Inverted Meckel's diverticulum as a cause of occult lower gastrointestinal hemorrhage.

Meckel's diverticulum is a common asymptomatic congenital gastrointestinal anomaly, but rarely it can present with hemorrhage. Over the last few years inverted Meckel's diverticulum has been reported in the literature with increasing frequency as an occult source of lower gastrointestinal hemorrhage. Here, we report a case of a 54-year-old male, who was referred for surgical evaluation with persistent anemia and occult blood per rectum after a work up which failed to localize the source over 12 mo, including upper and capsule endoscopy, colonoscopy, enteroclysis, Meckel scan, and tagged nuclear red blood cell scan. An abdominal computed tomography scan showed a possible mid-ileal intussusception and intraluminal mass. During the abdominal exploration, inverted Meckel's diverticulum was diagnosed and resected. We review the literature, discuss the forms in which the disease presents, the diagnostic modalities utilized, pathological findings, and treatment. Although less than 40 cases have been reported in the English literature from 1978 to 2005, 19 cases have been reported in the last 6 years alone (2006-2012) due to improved diagnostic modalities. Successful diagnosis and treatment of this disease requires a high index of clinical suspicion, which is becoming increasingly relevant to general gastroenterologists.

The effects of restricted work hours on clinical training.

Resident education has changed dramatically over the past 10 years. With the implementation of restricted work hours on clinical training, questions have arisen whether these restricted hours will affect clinical competency. This manuscript attempts to answer this question through a survey performed to assess the perception of residents about duty-hour restrictions and the potential effect on residents' clinical exposure. In this study, a majority of the respondents did believe that work-week restrictions significantly affected patient care and clinical exposure. However, few respondents were willing to accept an additional year of training to compensate for the loss of this clinical exposure. Regardless, work-hour restrictions are here to stay and will probably be further limited in the future. Training programs will have to adjust to provide the necessary clinical exposure while complying with these new ACGME guidelines.

Metaplastic breast cancer: clinical features and outcomes.

Metaplastic carcinoma of the breast, a neoplasm with both epithelial and mesenchymal elements, represents less than 1 per cent of all breast cancer. We reviewed the records of all patients diagnosed with localized metaplastic breast cancer from 1991 to 2003 at our institution. We identified 21 patients. Mean primary tumor size was 4.62 cm. Eight patients (38%) had axillary node involvement at presentation. All the tumors were high grade. Only two (10%) of the tumors were hormone receptor positive. Seventeen (81%) of the patients received adjuvant chemotherapy, and 12 (57%) of the patients received radiation. Ten (29%) patients suffered a local recurrence. With a mean follow-up of 46 months, the 5-year disease-free and overall survival was 42 per cent (95% CI: 20% to 65%) and 71 per cent (95% CI: 46% to 96%), respectively. Stage-specific overall survival was 100 per cent, 83 per cent, and 53 per cent for stages I, II, and III, respectively. By multivariate analysis, there was no impact on recurrence or survival with regard to size, age, menopausal status, nodal status, histologic subtype, adjuvant therapy, or extent of surgery. Metaplastic breast cancer is a unique neoplasm that tends to present at an advanced stage and has a propensity for local recurrence. When stratified by stage, however, survival appears similar to that of adenocarcinoma of the breast, and these tumors should be treated as such.

Metastatic meningioma to the liver successfully treated with a wedge resection and radiation therapy: report of a case.

Meningiomas account for approximately 15%-20% of all primary brain tumors. Metastatic meningiomas are rare. Less than 100 cases of extracranial metastatic meningiomas have been reported in the literature. An unusual case of metastatic meningioma to the liver successfully treated by a surgical resection and radiation therapy is presented.