Intergroup Contact Improves Medical Student Attitudes and Skill in Transgender Health Care.

Purpose: Poorer health outcomes for transgender and gender diverse (TGD) individuals have been associated with lack of health care provider knowledge and personal bias. Training at all levels of medical education has been positioned as one strategy to combat these inequities. This study sought to characterize preclinical medical student attitude, skill, and knowledge pre- and post-teaching with TGD community volunteers. Methods: This matched pre- and post-test study was conducted from July 2020 to August 2021 capturing two preclinical medical student cohorts exposed to the same teaching intervention. Students completed the Transgender Attitudes and Beliefs Scale (TABS) and the Transgender Development of Clinical Skills Scale (T-DOCSS) at baseline, 1 week, and 1 month after the clinical skills session. Tutors' attitudes to TGD health were measured before facilitating teaching, using the Attitudes Toward Transgender Patients and Beliefs and Knowledge about Treating Transgender Patients scales. Results: Fifty-nine students completed questionnaires at three time points and were included in this study. Total TABS and T-DOCCS scores increased from preintervention to 1-week follow-up, maintained at 1 month, with significant changes in Interpersonal Comfort and Sex and Gender Beliefs subscales. Scores on the Human Value subscale did not change, remaining consistently high. Postintervention knowledge-question scores were high. Nine of 13 tutors completed surveys, demonstrating overall positive attitudes toward gender diversity and TGD health. Conclusion: This study demonstrates improvement in preclinical medical student attitudes and self-reported skill toward gender health care sustained at 1 month after small-group teaching with TGD community volunteers.

Assessment of sonographic venous peak systolic velocity in detecting hemodialysis arteriovenous graft stenosis.

There is no single effective means of assessing arteriovenous access function, although monitoring hemodialysis venous pressure (VP) or measuring access recirculation may be of some benefit. The present study assesses prospectively the efficacy of following the peak systolic velocity (PSV) as a single measure to detect arteriovenous graft (AVG) stenosis. PSV was measured in 12 patients after new AVG placement and at approximately 2-month intervals. Angiography was also performed after new graft placement and when PSV was elevated to greater than 200 cm/sec, hemodialysis access VP increased to greater than 150 mm Hg on three consecutive readings, or access recirculation increased to greater than 11%. PSV was then compared with results from angiography, VP monitoring, and access recirculation. The 12 patients underwent 34 PSV studies, followed by angiography on 25 occasions. Each patient underwent at least one angiogram. Each abnormal PSV value was confirmed with the finding of stenosis on angiogram, except for two patients with PSVs greater than 400 cm/sec and normal angiography results. VP and recirculation were not elevated. During this period, two patients developed thrombosis of the AVG, and two patients underwent angioplasty with improvement in PSV. We conclude that elevations in PSV measured at the venous anastomosis are an effective means of screening for AVG stenosis, AVG stenosis can occur early after AVG placement, and elevated VP and recirculation are late findings in AVG dysfunction.

Anorectal Crohn's disease: surgical and medical management.

In some patients with Crohn's disease the anorectal complications are the major cause of symptoms and morbidity. Anorectal Crohn's disease may be present in patients with intestinal Crohn's disease, may be the initial manifestation of the disease, or rarely occurs without involvement of Crohn's disease elsewhere in the intestinal tract. The pathogenesis of these anorectal complications remains to be clarified. The anorectal examination is very important in the assessment of patients with suspected or documented inflammatory bowel disease. Meticulous physical examination, examination under anaesthesia and radiological imaging modalities may be utilised to specifically identify the location of abscesses and fistulae. Treatment strategy should be directed toward symptomatic relief; the most important symptom is pain. In most patients this pain will be attributable to an incompletely drained rectal abscess. Simple incision and drainage procedures are often all that is required as initial treatment of anorectal abscesses. Treatment of the anorectal fistulae that occur secondary to Crohn's disease requires combined medical and surgical therapy. Drug therapy is more often initiated for Crohn's disease that involves other areas of the gastrointestinal tract. The anorectal manifestations often respond to these same medications. Lay-open procedures (fistulotomies) are often all that is required surgically for simple (low) anorectal fistulae. High (complex) fistulae that involve large portions of the anorectal muscular ring are more difficult to treat. Patients with these fistulae must be treated on an individual basis, usually local surgical therapy combined with a medical regimen. Many surgical procedures are performed and many classes of medications are utilised on patients with these complex anorectal fistulae. Choosing the appropriate surgical and medical interventions is often quite difficult. Although sulfasalazine, mesalazine and corticosteroids have no lasting or maintenance value for fistulae, the immunosuppressive agents mercaptopurine, azathioprine and cyclosporin, the antibacterial metronidazole and the anti-tumour necrosis factor-alpha monoclonal antibody infliximab have varying degrees of effect. The goal of the combined regimen is to cure the fistula, or at least make it minimally symptomatic, without altering the patient's continence.

