Evaluation of Surgical Improvement of Clinical Knowledge Ops (SICKO), an Interactive Training Platform.

Over the past two decades, there have been numerous attempts at using surgical simulation software for training purposes. There has been extensive prior success at using digital laparoscopic tools and virtual and augmented reality in strengthening specific surgical techniques, but clinical decision-making simulation has been limited to multiple choice question banks. Surgical Improvement of Clinical Knowledge Ops (SICKO) is a web-based educational application that takes users through various aspects of clinical decision-making in the field of surgery.App SpecsApp name: Surgical Improvement of Clinical Knowledge Ops (SICKO)App developer: James Lau M.D., Dana Lin M.D., Julia Park M.D.App website/URL*: http://med.stanford.edu/sm/archive/sicko/game/SICKOTitle.html App price: The website is free to use and has no microtransactionsCategory: educational, surgery simulation, clinical decision makingTags: web-based app, surgical simulation, learning, healthcare, gamificationWorks offline: noBrowsers: Works on Google Chrome, Mozilla Firefox, Safari, and Microsoft EdgeFDA approval: N/A*It should be noted that although the URL leads to a website with a tab header that reads "SEPTRIS," an older iteration of the game, the interactive experience is actually SICKO, which the user can clearly see from the webpage itself.Quick Review (1 star, lowest; 5 stars, highest)Overall Rating (1-5): 4.5Content (1-5): 5Usability (1-5): 5Design (1-5): 4Ratings Disclosure: The SICKO application was reviewed by two independent medical student authors of this article, as well as a resident physician. The reviews were done anonymously through each reviewer's own input and were blinded to each other's ratings until completion of the simulation. Each reviewer completed full renditions of the game from beginning to end to experience a situation where the patient expired, as well as one where the patient was saved in order to observe the full user experience. Both authors felt that the game was remarkably useful, with the only criticism being the simple graphical design of the application. No reviewers or authors of this paper have any connection to the software content or development team of SICKO.

A Comprehensive Review of the Diagnosis, Treatment, and Management of Urologic Chronic Pelvic Pain Syndrome.

PURPOSE OF REVIEW: Urologic chronic pelvic pain syndrome (UCPPS) is a chronic, noncyclic pain condition which can lead to significant patient morbidity and disability. It is defined by pain in the pelvic region, lasting for greater than 3 to 6 months, with no readily identifiable disease process. The aim of this review is to provide a comprehensive update of diagnosis and treatment of UCPPS. RECENT FINDINGS: UCPPS encompasses chronic pelvic pain syndrome or chronic prostatitis (CP/CPPS) in men and interstitial cystitis or painful bladder syndrome (IC/PBS) in women. Underlying inflammatory, immunologic, and neuropathic components have been implicated in the pathogenesis of UCPPS. For optimal patient management, an individualized and multimodal approach is recommended. Medical management and physical therapy are the mainstays of treatment. Injection therapy may offer additional relief in medically refractory patients. Further minimally invasive management may include spinal cord and peripheral nerve stimulation, though evidence supporting efficacy is limited.

A Comprehensive Review of the Diagnosis, Treatment, and Management of Postmastectomy Pain Syndrome.

PURPOSE OF REVIEW: Postmastectomy pain syndrome (PMPS) remains poorly defined, although it is applied to chronic neuropathic pain following surgical procedures of the breast, including mastectomy and lumpectomy in breast-conserving surgery. It is characterized by persistent pain affecting the anterior thorax, axilla, and/or medial upper arm following mastectomy or lumpectomy. Though the onset of pain is most likely to occur after surgery, there may also be a new onset of symptoms following adjuvant therapy, including chemotherapy or radiation therapy. RECENT FINDINGS: The underlying pathophysiology is likely multifactorial, although exact mechanisms have yet to be elucidated. In this regard, neuralgia of the intercostobrachial nerve is currently implicated as the most common cause of PMPS. Numerous pharmacological options are available in the treatment of PMPS, including gabapentinoids, tricyclic antidepressants, selective serotonin reuptake inhibitors, NMDA receptor antagonists, and nefopam (a non-opioid, non-steroidal benzoxazocine analgesic). Minimally invasive interventional treatment including injection therapy, regional anesthesia, botulinum toxin, and neuromodulation has been demonstrated to have some beneficial effect. A comprehensive update highlighting current perspectives on the treatment of postmastectomy pain syndrome is presented with emphasis on treatments currently available and newer therapeutics currently being evaluated to alleviate this complex and multifactorial condition.

Clinical Considerations and Outcomes of Robotic Urologic Surgery in Obese Patients.

