Adopting the Swenson-like technique for patients with Hirschsprung disease in Vietnam.

PURPOSE: To evaluate outcomes of adopting the Swenson-like technique in transanal pull-through for Hirschsprung disease (HD) at a children's institution in Southeast Asia. METHODS: A retrospective chart review was performed over 42 months at a safety-net pediatric hospital in Vietnam. RESULTS: From January 2019 to June 2022, the Swenson-like technique was implemented and performed on 139 patients (115 male, 24 female, mean age 6.4 ± 11.96 months). There were 123 transanal-only resections, 5 transanal plus laparoscopic, and 11 transanal plus laparotomy. The mean operative time was 70.9 ± 43.6 min. The average length of the resected specimen was 18.8 ± 10.9 cm. No urethral or vaginal injuries occurred. Postoperative complications included 1 anastomotic leak (0.7%), 4 anastomotic stenoses (2.8%), and 2 perianal abscesses in the setting of recurrent enterocolitis (1.4%). With a mean follow-up of 26 ± 11.9 months (range 3-48 months), there were 25 enterocolitis cases (17.9%), 45 patients with constipation (32.3%), 1 episode of fecal incontinence lasting longer than 6 months (0.7%), and 1 rectal-vestibular fistula noted one year postoperatively (0.7%). There were no deaths. CONCLUSION: The Swenson-like technique in transanal pull-through for Hirschsprung's disease was safely adopted at our institution. The results show that applying this technique uniformly in a single institution led to excellent outcomes.

Frontal Lobe Hemorrhage With Surrounding Edema and Subarachnoid Hemorrhage.

We report the case of an 81-year-old woman who presented with a left hemineglect, a rightward gaze preference, and baseline disorientation. Her National Institutes of Health Stroke Score was 4. Her medical history was significant for dementia, osteoporosis, dyslipidemia, and a previous stroke. CT revealed a right-sided frontal lobe hemorrhage with surrounding edema and subarachnoid hemorrhage. Laboratory evaluation was significant for leukocytosis. The etiologies, clinical presentation, and diagnosis of this often devastating type of stroke are presented. While she did have a significant neurologic deficit (neglect), she was able to remain alert and protect her airway. Her hospital course consisted of observation in the ICU and blood pressure management. The case illustrates that intracerebral hemorrhage (ICH) can sometimes present indolently and does not always require surgical intervention.

Impact of Alzheimer's Disease on Caregivers in the United States.

Background/Objective: First discovered by Alois Alzheimer in 1906, Alzheimer's disease (AD) has become a growing global health concern with numerous implications for individuals and modern society. As patients' symptoms of dementia continue to worsen, they gradually grow more limited in their independence. As a result, family members and close acquaintances often become caregivers for the patient and become more involved in maintaining the patient's lifestyle. The authors of this research sought to study what motivates caregivers to look after AD patients and the impact of AD on their lifestyles and physical, mental, and social health. Methods: The authors crafted a survey of fourteen questions and collected data from 200 caregivers regarding AD's impact on their physical, emotional, and social health along with their key demographic and background information (e.g. whether or not they are a caregiver for a patient with AD). Results: The results indicate that most AD caregivers are family members (78%). AD often strains the caregiver's relationship with the patient (47.5%), and 58% of participating caregivers report extreme stress levels while 65% realize it is incredibly difficult to take care of a patient. Because of the increased levels of stress, 47% of participating caregivers sleep less; 43% feel more isolated from their family; and, 35.5% did not try to get help from others. Love and a strong sense of duty seem to be the primary motivation for caregivers to take care of a patient. Worry for the patient (50%), financial worries (12.5%), lack of medical experience (10.5%), and their own health (10.5%) seem to be the primary stressors for caregivers. Caregivers rely on numerous support systems and coping mechanisms, with physical activity (54.5%) and increased alcohol and marijuana usage (35.5%) the most frequent. Conclusions: Although caregivers have support systems and found coping methods that would alleviate their burden of caring for a patient with AD, the clear negative impact AD has on caregivers affects their physical, mental, and social health. As there is currently no cure for AD, compassion and greater support for caregivers are necessary.

Acute Submandibular Sialadenitis.

Sialadenitis is a stone in the salivary system that often presents as acute pain and swelling and can cause significant distress to patients. Here, we present a case of submandibular sialadenitis in a 41-year-old woman who experienced sudden-onset facial and neck pain and swelling. In addition, we discuss the diagnosis and emergency department management.

