Surgical Management of Tumoral Calcinosis of the Hand: A Case Report.

Primary tumoral calcinosis is a rare and benign condition characterized by calcium salt deposition in periarticular soft tissues. It typically presents as a firm, rubbery mass that arises around large joints. While an estimated 250 cases have been described since its discovery, very few cases have been identified in the hand. We present a case of multiple calcified masses in the hand, one of which required meticulous dissection from a digital neurovascular bundle, and our technique for surgical excision. We present this case to lower the threshold for clinical suspicion of tumoral calcinosis for patients who present with a soft tissue mass in the hand. Furthermore, we recommend prompt surgical excision due to low success rates of alternative treatment options and to prevent potential neurovasculature or tendon injury.

Postoperative Ovarian Vein Thrombosis and Treatment with Direct Oral Anticoagulant.

Postoperative ovarian vein thrombosis (OVT) is a rare complication following hysterectomy. Due to its ambiguous presentation, most frequently presenting as a fever with no known source and lower quadrant abdominal pain, OVTs are commonly diagnosed incidentally on computed tomography as a low-attenuation thrombus in place of the ovarian vein. The cornerstones of OVT treatment include anticoagulation and antibiotic therapy; however, there are no current guidelines to inform provider decision-making regarding specific anticoagulant agents, dosing, or length of therapy. We present a patient with a history of deep-vein thrombosis, who presented to the emergency department with OVT following a laparoscopic hysterectomy. She was treated with apixaban, a direct oral anticoagulant (DOAC), and experienced repeated episodes of vaginal bleeding and hematoma expansion. We present this case to instill a high index of suspicion for OVT after laparoscopic hysterectomy, and to discuss the role of DOACs in patients with thromboembolic disease and concurrent bleeding.

Feasibility and impact of a postpartum hemorrhage emergency care package using a bundle approach in Migori County, Kenya.

OBJECTIVE: To investigate the impact of the PPH Emergency Care package (PPH EmC)-a holistic intervention that uses a bundle approach that has been implemented in Kenya, India, Nepal, Bangladesh, and Central America-in a low-resource setting. METHODS: The feasibility and impact of PPH EmC implementation in Migori County, Kenya was studied using a qualitative research design. In March and April 2022 key informants were identified using purposive sampling. Semi-structured interviews were conducted over Zoom from March to May 2022 until thematic saturation was reached. Interviews were transcribed, coded, and analyzed for emerging themes. RESULTS: PPH EmC has positively impacted facility and health system preparedness, referral coordination, teamwork and communication, and overall capacity to provide quality PPH emergency care. Participants reported that PPH EmC is sustainable because of its low cost and support from local partners. CONCLUSION: Implementation of PPH EmC in Migori County, Kenya was feasible and positively impacted PPH emergency care.

Predictors of nonadherence to breast cancer screening guidelines in a United States urban comprehensive cancer center.

BACKGROUND: This study aimed to identify predictors of nonadherence to breast cancer screening guidelines in an urban screening clinic among high- and average-risk women in the United States. METHODS: We reviewed records of 6090 women who received ≥2 screening mammograms over 2 years at the Karmanos Cancer Institute to examine how breast cancer risk and breast density were associated with guideline-concordant screening. Incongruent screening was defined as receiving supplemental imaging between screening mammograms for average-risk women, and as not receiving recommended supplemental imaging for high-risk women. We used t-tests and chi-square tests to examine bivariate associations with guideline-congruent screening, and probit regression to regress guideline-congruence unto breast cancer risk, breast density, and their interaction, controlling for age and race. RESULTS: Incongruent screening was more likely among high- versus average-risk women (97.7% vs. 0.9%, p < 0.01). Among average-risk women, incongruent screening was more likely among those with dense versus nondense breasts (2.0% vs. 0.1%, p < 0.01). Among high-risk women, incongruent screening was more likely among those with nondense versus dense breasts (99.5% vs. 95.2%, p < 0.01). The significant main effects of density and high-risk on increased incongruent screening were qualified by a density by high-risk interaction, showing a weaker association between risk and incongruent screening among women with dense breasts (simple slope = 3.71, p < 0.01) versus nondense breasts (simple slope = 5.79, p < 0.01). Age and race were not associated with incongruent screening. CONCLUSIONS: Lack of adherence to evidence-based screening guidelines has led to underutilization of supplementary imaging for high-risk women and potential overutilization for women with dense breasts without other risk factors.

