Symptomatic esophageal intramural pseudodiverticulosis without stricture: A case report.

Esophageal intramural pseudodiverticulosis is a benign disease characterized by numerous, small outpouchings from the esophageal epithelium. Esophageal intramural pseudodiverticulosis has scarcely been reported with only 200-300 cases worldwide. The etiology of esophageal intramural pseudodiverticulosis is also unclear; however, there is an associated increased risk with diabetes mellitus, gastroesophageal reflux disease, esophageal candidiasis, and chronic alcohol and tobacco abuse. Esophageal intramural pseudodiverticulosis has a characteristic appearance on esophagogastroduodenoscopy. Treatment of esophageal intramural pseudodiverticulosis has historically been limited to symptom management with acid suppression, anti-fungal therapy, and endoscopic dilation in areas of stricture. This report is a case of a 52-year-old female status post two esophageal stricture repairs with dilation over prior 2 years, who presented with non-remitting solid food dysphagia and food impaction found to have esophageal intramural pseudodiverticulosis with concomitant jackhammer esophagus and esophageal candidiasis.

Electronic Patient Portal Use After Kidney Transplant: A Single-Center Retrospective Study.

INTRODUCTION: Online patient portals have become a core component of patient-centered care. Limited research exists on such portal use in patients after kidney transplantation. The aim of this study was to examine preoperative, perioperative, and postoperative factors associated with post-transplantation portal use. METHODS: This cross-sectional study included all patients who underwent kidney transplantation from April 2016 to May 2019 at the University of Toledo Medical Center. Exclusion criteria included international travel for transplantation and those without available postoperative lab or follow-up records. Data were collected for 2 y post-transplantation. Univariable and multivariable linear regression was performed to determine associations with portal use. RESULTS: Two hundred and forty-seven kidney transplant recipients were included in the study; 35.6% (n = 88) used the portal versus 64.4% (n = 159) did not. Preoperative factors associated with increased use included income >$40,000 (odds ratio [OR], 2.95; P = 0.006) and cancer history (OR, 2.46; P = 0.007), whereas diabetes history had reduced use (OR, 0.51; P = 0.021). The Black race had the least use. Perioperatively, reduced use was associated with dialysis before transplant (OR, 0.25; P < 0.001) and hospital stay ≥4 d (OR, 0.49; P = 0.009). Postoperatively, associations with increased use included average eGFR >30 (P = 0.04) and hospital readmissions (n = 102), whereas those with ER (n = 138) visits had decreased use. Multivariable analysis revealed increased use with income >$40,000 (OR, 2.51; P = 0.033). CONCLUSIONS: There was no observed difference in clinical outcomes for portal users and nonusers undergoing kidney transplantation, although portal use may decrease the likelihood of ER visits. Socioeconomic status and ethnicity may play a role on who utilizes the patient portals.

The relationship between lower extremity amputation and body mass index.