Obesity is associated with many significant physiological changes. These considerations are important to surgery, especially in urological procedures. Obese patients often undergo surgical procedures and are at higher risk of complications. This investigation reviews physiological and anaesthesia considerations for obese and morbidly obese patients. In addition, urological surgeries and procedures should be considered for these higher risk patients. Clinical anaesthesiologists must use detailed assessment and, when appropriate, consultation in developing safe anaesthesia plans for these patients. Newer technologies have improved safety related to airway management, advanced airway devices, and regional anaesthesia with ultrasound-guided nerve blocks, which can reduce the need for opioids postoperatively. Recent developments in drug and monitoring technologies have also been developed and can be effective for obese and morbidly obese patients undergoing urological procedures and perioperative surgery, thus improving the likelihood of safety in this higher risk population.

Sustained response to pembrolizumab in recurrent perivascular epithelioid cell tumor with elevated expression of programmed death ligand: a case report.

BACKGROUND: Perivascular epithelioid cell tumors are defined by the World Health Organization as "a collection of rare mesenchymal tumors composed of histologically and immunohistochemically distinctive perivascular epithelioid cells." Whereas localized perivascular epithelioid cell tumor is typically benign and treated successfully with surgical resection, prognosis for patients with advanced or metastatic perivascular epithelioid cell tumor is unfavorable, and there is no standard curative treatment. CASE PRESENTATION: We report a Caucasian case of metastatic perivascular epithelioid cell tumor previously treated with chemotherapy and surgery with elevated surface expression of programmed cell death ligand 1. Based on this result, treatment via immune checkpoint inhibition with the monoclonal antibody pembrolizumab was pursued. After 21 cycles, the patient sustained a complete response. Therapy was stopped after the 40th cycle, and she was moved to surveillance. She remained disease free 19 months off treatment. CONCLUSIONS: This case report of a patient with perivascular epithelioid cell tumor treated successfully with programmed cell death protein-1 targeted therapy suggests that programmed cell death ligand-1 levels should be measured in patients with perivascular epithelioid cell tumor and immunotherapy considered for recurrent or metastatic patients. Future phase II/III studies in this disease should focus on sequencing of surgery and immunotherapy with a design of curative intent.

Hyperprolactinemia, Clinical Considerations, and Infertility in Women on Antipsychotic Medications.

Infertility, the inability to establish a clinical pregnancy after 12 months of regular unprotected sexual intercourse, is caused by a wide variety of both male and female factors. Infertility is estimated to affect between 8-12% of couples trying to conceive globally. Female factor infertility can be subdivided into the following broad categories: ovulatory dysfunction, fallopian tubal disease, uterine causes, and oocyte quality. Hyperprolactinemia causes ovulary dysfunction along with other hormonal abnormalities, such as decreased estrogen, which can lead to infertility. In this regard, antipsychotics are commonly used for both schizophrenia and bipolar disorder. The use of these medications can be associated with hyperprolactinemia and hyperprolactinemia associated infertility. Antipsychotic-induced hyperprolactinemia occurs through blockade of D2 receptors on lactotroph cells of the anterior pituitary gland. Discontinuation of the hyperprolactinemia-inducing antipsychotic is an option, but this may worsen the patient's psychosis or mood. If antipsychotics are determined to be the culprit of infertility, the degree of hyperprolactinemia symptoms, length of treatment with the antipsychotic, and risk of relapse should be assessed prior to discontinuation, reduction, or switching of antipsychotic medications. The treatment of a women's mental health and her desire to have children should always be considered as treatment may influence fertility while on the medication.

Non-Opioid Perioperative Pain Strategies for the Clinician: A Narrative Review.

Alternative and non-opioid options for pain management are necessary in perioperative patient care. Opioids are no longer touted as cure-all medications, and furthermore, there have been tremendous advances in alternative therapies such as in interventional pain, physical therapy, exercise, and nutritional counseling that have proven benefits to combat pain. The center for disease control now strongly recommends the use of multimodal analgesia and multidisciplinary approaches based on the individual needs of patients: personalized medicine. In this manuscript, the specifics of non-opioid pharmacological and non-pharmacological analgesic approaches will be discussed as well as their possible indications and uses to reduce the need for excessive use of opioids for adequate pain control.

Clinical considerations for epidermal necrolysis.

BACKGROUND: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a spectrum of acute life-threatening mucocutaneous reactions that differ only in severity. Both diseases are characterized by mucous membrane and skin involvement, are often caused by medications, and are collectively known as epidermal necrolysis (EN). METHODS: A severity of illness score has been devised to predict prognosis in patients with EN. The scoring system addresses 7 prognostic factors. RESULTS: Patients with EN require supportive care. Those with extensive skin involvement should be admitted to an intensive care unit or burn unit if possible. Suspected, as well as unnecessary, medications should be discontinued. Baseline laboratory tests, imaging, cultures, and biopsies should be obtained. Intravenous access should be established and hydration and nutritional support begun. Daily oral care, wound care, pain control, and early physician consultation are also important aspects of treatment. CONCLUSION: EN requires early diagnosis, appropriate workup, and appropriate treatment to minimize potential morbidity and mortality. In many clinicians' experience, EN is rare; therefore, education and improved understanding of the potential causes and appropriate treatment regimens are vital when confronted with such a patient.