Late presenting complicated coronary stent infection of left anterior descending artery with antero-posterior communication.

Coronary stent infections (CSI) are rare but a potentially life-threatening disease, the incidence of which has been on a rise over the last two decades. We report the case of a patient who presented with episodes of fever and discharging sternal wound. The patient was diagnosed as CSI arising from the left anterior descending artery stent which was communicating anteriorly to the skin and posteriorly as lobar-fistula. He was treated by stent removal and plication of the fistula. Blood culture, culture of the pus and infected stent, and coronary angiography are the preferred diagnostic modalities, followed by positron emission tomography (PET) scan and cardiac magnetic resonance imaging (MRI) for delineating the extent of pathology. Surgery seems to be the treatment of choice, providing a definitive diagnosis of CSI and removing the source of infection, repairing aneurysms, and providing bypass vascular grafts if feasible. Thorough evaluation and a multidisciplinary approach with the institution of appropriate medical and surgical therapy lead to timely detection and good outcome.

Current insights into epigenetics, noncoding RNA interactome and clinical pharmacokinetics of dietary polyphenols in cancer chemoprevention.

Several studies have reported the health-beneficial effects of dietary phytochemicals, namely polyphenols, to prevent various diseases, including cancer. Polyphenols, like (-)-epigallocatechin-3-gallate (EGCG) from green tea, curcumin from turmeric, and ellagic acid from pomegranate are known to act by modulating antioxidant, anti-inflammatory and apoptotic signal transduction pathways in the tumor milieu. The evolving literature underscores the role of epigenetic regulation of genes associated with cancer by these polyphenols, primarily via non-coding RNAs (ncRNAs), such as microRNAs (miRNA) and long noncoding RNA (lncRNA). However, there is little clarity on the exact role(s) played by these ncRNAs and their interactions with other ncRNAs, or with their protein targets, in response to modulation by these dietary polyphenols. Here, we review ncRNA interactions and functional networks of the complex ncRNA interactome with their targets in preclinical studies along with the role of epigenetics as well as key aspects of pharmacokinetics and phytochemistry of dietary polyphenols. We also summarize the current state of clinical trials with these dietary polyphenols. Taken together, this synthetic review provides insights into the molecular aspects underlying the anticancer chemopreventive effects of dietary polyphenols as well as summarizes data on novel biomarkers modulated by these polyphenols for preventive or therapeutic purposes in various types of cancer.

Optimizing Care Teams by Leveraging Advanced Practice Providers Through Strategic Workforce Planning.

INTRODUCTION: Advanced practice providers (APPs) are integral members of the healthcare delivery team. However, there has been a lack of standardization and uniformity in how they are utilized across inpatient, ambulatory, and procedural settings. METHODS: A multidisciplinary workforce planning committee was formed in March 2021 to evaluate all new and replacement full-time equivalent APP positions at Stanford Health Care (SHC), an academic medical center of more than 600 APPs, to optimize and standardize the role of APPs as per national benchmarks. RESULTS: Six months since the launch of the committee, there has been a 10% increase in the number of visits and procedures performed by APPs providing better access for patients. In addition, there has been a 38.7% improvement in ambulatory APPs meeting their productivity target, 19.4% improvement in ambulatory APPs meeting utilization targets, and 36.8% improvement in ambulatory APPs meeting the 50th percentile and above as per the relative value unit benchmark published by the Medical Group Management Association for Academic Medical Centers. For inpatient APPs, there has been a 38.8% improvement in APPs meeting the average daily census target. DISCUSSION: APP utilization is an important topic that has not been consistently addressed in the literature. Inappropriate utilization and lack of top of licensure practice have been associated with increased turnover, decreased job satisfaction, and professional development. By developing a multidisciplinary workforce planning committee, full-time employee positions are evaluated with a goal of optimizing and standardizing the role of APPs at SHC.

Using community diagnosis on primary care placements for medical students.