OBJECTIVES: Non-traumatic lower extremity amputation (LEA) is associated with significant morbidity and mortality. Diabetes mellitus (DM) and peripheral vascular disease (PVD) are associated with increased risk for LEA. As such, DM and PVD account for 54% of all LEA's, performed in the United States annually. As obesity is highly associated with both DM and PVD, our study sought to explore the relationship between LEA and obesity defined by BMI. METHODS: Using the National Inpatient Sample (NIS) database, a retrospective review of patients who underwent non-traumatic LEA (LEA) between 2008 and 2014 was performed. The International Classification of Diseases 9th edition (ICD-9) codes were utilized to determine the diagnoses, comorbidities, and procedures. Patient BMIs were classified as follows: Non-obese [BMI <30], Obesity class I [BMI 30-34.9], Obesity class II [BMI 35-39.9], and Obesity class III [BMI ≥40]. Predictors for LEA were compared between groups using chi-square test and binary logistic regression to identify possible underlying factors associated with LEA. We also conducted a multivariate analysis to measure the effect of multiple variables on LEA. RESULTS: We identified 16,259 patients with non-traumatic LEA and a mean age of 59.9 years. Rate of amputation in females was lower than males at 0.35% vs 0.87% respectively (p < 0.001). Of patients that underwent amputation there was a V-shape trend based on BMI, with 30.4% in non-obese patients, 18.2% in obesity class I, 17.3% in obesity class II, and 34.1% in obesity class III. The incidence of diabetes increased with obesity class, while the incidence of PVD decreased. Interestingly, of those with DM there was an inverse relationship between amputation rate and BMI class, with LEA rates in non-obese versus obesity class III patients were 1.63% vs 0.98% respectively (p < 0.001). Similarly, patients who had both diabetes and PVD showed a downward trend in LEA rate as obesity class increased; non-obese patients had a LEA rate of 8.01%, while obesity class III had 4.65% (p < 0.001). Patients in higher income bracket have lower odds of LEA (OR 0.77, p < 0.001) compared to the lowest income patients. Also, patients with comorbidities such as PVD (OR 10.78), diabetes (OR 5.02), renal failure (OR 1.41), and hypertension (OR 1.36) had higher odds to get an LEA (p < 0.001). Individuals with obesity class III are almost at half the odds (OR 0.52) to get an LEA compared to non-obese (p < 0.001). CONCLUSIONS: Higher BMI and female gender are protective factors against lower extremity amputation. Factors that predisposing to LEA include lower household income and certain comorbidities such as PVD, diabetes, renal failure, and hypertension. These findings warrant further research to identify patients at high risk for LEA and help develop management guidelines for targeted populations.

Erythrodermic mycosis fungoides with large cell transformation: An unusual and complicated case.

Mycosis fungoides is the most common cutaneous T-cell lymphoma. It presents a diagnostic challenge due to resemblance with many other dermatologic conditions. The disease typically follows a progression from patches to plaques to skin-based tumors with potential for visceral involvement. Diagnosis is made by clinical presentation and histology. When early diagnosis is made, there is an estimated 88% five-year survival. This report details a 60-year-old Black man diagnosed with stage IIIA mycosis fungoides with a severe degree of cutaneous involvement. This case is unique due to the aggressive large cell transformation and rapid progression to death within 18 months of diagnosis. We highlight the challenge of diagnosing, treating, and monitoring the therapeutic response of mycosis fungoides. Finally, this case calls for a multi-disciplinary approach to treatment and to include mycosis fungoides on the differential diagnosis for patients presenting with a variety of vague, recurrent cutaneous symptoms, especially with patchy dyspigmentation or plaques.

Pleural Effusion as the Initial Presentation of Gastric Adenocarcinoma: A Case Report.

BACKGROUND Gastric adenocarcinoma is a common malignancy, representing the third most common cause of cancer-related death globally. Most patients are initially asymptomatic, but as the cancer progresses, patients typically present with vague gastrointestinal complaints, including early satiety, heart burn, vomiting, or abdominal pain. Metastatic gastric cancer is relatively uncommon, with ~26% of patients having metastasis to a single site and 13% having metastases to multiple sites. The most common site of metastasis is the liver, followed by peritoneum, lung, and bone. CASE REPORT In this case report we describe a 73-year-old man who presented with shortness of breath, found to have large hiatal hernia along with segmental branch pulmonary embolism, bilateral pleural effusion, and diffuse interlobular septal thickening. The pleural effusion was later found to be malignant in nature and the patient was diagnosed with metastatic stage IV infiltrative gastric adenocarcinoma with metastasis to the lung and bone. Notably, the patient had no hepatic involvement. CONCLUSIONS This represents a unique case, as only 2% of malignant pleural effusions are attributable to gastric cancer. Furthermore, malignant pleural effusion is an extremely rare initial presentation of gastric adenocarcinoma, especially without liver involvement, with few existing cases documented in the literature. This case demonstrates that gastric cancer should be included on the differential diagnosis as a rare cause of pleural effusion.

Conservative Management of Muscle Invasive Bladder Cancer in Kidney-Pancreas Transplant Patient.

