, serious morbidity, mortality, conversion to open, length of hospital stay, and the quality of oncological specimen. Of 107 patients, 57 were in the robotic and 50 were in the laparoscopic surgery groups. Overall, there were no significant differences in overall morbidity (46.8 vs. 53.2%, p = 0.9), serious morbidity (10.5 vs. 8%, p = 0.7), or mortality (0 vs. 4%, p = 0.2). Regarding oncological outcomes, there were no significant difference between the two groups regarding the number of lymph node harvested (17.7 ± 6.9 vs 19.0 ± 9.7, p = 0.5), R0 resections (92.7 vs. 87.1%, p = 0.5), and the rate of complete mesorectal excision (92.7 vs. 71.4%, p = 0.19). The study found that the robotic group had an 86% reduction in conversion rate to open surgery compared to the laparoscopic group, despite including more obese and physically dependent patients (OR = 0.14, 95% CI 0.03-0.7, p = 0.01). Robotic surgery appears to be a safe and effective as laparoscopic surgery in smaller colorectal surgery programs led by fellowship-trained robotic surgeons, with outcomes comparable to those of larger programs.

Situações de urgência e emergência na atenção primária reguladas pelo SAMU / Urgency and emergency situations in primary care regulated by SAMU / Situaciones de urgencia y emergencia en la atención primaria regulada por el SAMU

Objetivo: identificar as principais situações de urgência e emergência que chegam aos serviços de atenção primária e que são encaminhadas para serviços de maior complexidade reguladas pelo serviço de atendimento móvel de urgência. Método: estudo longitudinal e prospectivo realizado em 21 unidades de saúde. A coleta de dados ocorreu entre junho de 2014 a maio de 2015. Resultados: Foram realizadas 57 chamadas para o SAMU, sendo 28 originadas de unidades com estratégia de saúde da família. A idade média dos pacientes foi de 40,94+13,21 anos, a maioria era do sexo feminino e o sistema mais afetado foi o cardiovascular seguido pelo neurológico. Tempo médio de deslocamento para o SAMU chegar ao local do chamado foi 31,69±21,50 minutos. Os encaminhamentos realizados foram para unidade de pronto atendimento na sua maioria. Conclusão: Alterações dos sistemas cardiovascular e neurológico foram as mais prevalentes dentre as situações reguladas pelo serviço de atendimento móvel de urgência na atenção primária.

Objective: To identify the main emergency and emergency situations that reach the primary care services and which are sent to more complex services regulated by the mobile emergency service. Method: A prospective longitudinal study performed in 21 health units. Data collection occurred between June 2014 and May 2015. Results: 57 calls were made to SAMU, 28 of which originated from units with a family health strategy. The mean age of the patients was 40.94 + 13.21 years, the majority was female and the system most affected was the cardiovascular followed by the neurological. Average travel time for the SAMU arriving at the named location was 31.69 ± 21.50 minutes. The referrals were made to the nearest emergency care unit. Conclusion: Changes in the cardiovascular and neurological systems were the most prevalent among the situations regulated by the emergency mobile service in primary care.

Objetivo: Identificar las principales situaciones de urgencia y emergencia que llegan a los servicios de atención primaria y que son encaminadas para servicios de mayor complejidad reguladas por el servicio de atención móvil de urgencia. Método: Estudio longitudinal prospectivo realizado en 21 unidades de salud. La recolección de datos ocurrió entre junio de 2014 a mayo de 2015. Resultados: Se realizaron 57 llamadas para el SAMU, siendo 28 originadas de unidades con estrategia de salud de la familia. La edad media de los pacientes fue de 40,94 + 13,21 años, la mayoría era del sexo femenino y el sistema más afectado fue el cardiovascular seguido por el neurológico. Tiempo promedio de desplazamiento para el SAMU llegar al lugar del llamado fue 31,69 ± 21,50 minutos. Los encaminamientos realizados fueron para unidad de pronta atención en su mayoría. Conclusión: Alteraciones de los sistemas cardiovascular y neurológico fueron las más prevalentes entre las situaciones reguladas por el servicio de atención móvil de urgencia en la atención primaria.

Epinephrine Autoinjector Prescribing Trends: An Outpatient Population-Based Study in Olmsted County, Minnesota.