BACKGROUND: Over 35 years ago Julian Tudor Hart highlighted how medical undergraduate education needed to adapt to produce clinicians who were better situated in communities. However, we still struggle to engage medical students in understanding the social and environmental determinants of health, the value population level data and public health interventions. Our approach: Third year medical students carried out a community diagnosis project where they evaluated quantitative, qualitative and observational data for the community in which they were living. They examined Public Health England fingertips data to choose a topic, gathered and evaluated further information, considered potential solutions, and created a 5-min presentation for their small group tutorial. The students were supported by GP tutors from East London, allowing a novel role for GP tutors to teach on this topic. EVALUATION: GP tutors and students gave positive feedback on both the design and delivery of the module. Students frequently made the link between their previous theoretical teaching in public health and the application of it in the GPCD module, appreciated the value of investigating their local area and commented upon the opportunity to consider the wider determinants of health. The GP tutors felt the project gave the students an insight into the lived realities of others. CONCLUSIONS: This module was an effective cross-collaborative approach between primary care and public health. It gave a practical application to build on previous theoretical public health learning, and evidence of transformational learning for the students, helping them to understand the impact of health inequalities.

Late coronary stent infection: a difficult to diagnose rare complication after percutaneous coronary intervention.

Percutaneous transluminal coronary angioplasty (PTCA) with drug-eluting stent placement is a well-established treatment modality for coronary stenotic lesions. Although infection involving implanted stent is rare, it can occur at any point of time, leading to high morbidity and mortality. We describe a rare case of infected coronary stents complicated with recurrent stent thrombosis, sepsis, and myocardial abscess formation after 2 years of percutaneous cornary intervention (PCI). Using multi-modality imaging final diagnoses to evaluate the precise location, extent and morphology of myocardial abscess (MA) was done. "On pump" coronary artery bypass graft (CABG) was performed, left anterior descending (LAD) artery intramyocardially was opened up, about 7-10 ml of pus was evacuated, and two drug-eluting stents (DES) were removed. The isolated identified organism was Pseudomonas aeruginosa which had remained dormant and restricted to the stent area for almost 2 years thinning the myocardium; an unusual trait of a very virulent bacterium which otherwise spreads fast to cause septicemia. The present case exemplifies the high index of clinical sensitivity with early multi-modality diagnosis, aggressive medical therapy, multidisciplinary care, and timely surgical intervention saving the patient's life in otherwise fatal condition.

Reducing the Time from Surgery to Adjuvant Radiation Therapy: An Institutional Quality Improvement Project.

Objective The National Comprehensive Cancer Network guidelines recommend an interval between surgery and adjuvant radiation therapy of less than 6 weeks, but only 44% of patients meet this metric nationally. We sought to identify key components of an improvement process focused on starting adjuvant radiation therapy within 6 weeks of surgery. Methods This project used an A3 model to improve a defined process measure. We studied a consecutive sample of 56 patients with oral cavity carcinoma who were treated at our institution with upfront surgical resection followed by adjuvant radiation therapy. Twelve proposed interventions tested during the study period focused on 3 key drivers of delays: delayed dental evaluation and teeth extraction, delayed radiation oncology consults, and inadequate patient engagement. The primary outcome measure was the number of days from surgery to the start of radiation therapy. Results Prior to the intervention, 62% of patients received adjuvant radiation within 6 weeks of surgery. Following the intervention, 73% of patients achieved this metric. The percentage of patients with avoidable delays decreased from 24% to 9%. The percentage of patients with unavoidable delays was relatively constant before and after the intervention (15% and 18%, respectively). Discussion Defining disease-specific metrics is critical to improving care in our head and neck cancer patient population. We demonstrate several key components to develop and improve self-defined metrics. Implications for Practice As we transition to a system of value-based care, structured quality improvement projects can have a measurable impact on cancer patient process measures.