Introduction. Solid organ transplant increases the risk for muscle-invasive bladder cancer (MIBC). Although a common tumor, urothelial cell carcinoma (UCC) of the bladder in patients with kidney-pancreas transplants is scarcely reported. Case Presentation. A 65-year-old male with history of type 1 diabetes and a 14-year status post deceased donor pancreas-kidney transplant presented with 3 weeks of gross hematuria. CT scan showed multiple bladder masses. Transurethral resection of bladder tumor (TURBT) showed papillary UCC. 5 months later, the patient reported new-onset gross hematuria. TURBT showed MIBC. The patient elected for bladder-preserving TMT. On cystoscopy there was no gross evidence of carcinoma at 3.5 years of follow up. Discussion. Currently, no specific management guidelines target this population with MIBC. The first-line treatment for MIBC is radical cystectomy (RC) with neoadjuvant chemotherapy. For patients that are medically unfit or unwilling to undergo RC, trimodal therapy (TMT) is an alternative. TMT for bladder cancer consists of complete tumor resection with chemotherapy and radiation. This report demonstrates a unique case of a patient with kidney-pancreas transplant diagnosed with MIBC treated with TMT that has no evidence of gross tumorigenesis at 3.5 years after diagnosis. Our findings suggest that trimodal therapy should be considered for treatment of MIBC in patients with kidney-pancreatic transplants to preserve the donated allografts.

Impact of educational instruction on medical student performance in simulation patient.

Objectives: This study aimed to evaluate the effects, and timing of, a video educational intervention on medical student performance in manikin-based simulation patient encounters. Methods: This prospective mixed-methods study was conducted as part of the University of Toledo College of Medicine and Life Sciences undergraduate medical curriculum. One hundred sixty-six students second-year students participated in two simulations on a single day in September 2021. A 7-minute video intervention outlining the clinical diagnostic approach to pulmonary complaints was implemented. Students were randomized into 32 groups which were divided into two cohorts. One received the video prior to simulation-1 (n=83) and the other between simulation-1 and simulation-2 (n=83). Each simulation was recorded and assessed using a 44-point standardized checklist. Comparative analysis to determine differences in performance scores was performed using independent t-tests and paired t-tests. Results: Independent t-tests revealed the video-prior cohort performed better in simulation-1 (t(30)= 2.27, p= .03), however in simulation-2 no significant difference was observed between the cohorts. Paired t-test analysis revealed the video-between cohort had significant improvement from simulation-1 to simulation-2 (t(15)= 3.06, p = .01); no significant difference was found for the video-prior cohort. Less prompting was seen in simulation-2 among both the video-prior (t(15)= -2.83, p= .01) and video-between cohorts (t(15)= -2.18, p= .04). Conclusions: Simulation training, and targeted educational interventions, facilitate medical students to become clinically competent practitioners. Our findings indicate that guided video instruction advances students' clinical performance greater than learning through simulation alone. To confirm these findings, similar investigations in other clinical training exercises should be considered.

Anaplastic Large Cell Lymphoma Presenting as Ulcerative Facial Mass: A Case Report.

Anaplastic large cell lymphoma (ALCL) is a rare form of non-Hodgkin lymphoma (NHL) that can be aggressive with rapid speed, thus mandating a timely diagnosis to optimize treatment and deter progression. NHL classically presents with lymphadenopathy and constitutional symptoms. However, ALCL can present with nonspecific cutaneous manifestations with minimal or absent constitutional symptoms. The cutaneous involvement may resemble common dermatologic conditions, delaying diagnosis. We present a case of an aggressive cutaneous ALCL lesion mimicking facial cellulitis that rapidly progressed from a small comedone to a large, exophytic mass over the course of 1 month. Prior to presentation at our institution, the patient was previously diagnosed and treated for suspected bacterial infection with no response to therapy. Core needle biopsy of the forehead lesion confirmed the diagnosis of anaplastic lymphoma kinase-negative ALCL. Chemotherapy with brentuximab vedotin, cyclophosphamide, doxorubicin, and prednisone was planned for a total of 6-8 cycles with curative intent. By cycle 5, positron emission tomography and computed tomography demonstrated response to therapy with no enlarged or metabolically active lymph nodes appreciated. Our case report highlights the importance of developing a broad differential diagnosis for ulcerative facial masses, particularly when unresponsive to antimicrobial therapies. Lymphomas should be included in the differential diagnosis of patients with rapidly growing facial lesions.

