Left Shoulder Fungating Mass in a 46-Year-Old Man.

A 46-year-old man presented with a left shoulder mass. He reported limited shoulder movements and denied other symptoms. What is your diagnosis?

Phantom limb therapy improves cortical efficiency of the sensorimotor network in a targeted muscle reinnervation amputee: a case report.

Targeted muscle reinnervation (TMR) surgery involves the coaptation of amputated nerves to nearby motor nerve branches with the purpose of reclosing the neuromuscular loop in order to reduce phantom limb pain. The purpose of this case study was to create a phantom limb therapy protocol for an amputee after undergoing TMR surgery, where the four main nerves of his right arm were reinnervated into the chest muscles. The goal of this phantom limb therapy was to further strengthen these newly formed neuromuscular closed loops. The case participant (male, 21- years of age, height = 5'8″ and weight = 134 lbs) presented 1- year after a trans-humeral amputation of the right arm along with TMR surgery and participated in phantom limb therapy for 3 months. Data collections for the subject occurred every 2 weeks for 3 months. During the data collections, the subject performed various movements of the phantom and intact limb specific to each reinnervated nerve and a gross manual dexterity task (Box and Block Test) while measuring brain activity and recording qualitative feedback from the subject. The results demonstrated that phantom limb therapy produced significant changes of cortical activity, reduced fatigue, fluctuation in phantom pain, improved limb synchronization, increased sensory sensation, and decreased correlation strength between intra-hemispheric and inter-hemispheric channels. These results suggest an overall improved cortical efficiency of the sensorimotor network. These results add to the growing knowledge of cortical reorganization after TMR surgery, which is becoming more common to aid in the recovery after amputation. More importantly, the results of this study suggest that the phantom limb therapy may have accelerated the decoupling process, which provides direct clinical benefits to the patient such as reduced fatigue and improved limb synchronization.

Successful Management of a High-output Lymphorrhea via Lymphaticovenous Anastomosis after Cannulation for Cardiopulmonary Bypass.

Lymphatic leaks are a rare phenomenon, but can be a troublesome and persistent problem, especially in an already debilitated patient. Historically, management of lymphorrhea has involved non- and minimally-invasive techniques of elevation, compression, aspiration, or drain placement, among others. Ligation and sclerotherapy are additional utilized techniques, directly targeting the lymphatic vessel. Microsurgical management of lymphatic leaks via lymphaticolymphatic and lymphaticovenous anastomosis has gained popularity amongst surgeons as an alternative solution to the problem. We present a patient who developed a high-output lymphocutaneous fistula after a femoral cannulation procedure for cardiopulmonary bypass for an orthotopic heart transplantation. After multiple unsuccessful attempts at traditional management options, the patient had a successful resolution of the high-output lymphorrhea via a lymphaticovenous anastomosis utilizing end-to-end coaptation with an interpositional vein graft. This case uniquely describes a lymphaticovenous anastomosis and bypass of a lymph node in the setting of significant lymphorrhea (>1.0 L per day) and associated lymphocutaneous fistula, that was effectively managed in the acute postoperative setting. Management of lymphorrhea by microsurgical techniques and lymphatic vessel manipulation in the postoperative period provides surgeons with an enhanced option for direct operative management of lymphatic vessels and their associated sequelae.

Cross-Suturing is Effective for Teaching Suturing Skills: A Randomized, Controlled Trial.

INTRODUCTION: Basic suturing is a skill expected from graduating medical students. A proposed concept to increase suturing competency is to integrate art by mixing cross-stitching with suturing. We hypothesize that students trained with "cross-suturing" would improve suturing performance. METHODS: We performed a randomized controlled trial of preclinical medical students using an art-based cross-stitching method intervention compared with conventional suturing. Both groups were provided with an introductory suturing video. Assessment of simple interrupted suturing were conducted preintervention and postintervention, and at 2-wk follow-up with a video review by blinded expert raters using the American College of Surgeons basic suturing and knot tying performance rating tool. Students completed a self-assessment of proficiency, confidence, and anxiety. Statistical analysis was performed using unpaired t-tests. RESULTS: A total of 16 preclinical medical students participated. Self-assessment and objective suturing performance were comparable in the preintervention measurements. The intervention group showed significant improvement compared to the control group with median (interquartile range) self-assessment scores 9 (8.5-9) compared with 6.5 (6-7.5) (P < 0.01) and objective performance scores of 25.25 (22.75-27) compared with 16.5 (14.5-18.5) (P < 0.01). The intervention group showed retained skills at the 2-wk follow up with no differences in self-assessment or objective suturing scores immediately postintervention compared with two-wk follow-up with self-assessment scores of 9 (8.5-9) versus 9 (8-9) at 2 wk (P = 0.16) and objective performance score of 25.25 (22.75-27) versus 24.75 (23.5-26.5) at 2 wk (P = 0.29). CONCLUSIONS: The cross-suturing intervention improved suturing skills in this cohort. This low-cost approach to medical student surgical education should be explored on a larger scale.