Case Reporting, Competence, and Confidence: A Discrepancy in the Numbers.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) continues to play an integral role in accreditation of surgical programs. The institution of case logs to demonstrate competency of graduating residents is a key component of evaluation. This study compared the number of vascular cases a surgical resident has completed according to the ACGME operative log to their operative proficiency, quality of anastomosis, operative experience, and confidence in both a simulation and operative setting. MATERIALS AND METHODS: General surgery residents ranging from PGY 1 to 5 participated in a simulation laboratory in which they completed an end-to-side vascular anastomosis. Each participant was given a weighted score based on technical proficiency and anastomosis quality using a previously validated Global Rating Scale (Duran et al, 2014). These scores were correlated to the General Surgery Milestones. Participants completed preoperative and postoperative surveys assessing resident operative experience using the 4-level Zwisch scale (DaRosa et al., 2013), confidence with vascular procedures and confidence performing simulated anastomoses. Confidence was assessed on a scale from 1 to 9 (not confident to extremely confident). Case logs were recorded for each participant. An IRB approved questionnaire was distributed to assess preoperative and postoperative roles of both the resident physician and faculty, with a defined goal. Univariate and multivariate analysis was performed. RESULTS: Twenty-one general surgery residents were evaluated in the simulation laboratory and 8 residents were assessed intraoperatively. The residents were evenly distributed throughout clinical years. Groups of residents were divided into quartiles based upon the number of vascular cases recorded in the ACGME database. No correlation was found between number of cases, Milestones score and the weighted score (p = 0.94). No statistical significance was found between confidence and quality of anastomosis (p = 0.1). Resident operative experience per the Zwisch scale was categorized most commonly as "Smart Help" by both the trainee and attending surgeon, despite mean resident confidence ratings of 6.67 (± 1.61) with vascular procedures. CONCLUSIONS: ACGME case logs, which are utilized to assess readiness for completion of general surgery residency, may not be indicative of a resident's operative competency and technical proficiency. Confidence is not correlated with technical ability. Faculty and resident insight as to their role in a procedure differ, as faculty feel that they are providing less help than the resident perceives. Careful examination of resident operative technique is the best measure of competency.

Mifepristone and Misoprostol vs Misoprostol Alone in Second Trimester Termination of Pregnancy.

INTRODUCTION: During the last decade, medical methods for second trimester abortion have considerably improved and become safe and more accessible. The combination of mifepristone and misoprostol is now an established and highly effective method for second trimester abortion. But where mifepristone is not available or affordable, misoprostol alone has also been shown to be effective. The objective of this study is to compare the efficacy of mifepristone with misoprostol and misoprostol alone for second trimester termination of pregnancy. METHODS: It is a comparative study conducted on 60 patients from 13 to 18 weeks of gestation admitted for second trimester termination on legal indications. RESULTS: Mean induction abortion interval was comparable in both the groups. Of the 30 cases in each group, nine cases in each Group A and six cases in Group B had incomplete/failed expulsion. Among these 15 cases, only nine required check curettage for complete evacuation while others received oxytocics only for completion. The distribution of these cases was also comparable in both the groups. Only one patient in Group B had complete failure of expulsion and underwent surgical evacuation. However, the difference in dosage of misoprostol required for complete expulsion and incidence of side effects were significantly higher in the group B. CONCLUSIONS: Mifepristone and misoprostol combined together is now an established, highly effective and safe method for medical method of second trimester termination. However, when mifepristone is not available or affordable, misoprostol alone can also be used effectively, although a higher total dose is needed and side effects are higher than with the combined regimen.

Health and Socioeconomic Status of the Elderly People Living in Hilly Areas of Pakhribas, Kosi Zone, Nepal.

BACKGROUND: The rising geriatric population is facing significant health and social problems in the developing world that are impacting the quality of their lives. OBJECTIVE: The study describes the general health status and the socioeconomic characteristics of the elderly people of Pakhribas village development committee (VDC) of Eastern Nepal. MATERIALS AND METHODS: Descriptive cross-sectional study was carried out targeting the people aged 60 years and above in the sample area using a semi-structured questionnaire and convenient sampling to get the required sample size. A total of 189 elderly people who consented were interviewed in May 2010. RESULT: The major part of the elderly population was in the age group of 60-69 years. Seventy-two percent were illiterate and 75% were still earning with the majority involved in farming. Nine out of ten were living with their families and still made decisions for the household, Eighty-two percent did not feel lonely and 88.4% did not report any misbehavior by the house members. Regarding health, 69% had some diagnosed health issue with 36% suffering from gastritis and 20.4% from chronic lung disease. Using the ICD 10 criteria, depression was found among 18%. The most prevalent geriatric problem was a dental problem as found in 61% even though 87% claimed to brush their teeth regularly. More than half were suffering from visual difficulty and the proportions suffering from memory and hearing issues were also substantive. Smoking habit was found in 60%, and the relation between smoking and chronic respiratory diseases had a statistical association (P = <0.05). The geriatric cases who were misbehaved with felt depressed or neglected in the family (P = <0.0001). CONCLUSIONS: The results of the study show that employment, family support, and pension schemes have a positive impact on the social status of the elderly. Health screening clinics should be established in the community to detect health-related disorders. Elderly populations need health education to emphasize the importance of personal and dental hygiene and to abstain from smoking and alcohol.