Case report of congenital intestinal malrotation in an adult discovered three months status-post appendectomy.

INTRODUCTION AND IMPORTANCE: Intestinal malrotation is a congenital anomaly primarily diagnosed in children, with limited cases reported in adults. Prompt recognition is necessary to prevent life-threatening complications including bowel ischemia and death. We present a rare case of adult intestinal malrotation highlighting difficulty in diagnosis and surgical management. CASE PRESENTATION: A 37-year-old Caucasian woman presented with a 3-day history of worsening diffuse abdominal pain, three months status-post laparoscopic appendectomy. CT scan with contrast of the abdomen and pelvis demonstrated small bowel mesenteric swirling and descending duodenal transition point. Differential diagnosis included intestinal malrotation versus small bowel obstruction. Pre-operatively, the patient expressed frustration with years of abdominal pain and lack of improvement. Treatment with open surgical small bowel detorsion and ligation of the Ladd's bands was performed, after initial laparoscopic intervention was complicated by enterotomy. The patient recovered well post-operatively with final diagnosis of intestinal malrotation with midgut volvulus. Discharge home was delayed due to polysubstance withdrawal. Post-operatively, the patient reported immediate relief of symptoms which persisted at 2-week and 2-month follow-ups. CLINICAL DISCUSSION: Few reports of congenital malrotation diagnosed in adulthood are reported. This highlights the importance of evaluating all patients for malrotation when the appendix is found outside of the normal positioning in the RLQ, as surgical correction of malrotation is of utmost importance in such patients. CONCLUSION: Clinicians should consider intestinal malrotation in adults with recurrent vague abdominal symptoms. To our knowledge, this is the first report of congenital malrotation discovered in an adult after prior appendectomy.

Treatment of duodenal lipoma with robotic-assisted transverse duodenotomy: A case report of novel approach.

INTRODUCTION AND IMPORTANCE: Lipomas are the third most common benign tumor of the gastrointestinal (GI) tract, typically occurring in the colon or small intestine. Less than 100 cases of symptomatic duodenal lipomas have been reported. Symptoms include non-specific upper GI complaints of heartburn, fullness, or abdominal pain. This report highlights the rarity of symptomatic duodenal lipomas, lack of specific treatment guidelines, and adds to surgical literature a new treatment approach. CASE PRESENTATION: A 53-year-old Caucasian woman presented with 2-year history with main concerns for early satiety and constipation. CT scan with contrast of the abdomen and pelvis demonstrated a duodenal mass. Differential diagnosis included duodenal lipoma versus stricture, and IBS. Subsequent EGD revealed a 4 cm transverse duodenal submucosal mass. Endoscopic removal was deemed too great a risk of bleeding. Pre-operatively, the patient expressed frustration as the patient was tolerating only a liquid diet with one bowel movement weekly. Treatment with robotic assisted transverse duodenotomy was performed, with final pathology of benign lipomatous tissue. Post-operatively the patient had immediate relief of symptoms which persisted at 2-week and 4-month follow-ups. CLINICAL DISCUSSION: This case demonstrates 3 primary learning points. First, duodenal lipomas should be included in the differential of vague upper GI symptoms. Second, we propose that surgeons consider treatment of duodenal lipomas utilizing robotic assisted approach. Third, we document the first robotic-assisted transverse duodenotomy for duodenal lipomas. CONCLUSION: Clinicians should consider duodenal lipoma for patients with vague abdominal symptoms. We present a case of successful treatment with robotic-assisted transverse duodenotomy.