RESUMEN
Typhoid fever is an infectious febrile illness caused by Salmonella typhi that is rare in the United States but is endemic in regions of South Asia and Africa. Typhoid fever initially presents with nonspecific symptoms such as fever, malaise, and abdominal pain. We describe a case of typhoid fever in an adult in the United States with recent travel to Mexico. After a nonspecific presentation, the patient developed Faget sign and computed tomography (CT) of the abdomen revealed mesenteric adenitis, which prompted additional workup. Diagnosis of typhoid fever was established by blood culture and the patient was treated with ciprofloxacin.
RESUMEN
Macroenzymes are high molecular weight complexes that are formed by the binding of normal serum enzymes with circulating immunoglobulins - primarily IgG, IgA, and IgM. These high molecular weight complexes are difficult to clear through the kidneys, therefore they remain persistently elevated in the serum leading to inaccurate diagnoses and unnecessary workup. The prevalence of macroenzymes is relatively rare in the general population; however, it is an important phenomenon to be aware of when working up isolated elevations in serum enzymes. A quick and efficient test for the detection of macroenzymes is the polyethylene glycol precipitation test. Here, we present a case of macro-aspartate aminotransferase masquerading as an underlying hepatobiliary disease ultimately leading to an extensive evaluation before arriving at the correct diagnosis. This case highlights the importance of an accurate and efficient diagnosis of macroenzymes in the serum in order to prevent unnecessary healthcare utilization and also to decrease the psychological burden on the patient.
RESUMEN
Adult duodenoduodenal intussusception is extremely rare due to the retroperitoneal fixation of the second, third, and fourth parts of the duodenum. A majority of clinically significant intussusception with identifiable etiologies is typically neoplastic with more rare causes including retained food and indwelling enteral tubes, specifically with gastrojejunostomy (GJ) tubes. Herein, we discuss the case of a 23-year-old male who developed duodenoduodenal intussusception upon a PEGJ placement with associated gastroduodenal dilation and telescope phenomenon. To the best of our knowledge, there are no reports of intussusception found to be caused by GJ tubes in the adult population. The reported patient was found to have a 4-cm enteroenteric intussusception without obstruction or ischemia with bowel thickening proximal to the pathology. Although adult intussusception cases are typically managed surgically, we were able to reduce the intussusception via endoscopy due to rapid diagnosis upon presentation and intervention before the bowel wall could be compromised.
RESUMEN
OBJECTIVE: Current surgical training programs rely heavily on subjective assessments to measure operative proficiency, despite heavy emphasis on standardized testing as a means to rank scholastic ability. A compact laparoscopic simulator was developed with the intention to create a technical skill evaluation system that resembles standardized testing to provide the user with real-time percentile scores in a variety of skill metrics. The calculation of percentiles is only accurate if the pool of scores resembles a specific distribution (e.g., normal or log-normal distribution). We hypothesize that the grading measures provided by the simulator will follow normal or log-normal distributions. MATERIALS AND METHODS: A total of 29 surgical trainees with varying levels of laparoscopic experience were surveyed regarding their current training, proficiencies, and experience with the Fundamentals of Laparoscopic Surgery curriculum and then asked to perform a standard peg-transfer task 5 times. A proprietary device placed along the trocars of a laparoscopic box trainer was used to gather data that, when subjected to unique algorithms, gave real-time, web-based feedback to trainees on the following metrics: volume of instrument use, economy of movement, angular instrument path, instrument rotation, bimanual coordination, smoothness, time to task completion, and depth perception. Numerical data were plotted on a frequency histogram. Minitab software was used to identify if individual metrics fit a standard distribution curve. Analysis of variance was used to differentiate among 3 established physician skill levels, as a means of assessing construct validity. RESULTS: In the goodness-of-fit tests performed, angular path, depth perception, rotation, and smoothness were found to best fit a log-normal distribution (p > 0.1). Bimanual coordination was found to fit a normal distribution (p ≥ 0.067). However, both normal and log-normal distributions were rejected (p ≤ 0.01) for the metrics of time, volume, and economy of movement. After separating participants into 3 groups based on level of experience with the Fundamentals of Laparoscopic Surgery curriculum, analysis of variance showed significant differences among all group means across the 5 metrics (i.e., angular path, depth perception, rotation, smoothness, and bimanual coordination; p ≤ 0.023). CONCLUSION: A proprietary device provided quantitative assessment of laparoscopic skills, which can be used to differentiate among skill levels. Of the 8 tested metrics, 5 fit a normal or log-normal distribution, meaning the scores can statistically be ranked by percentile. Time, volume, and economy of movement did not fit desired distributions. The grading system proved to have construct validity, indicating it may be useful in the longitudinal assessment of laparoscopic skills of surgical trainees.