Milestones: The Road to Faculty Development.

PURPOSE: Milestones for the assessment of residents in graduate medical education mark a change in our evaluation paradigms. The Accreditation Council for Graduate Medical Education has created milestones and defined them as significant points in development of a resident based on the 6 competencies. We propose that a similar approach be taken for resident assessment of teaching faculty. We believe this will establish parity and objectivity for faculty evaluation, provide improved data about attending surgeons' teaching, and standardize faculty evaluations by residents. METHODS: A small group of advanced surgery educators determined appropriate educational characteristics, resulting in creation of 11 milestones (Fig. 2) that were reviewed by faculty and residents. The residents have historically answered 16 questions, developed by our surgical education committee (Fig. 3), on a 5-point Likert score (never to very often). Three weeks after completing this Likert-type evaluation, the residents were asked to again evaluate attending faculty using the Faculty Milestones evaluation. The residents then completed a survey of 7 questions (scale of 1-9-disagree to strongly agree, neutral = 5), assessing the new milestones and compared with the previous Likert evaluation system. RESULTS: Of 32 surgery residents, 13 completed the Likert evaluations (3760 data points) and 13 completed the milestones evaluations (1800 data points). The number completing both or neither is not known, as the responses are anonymous when used for faculty feedback. The Faculty Milestones attending physicians' scores have far fewer top of range scores (21% vs 42%) and have a wider spread of data giving better indication of areas for improvement in teaching skills. The residents completed 17 surveys (116 responses) to evaluate the new milestones system. Surveys indicated that milestones were easier to use (average rating 6.13 ± 0.42 Standard Error (SE)), effective (6.82 ± 0.39) and efficient (6.11 ± 0.53), and more objective (6.69 ± 0.39/6.75 ± 0.38) than the Likert evaluations are. Average response was 6.47 ± 0.46 for overall satisfaction with the Faculty Milestones evaluation. More surveys were completed than evaluations, as all residents had an opportunity to review both evaluation systems. CONCLUSIONS: Faculty Milestones are more objective in evaluating surgical faculty and mirror the new paradigm in resident evaluations. Residents found this was an easier, more effective, efficient, and objective evaluation of our faculty. Although our Faculty Milestones are designed for surgical educators, they are likely to be applicable with appropriate modifications to other medical educators as well.

Ileal malignant hemangioendothelioma as a hypervascular lesion on computed tomography scan.

INTRODUCTION: Malignant epithelioid hemangioendothelioma (EHE) is an uncommon and grave vascular tumor. EHE is frequently angiocentric and is associated with a medium sized vessel, especially a vein. No definite etiological associations have been ascribed to this tumor so far, except an association with oral contraceptives in EHE of liver. PRESENTATION OF CASE: A 47 year old man presented with the complaint of intermittent black stool over the past two weeks. Occasionally, he experienced pain in left lower abdomen. On Computed Tomography (CT), it showed hypervascular lesion in the ileum with persistent enhancement. An exploratory laparotomy was performed with short segmental resection and functional end-to-end anastomosis. It was diagnosed finally with the histopathological and immunohistochemical analysis as a malignant EHE. DISCUSSION: EHE is an uncommon endothelial tumor that most frequently arises in soft tissue, liver, lung and skeleton. It behaves biologically in between benign epithelioid hemangioma and the more aggressive epithelioid angiosarcoma. Although a standard systemic treatment for malignant EHE has not been fully established, complete surgical excision is strongly recommended if feasible. CONCLUSION: EHE has a variable presentation and CT is helpful in identifying ileal EHE timely in the early stage, even when there is no obvious mass formation, however the diagnosis can be confirmed only after histopathological and immunohistochemical studies.