PASS-A course in Pediatric Acute Surgical Support to build pediatric surgical emergencies capacity in developing countries.

OBJECTIVES: The burden of pediatric trauma and emergency, including pediatric surgical emergencies in low middle income countries (LMIC) is high. The goal of Pediatric Acute Surgical Support (PASS) course is to prepare caregivers in LMIC for the acute management of life-threatening pediatric surgical emergencies. We aim to show the feasibility of its initial deployment. METHODS: PASS was developed in 2016 with LMIC faculty from a teaching children hospital CH. The course contents consisted of a mix of didactic materials for serious general neonatal and pediatric surgery modified PALS/ATLS, in-person multidisciplinary team-based skill stations, interactive clinical scenarios and simulated trauma cases. The course was subsequently revised and delivered to 92 learners in four classes of 2.5-days sessions at two CHs between 2017 and 2019. Learners' demographics, written exams, team-based case performance, and post-course survey data were prospectively collected and retrospectively analyzed. RESULTS: Physician (60%) and nurse learners (40%) from pediatric critical care (36%), surgery (23%), emergency medicine (20%) and anesthesiology (9%) had 3.6 +/- 3.6 years of clinical practice; pre- and post-course written exam score of 55.4+/-15.5% vs 71.6+/-12.8%, team-based trauma scenario management 22.6 ± 7.8% vs 54.7 ± 16.6% and team-based dynamic scores 17+/- 10% vs 53.3+/- 15.5%, respectively (p<0.0001). Self-reported satisfaction scores were ≥ 95% for course method, level of difficulty, clinical applicability, and quality of instructors. CONCLUSION: PASS is well-received by LMIC learners, with short-term improvement in knowledge-, team-based management of acute pediatric surgery emergencies; and has the potential to be a model of horizontal capacity building for pediatric surgery in LMIC. LEVEL OF EVIDENCE: II.

Granulocyte-colony stimulating factor GCSF mobilizes hematopoietic stem cells in Kasai patients with biliary atresia in a phase 1 study and improves short term outcome.

AIMS: In RCT of adults with decompensated cirrhosis, GCSF mobilizes hematopoietic stem cells HSC and improves short-term outcome. An FDA-IND for sequential Kasai-GCSF treatment in biliary atresia BA was approved. This phase 1 study examines GCSF safety in Kasai subjects. Preliminary short-term outcome was evaluated. METHODS: GCSF (Neupogen) at 5 or 10 µg/kg (n = 3/group) was given in 3 daily doses starting on day 3 of Kasai surgery (NCT03395028). Serum CD34+ HSC cell counts, and 1-month of GCSF-related adverse events were monitored. The 6-months Phase 1 clinical outcome was compared against 10 subsequent post Phase 1 Kasai patients who did not receive GCSF. RESULTS: With GCSF, WBC and platelet count transiently increased, LFT and serum creatinine remained stable. Reversible splenic enlargement (by 8.5-20%) occurred in 5/6 subjects. HSC count increased 12-fold and 17.5-fold for the 5 µg/kg and10 ug/kg dose respectively; with respective median total bilirubin levels for GCSF vs no-GCSF groups of 55 vs 91 µM at 1 month, p = 0.05; 15 vs 37 µM at 3 months, p = 0.24); and the 6-months cholangitis frequency of 40% vs 90%, p = 0.077. CONCLUSIONS: GCSF safely mobilizes HSC in Kasai infants and may improve short-term biliary drainage and cholangitis. Phase 2 efficacy outcome of GCSF adjunct therapy for sequential Kasai and GCSF is pending.

Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings.

PROBLEM: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. APPROACH: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum-including 2 years dedicated to global surgery-with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. OUTCOMES: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. NEXT STEPS: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step toward contributing to the delivery of safe surgical care worldwide.

Twelve Tips on enhancing global health education in graduate medical training programs.

Investment in healthcare infrastructure in resource-limited settings is a vital and cost-effective approach for diminishing world-wide disease burden, increasing quality of life, and lengthening life expectancy. Graduate medical trainees enthusiastically express interest in supporting global health efforts that expand healthcare access and capacity in resource-limited settings. Academic institutions are responding by developing training programs to equip graduate medical trainees with the technical, interpersonal, scholastic, and ethical skillsets necessary for the pursuit of global health efforts. Drawn from real-world experience and current literature, the following twelve tips will strengthen a global health curriculum in graduate medical training programs with dedicated global health education.

Obliterative Portal Venopathy Without Cirrhosis Is Prevalent in Pediatric Cystic Fibrosis Liver Disease With Portal Hypertension.