BACKGROUND: The prescribing pattern of epinephrine over time is an indicator of the secular trend of anaphylaxis. However, it is not well known in a population level in the United States. OBJECTIVE: To evaluate the trend of prescriptions for epinephrine autoinjectors in Olmsted County, Minn, residents. METHODS: Outpatient prescriptions for epinephrine were identified among residents of Olmsted County, Minn, between January 1, 2004, and December 31, 2010. We used the first prescription per patient per year, and the first prescription per patient during the study period to calculate incidence rates. Incidence rates per 100,000 person-years were calculated using patients prescribed epinephrine per year as the numerator and age- and sex-specific counts of the population of Olmsted County as the denominator. The relationships of age group, sex, and year of prescription with incidence rates were assessed by fitting Poisson regression models using the SAS procedure GENMOD. RESULTS: The overall incidence rate of epinephrine autoinjector prescriptions during the study period was 757 per 100,000 person-years (95% confidence interval: 740-774). The prescription rates per patient per year increased over time, with an annual rate of increase of 8% (P < .001), but the rates per patient remained stable (P = .077). For each year, incidence rates overall were higher in women compared with men (P < .001). From ages 0 to 19, incidence rates were higher in boys compared with girls. At age 20 and above, incidence rates were higher in women compared with men. CONCLUSIONS: The overall rate of epinephrine autoinjector prescriptions increased, but the rate of first-time prescriptions was stable from 2005 to 2010. In childhood, boys were more likely to receive a prescription than girls, but this reversed in later ages.

Comparison of medical versus surgical management of peritonsillar abscess: A retrospective observational study.

OBJECTIVES/HYPOTHESIS: To compare clinical characteristics and outcomes in patients presenting with peritonsillar abscess (PTA) treated with either initial medical or surgical management. STUDY DESIGN: Retrospective observational cohort. METHODS: A consecutive cohort of patients presenting between 2010 and 2014 with the final diagnosis of PTA (International Classification of Diseases, Ninth Revision code 475) were included. Comparisons between groups were evaluated using two-sample t, Wilcoxon rank sum, χ(2) , and Fisher exact tests. RESULTS: Among 297 patients who presented with PTA during the 5-year period, 97 (33%) underwent primary medical management, and 200 (67%) received surgical treatment. Patients who received initial surgical management had larger abscess size (2.6 vs. 1.3 cm, P < .001) and were and more likely to have muffled voice (79% vs. 47%, P < .001), drooling (29% vs. 17%, P = .03), peritonsillar bulge (91% vs. 66%, P < .001), trismus (65% vs. 22%, P < .001), and dysphagia (86% vs. 73%, P = .008). There was no difference in the rates of imaging (55% vs. 59%) or antibiotic administration (100% in both groups), length of hospital stay (median 2 vs. 1 day, P = .27) or complications (1% vs. 2%, P = .6). Patients treated medically were more likely to be admitted to the hospital (22% vs. 11%, P = .014) and less likely to receive steroids (78% vs. 95%, P < .001). There was no difference in return visits (20% medical vs. 14% surgical, P = .17) or failure rates (5% medical vs. 3% surgical, P = .30). CONCLUSIONS: Initial medical management can be considered in patients with less advanced symptoms or smaller abscess size without compromising outcome. Those with more advanced symptoms may benefit from surgical drainage. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1529-1534, 2016.

Impact of video game genre on surgical skills development: a feasibility study.

BACKGROUND: The playing of video games (VGs) was previously shown to improve surgical skills. This is the first randomized, controlled study to assess the impact of VG genre on the development of basic surgical skills. MATERIALS AND METHODS: Twenty first-year, surgically inexperienced medical students attended a practical course on surgical knots, suturing, and skin-flap technique. Later, they were randomized into four groups: control and/or nongaming (ContG), first-person-shooter game (ShotG), racing game (RaceG), and surgery game (SurgG). All participants had 3 wk of Nintendo Wii training. Surgical and VG performances were assessed by two independent, blinded surgeons who evaluated basal performance (time 0) and performance after 1 wk (time 1) and 3 wk (time 2) of training. RESULTS: The training time of RaceG was longer than that of ShotG and SurgG (P = 0.045). Compared to SurgG and RaceG, VG scores for ShotG improved less between times 0 and 1 (P = 0.010) but more between times 1 and 2 (P = 0.004). Improvement in mean surgical performance scores versus time differed in each VG group (P = 0.011). At time 2, surgical performance scores were significantly higher in ShotG (P = 0.002) and SurgG (P = 0.022) than in ContG. The surgical performance scores of RaceG were not significantly different from the score achieved by ContG (P = 0.279). CONCLUSIONS: Different VG genres may differentially impact the development of surgical skills by medical students. More complex games seem to improve performance even if played less. Although further studies are needed, surgery-related VGs with sufficient complexity and playability could be a feasible adjuvant to improving surgical skills.

Functional and psychological features immediately after discharge from an intensive care unit: prospective cohort study.