Design and Evaluation of a Novel Health Security, Infectious Diseases, Health Systems Science, and Service Learning Course During the COVID-19 Pandemic.

During the COVID-19 pandemic, academic health centers suspended clinical clerkships for students. A need emerged for innovative virtual curricula to continue fostering professional competencies. In March 2020, a multidisciplinary team from the University of Nebraska Medical Center had 2 weeks to create a course on the impact of infectious diseases that addressed the COVID-19 pandemic in real time for upper-level medical and physician assistant students. Content addressing social determinants of health, medical ethics, population health, service learning, health security, and emergency preparedness were interwoven throughout the course to emphasize critical roles during a pandemic. In total, 320 students were invited to complete the survey on knowledge gained and attitudes about the course objectives and materials and 139 responded (response rate 43%). Students documented over 8,000 total hours of service learning; many created nonprofit organizations, aligned their initiatives with health systems efforts, and partnered with community-based organizations. Thematic analysis of qualitative evaluations revealed that learners found the greatest value in the emphasis on social determinants of health, bioethics, and service learning. The use of predeveloped, asynchronous e-modules were widely noted as the least effective aspect of the course. The COVID-19 pandemic introduced substantial challenges in medical education but also provided trainees with an unprecedented opportunity to learn from real-world emergency preparedness and public health responses. The University of Nebraska Medical Center plans to create a health security elective that includes traditional competencies for emergency preparedness and interrogates the social and structural vulnerabilities that drive disproportionately worse outcomes among marginalized communities. With further evaluation, many components of the curriculum could be broadly scaled to meet the increasing need for more public health and health security medical education.

Nursing Home Education During the COVID-19 Pandemic.

OBJECTIVE: To help older adults living in nursing homes (NHs) while educating medical and physician assistant (MD/PA) students during the COVID-19 pandemic. METHODS: Using a multicomponent iterative process, we piloted multiple student led service-learning projects in 2 NHs and 1 hospice agency in the Midwest. Pre-post online student surveys were completed to match student interests with facility needs and to assess learning and obtain feedback regarding their experiences. RESULTS: All 12 interested students completed the initial survey; n = 23 ultimately volunteered (word of mouth); n = 11 (48%) completed the follow-up survey. Opportunities were medical record transfer, grounds beautification, resident biographies, window entertainment, and No-One-Dies-Alone program. Students averaged 9.2 volunteer hours; stated the opportunities were enjoyable, clinically applicable, and socially distanced; and reported learning about unique experiences of older adults in NHs. DISCUSSION: Despite limitations created by the pandemic, mutually beneficial and safe opportunities remain for education in the NH setting.

Integrated Comprehensive Care for Transcare and Gender Diverse Clinic Patients: An Assessment of Physical, Mental, and Social Needs.