Liver resection for metastatic colorectal cancer: assessing the risk of occult irresectable disease.

BACKGROUND: Liver resection is standard therapy for selected patients with metastatic colorectal cancer. Extrahepatic metastases and inability to remove all hepatic disease usually preclude curative resection and are the most common contraindications. This study analyzes irresectability in patients considered to have resectable disease taken to operation for potentially curative hepatic resection. We describe preoperative factors associated with irresectability and propose a preoperative scoring system that identifies patients at particularly high risk for occult irresectable disease. STUDY DESIGN: Patients considered to have resectable hepatic colorectal metastases were identified from a prospective database. Intraoperative findings that precluded liver resection were recorded. Demographic data, characteristics of the primary tumor, and characteristics of the hepatic metastases were recorded and analyzed. RESULTS: From April 1992 through July 1997, 416 patients were explored with the intention of performing a potentially curative liver resection; 329 (79%) were resected. Eighty-seven patients (21%) had apparently resectable tumors on preoperative imaging but irresectable disease at laparotomy. Forty-four patients (51%) had irresectable disease limited to the liver; 32 had extensive bilobar disease not appreciated before surgery, and 12 were not resected for technical or other reasons unrelated to disease extent. Forty-three patients (49%) had extrahepatic disease, 31 of whom had resectable hepatic tumors. Of the several preoperative factors analyzed, only the estimated number of hepatic tumors was an independent predictor of irresectable findings at operation. This held true for patients with extrahepatic metastases and those with extensive hepatic disease. From these data, we devised a preoperative scoring system that estimates the probability of finding occult irresectable disease. Resectability ranged from 95% in patients with a score of 0 (solitary, unilobar) to 62% in those with a score of 3 (multiple, bilobar; p = 0.0001). The predictive value of this scoring system was then validated by applying it prospectively to an additional group of 118 patients taken to surgery for resection; the results were similar. CONCLUSIONS: Standard preoperative investigations predicted resectability in 79% of patients with hepatic colorectal metastases. Unresectable disease limited to the liver and extrahepatic disease were seen with nearly equal frequency. The majority of patients with extrahepatic metastases had resectable hepatic disease (31 of 43, 72%). A preoperative scoring system is proposed that identifies patients at high risk for unrecognized irresectable disease and may help focus the use of additional diagnostic modalities such as laparoscopy and positron emission tomography (PET).

Carcinoma arising in anorectal fistulas of Crohn's disease.

PURPOSE: Anorectal fistulas are commonly associated with Crohn's disease. Carcinoma arising in an anal fistula in the absence of Crohn's disease occurs rarely. Carcinoma arising in an anorectal fistula of Crohn's disease is likewise rare and is the subject of this article. METHODS: We have seen eight cases in seven patients. Four of these were squamous carcinoma and three were adenocarcinoma. Details of these seven patients are presented. RESULTS: Two deaths in the four patients with squamous carcinoma and one in the two patients with adenocarcinoma with adequate follow-up suggest a poorer prognosis in both types of malignancy than when these lesions occur without Crohn's disease. CONCLUSION: Carcinoma does arise in the midst of the anorectal fistulas and abscesses of Crohn's disease. Carcinoma arising in a Crohn's disease fistula can be very difficult to diagnose. Examination may be limited by pain, stricture, or induration of the perianal and perineal tissues. Examination under anesthesia can also overlook the lesion. Diagnostic examination under anesthesia yields increases with biopsies or curettage of the fistulous tracts.

Experience with papillary and solid epithelial neoplasms of the pancreas in children.

BACKGROUND: Papillary cystic tumour of the pancreas in children is a rare tumour. METHODS: Ten patients admitted to The Hospital for Sick Children, Toronto, have been reviewed, and presentation and management are documented. RESULTS: One patient who had disseminated disease at presentation died. CONCLUSION: Excision of the tumour irrespective of size is recommended.

Polycythemia secondary to focal nodular hyperplasia.

An otherwise healthy 14-year-old girl presented with polycythemia and elevated serum erythropoietin. A lesion was identified in the liver by ultrasound scan and computerized axial tomography. The pathology findings of the mass excised by hepatic segmentectomy showed focal nodular hyperplasia that stained positively for erythropoietin by immunohistochemistry. Resection resulted in a cure of the polycythemia with serum erythropoietin, hemoglobin, and hematocrit returning to normal range in subsequent follow-up. To our knowledge, this is the first report of focal nodular hyperplasia resulting in secondary polycythemia.