OBJECTIVE: To assess the functional and psychological features of patients immediately after discharge from the intensive care unit. METHODS: Prospective cohort study. Questionnaires and scales assessing the degree of dependence and functional capacity (modified Barthel and Karnofsky scales) and psychological problems (Hospital Anxiety and Depression Scale), in addition to the Epworth Sleepiness Scale, were administered during interviews conducted over the first week after intensive care unit discharge, to all survivors who had been admitted to this service from August to November 2012 and had remained longer than 72 hours. RESULTS: The degree of dependence as measured by the modified Barthel scale increased after intensive care unit discharge compared with the data before admission (57 ± 30 versus 47 ± 36; p < 0.001) in all 79 participants. This impairment was homogeneous among all the categories in the modified Barthel scale (p < 0.001) in the 64 participants who were independent or partially dependent (Karnofsky score ≥ 40) before admission. The impairment affected the categories of personal hygiene (p = 0.01) and stair climbing (p = 0.04) only in the 15 participants who were highly dependent (Karnofsky score < 40) before admission. Assessment of the psychological changes identified mood disorders (anxiety and/or depression) in 31% of the sample, whereas sleep disorders occurred in 43.3%. CONCLUSIONS: Patients who remained in an intensive care unit for 72 hours or longer exhibited a reduced functional capacity and an increased degree of dependence during the first week after intensive care unit discharge. In addition, the incidence of depressive symptoms, anxiety, and sleep disorders was high among that population.

Aspectos funcionais e psicologicos imediatamente apos alta da Unidade de Terapia Intensiva: coorte prospectiva / Functional and psychological features immediately after discharge from an Intensive Care Unit: prospective cohort study

OBJETIVO: Avaliar aspectos funcionais e psicológicos dos pacientes imediatamente após alta da unidade de terapia intensiva. MÉTODOS: Coorte prospectiva. Na primeira semana após alta da unidade de terapia intensiva, por meio de uma entrevista estruturada, foram aplicados questionários e escalas referentes à avaliação do grau de dependência e da capacidade funcional (escalas de Barthel modificada e Karnofsky), e aos problemas psíquicos (questionário hospitalar de ansiedade e depressão), além da escala de sonolência de Epworth, em todos os sobreviventes com mais de 72 horas de internação na unidade de terapia intensiva, admitidos de agosto a novembro de 2012. RESULTADOS: Nos 79 pacientes incluídos no estudo, houve aumento do grau de dependência após a alta da unidade de terapia intensiva, quando comparados aos dados pré-hospitalização, por meio da escala de Barthel modificada (57±30 versus 47±36; p<0,001). Nos 64 pacientes independentes ou parcialmente dependentes previamente à internação (Karnofsky >40), o prejuízo foi uniforme em todas as categorias da escala de Barthel modificada (p<0,001). Já nos 15 pacientes previamente muito dependentes (Karnofsky <40), o prejuízo ocorreu somente nas categorias de higiene pessoal (p=0,01) e na capacidade de subir escadas (p=0,04). Na avaliação dos distúrbios psicológicos, os transtornos do humor (ansiedade e/ou depressão) ocorreram em 31% dos pacientes e os distúrbios do sono em 43,3%. CONCLUSÃO: Em pacientes internados na unidade de terapia intensiva por 72 horas ou mais, observaram-se redução da capacidade funcional e aumento do grau de dependência na primeira semana após alta da unidade de terapia intensiva, bem como elevada incidência de sintomas depressivos, de ...

OBJECTIVE: To assess the functional and psychological features of patients immediately after discharge from the intensive care unit. METHODS: Prospective cohort study. Questionnaires and scales assessing the degree of dependence and functional capacity (modified Barthel and Karnofsky scales) and psychological problems (Hospital Anxiety and Depression Scale), in addition to the Epworth Sleepiness Scale, were administered during interviews conducted over the first week after intensive care unit discharge, to all survivors who had been admitted to this service from August to November 2012 and had remained longer than 72 hours. RESULTS: The degree of dependence as measured by the modified Barthel scale increased after intensive care unit discharge compared with the data before admission (57±30 versus 47±36; p<0.001) in all 79 participants. This impairment was homogeneous among all the categories in the modified Barthel scale (p<0.001) in the 64 participants who were independent or partially dependent (Karnofsky score ≥40) before admission. The impairment affected the categories of personal hygiene (p=0.01) and stair climbing (p=0.04) only in the 15 participants who were highly dependent (Karnofsky score <40) before admission. Assessment of the psychological changes identified mood disorders (anxiety and/or depression) in 31% of the sample, whereas sleep disorders occurred in 43.3%. CONCLUSIONS: Patients who remained in an intensive care unit for 72 hours or longer exhibited a reduced functional capacity and an increased degree of dependence during the first week after intensive care unit discharge. In addition, the incidence of depressive symptoms, anxiety, and sleep disorders was high among that population. .