Cystic fibrosis liver disease (CFLD) has long been postulated to be secondary to dysfunctional cystic fibrosis transmembrane conductance regulator in the apical biliary epithelium, leading to bile stasis and eventually cirrhosis with portal hypertension. However, pathologic changes in the cystic fibrosis (CF) liver are distinct from the pancreas and lungs in that fibrocystic changes are absent.1,2 Furthermore, the lack of clinically evident biliary obstruction and liver dysfunction suggest there may be alternative mechanisms that contribute to CFLD. Two recent studies in young adults described obliterative portal venopathy (OPV) and noncirrhotic portal hypertension (NCPH) as the predominant pathophysiology in young adults (median, 22 y) with CFLD.3,4 It is unknown if OPV develops early in childhood. Herein, we report the clinical features and liver pathology in 17 explants from children and adolescents with CF, representing 13.6% (17 of 125) of the CF liver transplant population in the United States according to the United Network for Organ Sharing and Organ Procurement and Transplantation Network.

Sustained impact of short-term international medical mission trips: resident perspectives.

PURPOSE: To assess perspectives of residents: (1) who participated in short-term international medical mission trips (STIMMTs) as medical students regarding impact of the experiences on their professional development; and (2) who did not participate in STIMMTs regarding barriers to participation. METHODS: Three hundred seventy-nine residents from 16 programs at two Florida institutions completed surveys requesting Participant and Trip Details and Impact of Participation (including items rating learning, cultural competency, and social responsibility). RESULTS: One hundred thirty-one residents participated in at least one STIMMT. They identified improved adaptability to new healthcare settings, communication with patients and professionals from different backgrounds, and appreciation for the impact of culture on health as positive outcomes. Leading barriers to STIMMT participation included cost, timing, and lack of availability. CONCLUSIONS: Years after participation in STIMMTs, residents perceived sustained benefits in cultural competency, communication skills, adaptability, and desire for service. Institutions may consider facilitating STIMMTs as one way to address standards specified by accrediting authorities to provide training in cultural competency, social responsibility, altruism, and understanding the importance of caring for underserved populations. Barriers to STIMMT participation may be reduced through availability of institution-sponsored scholarships, identification of external grant and scholarship opportunities, and coordination of fund-raising activities.

Clinical and structural effects of traditional Chinese medicine and the herbal preparation, Iberogast, in a rat model of ulcerative colitis.

Plant-sourced formulations such as Iberogast and the traditional Chinese medicine formulation, Cmed, purportedly possess anti-inflammatory and radical scavenging properties. We investigated Iberogast and Cmed, independently, for their potential to decrease the severity of the large bowel inflammatory disorder, ulcerative colitis. Sprague Dawley rats (n = 8/group) received daily 1 mL gavages (days 0-13) of water, Iberogast (100 µL/200 µL), or Cmed (10 mg/20 mg). Rats ingested 2% dextran sulfate sodium or water ad libitum for 7 days commencing on day 5. Dextran sulfate sodium administration increased disease activity index scores from days 6 to 12, compared with water controls (P < .05). On day 10, 200 µL Iberogast decreased disease activity index scores in colitic rats compared with colitic controls (P < .05). Neither Iberogast nor Cmed achieved statistical significance for daily metabolic parameters or colonic crypt depth. The therapeutic effects of Iberogast and Cmed were minimal in the colitis setting. Further studies of plant extracts are required investigating greater concentrations and alternative delivery systems.

Prostaglandin ethanolamides attenuate damage in a human explant colitis model.

Endocannabinoids are protective in animal colitis models. As endocannabinoids also form novel prostaglandin ethanolamides (prostamides) via COX-2, we investigated the effects of prostamides and other COX-2 mediators on tissue damage in an ex vivo human mucosal explant colitis model. Healthy human colonic mucosae were incubated with pro-inflammatory cytokines TNF-α and IL-1ß to elicit colitis-like tissue damage. The PGF-ethanolamide analogue, bimatoprost decreased colitis scores which were reversed by a prostamide-specific antagonist AGN 211334, but not the FP receptor antagonist AL-8810. PGF-ethanolamide and PGE-ethanolamide also reduced cytokine-evoked epithelial damage. Anandamide was protective in the explant colitis model; however COX-2 inhibition did not alter its effects, associated with a lack of COX-2 induction in explant mucosal tissue. These findings support an anti-inflammatory role for prostamides and endocannabinoids in the human colon.