Bias in Surgical Residency Evaluations: A Scoping Review.

OBJECTIVE: Given widespread disparities in the surgical workforce and the advent of competency-based training models that rely on objective evaluations of resident performance, this review aims to describe the landscape of bias in the evaluation methods of residents in surgical training programs in the United States. DESIGN: A scoping review was conducted within PubMed, Embase, Web of Science, and ERIC in May 2022, without a date restriction. Studies were screened and reviewed in duplicate by 3 reviewers. Data were described descriptively. SETTING/PARTICIPANTS: English-language studies conducted in the United States that assessed bias in the evaluation of surgical residents were included. RESULTS: The search yielded 1641 studies, of which 53 met inclusion criteria. Of the included studies, 26 (49.1%) were retrospective cohort studies, 25 (47.2%) were cross-sectional studies, and 2 (3.8%) were prospective cohort studies. The majority included general surgery residents (n = 30, 56.6%) and nonstandardized examination modalities (n = 38, 71.7%), such as video-based skills evaluations (n = 5, 13.2%). The most common performance metric evaluated was operative skill (n = 22, 41.5%). Overall, the majority of studies demonstrated bias (n = 38, 73.6%) and most investigated gender bias (n = 46, 86.8%). Most studies reported disadvantages for female trainees regarding standardized examinations (80.0%), self-evaluations (73.7%), and program-level evaluations (71.4%). Four studies (7.6%) assessed racial bias, of which all reported disadvantages for trainees underrepresented in surgery. CONCLUSIONS: Evaluation methods for surgery residents may be prone to bias, particularly with regard to female trainees. Research is warranted regarding other implicit and explicit biases, such as racial bias, as well as for nongeneral surgery subspecialties.

Humicola Trauma-related Invasive Fungal Infection in an Immunocompetent Patient.

The majority of invasive fungal infections arise in immunocompromised patients; however, there exist many clinical interventions and physiologic phenomena in the setting of traumatic injury that induce immunosuppressant states. Enhanced clinical suspicion and early detection of invasive fungal infections has played an increasingly pertinent role in clinical management of patients admitted for traumatic injury, given its substantial morbidity and mortality rates. In this case report, we discuss a case of trauma-related invasive fungal infection by a rare humicola pathogen in a previously immunocompetent patient. We present this case in hopes of instilling a high index of clinical suspicion for trauma-related invasive fungal infections. We also discuss the role of negative pressure wound therapy and aggressive surgical management, including debridement and various levels of amputation to optimize patient outcomes. Clinical management of trauma-related IFI has adopted increasingly aggressive approaches with respect to its formidable morbidity and mortality rates. Multidisciplinary discussions and patient-centered care are essential when making surgical decisions that impact quality of life such as amputation level.

E-Z Point: A New Safe and Reproducible Laparoscopic Entry in the Left Upper Quadrant Using a Veress Needle.

Background: Over half of all fatal complications occur during primary laparoscopic entry. In our practice, we developed a novel modification of closed LUQ entry at Palmer's point and designated it "E-Z" entry. Aims: To evaluate the risks and safety of left subcostal entry, a technique we have designated 'E-Z' entry at our institution. Settings and Design: A retrospective chart review was conducted at a tertiary care medical centre of patients who underwent laparoscopic procedures by a single surgeon known to perform left subcostal entry for the last 10 years, using the E-Z entry technique. Materials and Methods: Retrospective chart review and description of surgical technique. Statistical Analysis Used: Simple descriptive statistics and univariate two-group comparisons. Results: One hundred ninety-eight laparoscopic cases were identified as performed by a single surgeon in the last 10 years: 149 underwent umbilical entry and 49 underwent E-Z entry. The average number of previous abdominal surgeries was higher in the E-Z entry group compared to the umbilical group, 1.3 versus 0.5, respectively (P = 0.003). The umbilical entry group had no complications. One complication was noted with the E-Z entry technique, in which the Veress needle was noted to perforate the liver capsule but was managed expectantly. Conclusion: We propose the E-Z entry technique for Veress needle entry as an ergonomic and easily reproducible entry technique in the left upper quadrant in the setting of suspected intraperitoneal adhesions.