Introduction There is a large body of research reporting the healthcare needs of groups identifying as lesbian, gay, bisexual, transgender, and/or queer (LGBTQ); however, a gap exists in the research literature because many epidemiological studies focus on sexual orientation rather than gender identify/incongruence. To address the lack of specific data from transgender and gender diverse (TGD) individuals, our organization designed and deployed a survey to assess the gender-affirming physical, mental, and social care needs of current patients. Methods A group of subspecialty physicians currently working with TGD patients created a list of questions and requested feedback from medical professionals familiar with the healthcare needs of this population. In addition, patients reviewed the survey for content and clarity. The final 68-item survey was distributed in April 2020 to patients or patients' representatives with an email address on file at the Nebraska Medicine Transgender Care Clinic (NMTCC). Participants were asked to respond to questions regarding their gender identity, their transition-related medical decisions, and their interest in services. Results Invitations were sent to 690 patients and 168 surveys were completed (response rate: 24.3%). Over 90% (n = 153) of the participants were patients and 9% (n = 15) answered survey questions on the patient's behalf. A majority (77.2%) had started the medical transition (hormones or puberty blockers) in the past four years. Nearly half (46.4%) identified as trans women, 43.4% identified as trans men, and 10.2% indicated they were nonbinary or gender expansive. Participants' sex assigned at birth was 50.9% female and 46.1% male. Most patients (n = 149; 92%) reported currently receiving hormone treatment within the Nebraska Medicine healthcare system. Results indicated the highest level of clinical services interest was primary care (38.4%), gender-affirming surgery (73.5%), voice therapy (49.0%), and hair removal (37.5%). In addition, participants were very likely to participate in support groups with "people of similar gender identity" (32.9%), with "others around my age" (28.6%), and "including a mix of ages and identities" (26.9%). Discussion This study suggests that our TGD patients would utilize integrated services to access a variety of clinical and non-clinical services. Ongoing community engagement and direct feedback from patients are critical to the success and growth of our gender-affirming care clinic. The results of this study will inform the planning and further evolution of a program designed to build trust and address health inequities for TGD individuals throughout the region.

Syndrome of the trephined: A rare challenge in head & neck reconstruction.

BACKGROUND: Syndrome of the trephined (ST) refers to the rare, reversible event of neurological deterioration following craniectomy. ST is also known as "sinking skin flap syndrome" and typically occurs in the weeks to months following operation. The mechanism underlying syndromic onset is poorly understood. Changes to cerebrospinal fluid flow, alteration of temperature-related perfusion, and scarring at the intracranial surgical site have all been proposed. Patients present with a variety of symptoms related to paradoxical increased intracranial pressure. Sometimes falsely attributed as a consequence of the initial cranial insult, ST is more specifically a symptomatic process resulting as direct consequence of the craniectomy procedure. With timely identification and subsequent cranioplasty, the associated neurological dysfunction can be corrected - this rectification being the primary confirmatory feature of the syndrome. CASE: A 59-year-old female was seen with regards to a wound of the temporoparietal scalp, with exposed cranial implant. She had suffered a traumatic brain injury and underwent craniectomy after a motor vehicle accident 10 years prior. Her injury was complicated by necrosis of her cranial bone flap after reimplantation and at least 10 subsequent attempts to reconstruct her wound. When delayed cranial reconstruction was attempted on two separate occasions, the patient suffered severe syndrome of the trephined and required hospitalization for symptoms of impending herniation. Ultimately, she required revision and replacement of titanium mesh and latissimus dorsi free flap for soft tissue coverage of the titanium mesh. CONCLUSION: This case presents a unique surgical challenge in that chronic infection was perpetuated by the replacement of implant material in the wound. Soft tissue reconstruction alone was not possible given the patient's severe ST. Free tissue transfer was required in order to bring vascularized myofascial tissue to prevent recolonization of the newly implanted mesh and allow the cranial wound to heal.

Application of total care time and payment per unit time model for physician reimbursement for common general surgery operations.

BACKGROUND: The relative value unit system relies on subjective measures of physician input in the care of patients. A payment per unit time model incorporates surgeon reimbursement to the total care time spent in the operating room, postoperative in-house, and clinic time to define payment per unit time. We aimed to compare common general surgery operations by using the total care time and payment per unit time method in order to demonstrate a more objective measurement for physician reimbursement. STUDY DESIGN: Average total physician payment per case was obtained for 5 outpatient operations and 4 inpatient operations in general surgery. Total care time was defined as the sum of operative time, 30 minutes per hospital day, and 30 minutes per office visit for each operation. Payment per unit time was calculated by dividing the physician reimbursement per case by the total care time. RESULTS: Total care time, physician payment per case, and payment per unit time for each type of operation demonstrated that an average payment per time spent for inpatient operations was $455.73 and slightly more at $467.51 for outpatient operations. Partial colectomy with primary anastomosis had the longest total care time (8.98 hours) and the least payment per unit time ($188.52). Laparoscopic gastric bypass had the highest payment per time ($707.30). CONCLUSIONS: The total care time and payment per unit time method can be used as an adjunct to compare reimbursement among different operations on an institutional level as well as on a national level. Although many operations have similar payment trends based on time spent by the surgeon, payment differences using this methodology are seen and may be in need of further review.