Posterior nutcracker syndrome with left renal vein duplication: An uncommon cause of hematuria.

INTRODUCTION: Posterior Nutcracker syndrome (NCS) is a rare anomaly in which the left renal vein passes behind the aorta which compresses it against the vertebral column, restricting the venous drainage of the left kidney. PRESENTATION OF CASE: A 46 year-old lady presented with intermittent painless hematuria for 6 years. Urinalysis showed microscopic hematuria. An abdominal CT scan showed left renal vein duplication with the retroaortic branch trapped between the vertebral column and the aorta at the level of the aortic bifurcation, suggestive of posterior NCS. There were multiple small cortical cysts, sand-like stones in the left kidney and duplication of both right and left renal arteries. DISCUSSION: Posterior NCS in a patient with a duplicated left renal vein may not show all the clinical features of a typical NCS as the elevated pressure due to compression is dissipated through the pre-aortic branch of the duplicated renal vein. CT Angiography can be helpful in such a patient with multiple abnormalities. Management can range from simple surveillance to nephrectomy depending on the symptoms and renocaval pressure gradient. CONCLUSION: Although posterior NCS is a rare anomaly of the left renal vein, it should be considered in the differential diagnosis of haematuria.

Uncommon solitary mesenteric mass: mesenteric panniculitis.

Mesenteric panniculitis is a rare, benign disease characterized by a chronic non-specific inflammatory process of mesenteric fat tissue with unknown etiology. Its clinical outcome ranges from complete resolution without any treatment to rapid progression culminating in death. So far, there is no established treatment available for its management. A 53-year-old female was admitted to our hospital because of intermittent abdominal pain, abdominal distension and early satiety for three months. Her abdominal CT scan revealed a solitary, well-defined, heterogeneous mass with a diameter of approximately 3.5cm x 2.8cm in the mesentery of small bowel. Exploratory laparotomy revealed yellowish-grey mass with a gritty consistency and histopathology of the resected specimen confirmed it to be mesenteric panniculitis. An increased awareness may lead to the use of a less invasive diagnostic approach and optimal management of this rare disease entity.

Sex preferences for colonoscopists and GI physicians among patients and health care professionals.

BACKGROUND: There are indications that many women prefer female health care providers. OBJECTIVE: To determine whether (1) patients and health care professionals have sex preferences for gastroenterologists (for office visit and colonoscopy) and (2) the reasons behind these preferences. DESIGN: Prospective survey. SETTING: Patients from primary care clinics at a Veterans Affairs and a community hospital and health care professionals. PATIENTS: A total of 1364 individuals completed the survey: 840 patients (566 men and 274 women) and 524 health care professionals (211 men and 313 women). MAIN OUTCOME MEASUREMENTS: Sex preferences for colonoscopists and gastroenterologists at a clinic. RESULTS: Women had a stronger sex preference (compared with no preference) for an office visit with a gastroenterologist (44.3%) and for a colonoscopist (53%) than men (23% and 27.8% respectively; P < .001). For health care professionals, there was a significant difference in sex preferences for women and men for a gastroenterologist office visit (30.4% vs 17.6%; P < .001) and for a colonoscopist (43.1% vs 26.1%; P < .001). Of all respondents with a sex preference, the most common reason was embarrassment for both office visit and colonoscopy. For all respondents with a sex preference for colonoscopy, a higher level of education was an independent predictor of patients feeling embarrassed (P = .003). LIMITATIONS: Single city, patient population from only 2 institutions. CONCLUSIONS: Female patients and female health care professionals have sex preferences in choosing a gastroenterologist for an office visit and colonoscopy, and the reasons for this are significantly influenced by their level of education.

Intermittent obstruction of jejunostomy tube due to Ascaris lumbricoides infection.

A 45-year-old Costa Rican woman was seen for a jejunostomy tube malfunction. There was no evidence of tube malposition or intestinal obstruction. During endoscopy, a long worm was retrieved from the distal duodenum; it was later confirmed to be Ascaris lumbricoides. After treatment with mebendazole, no further episodes of tube occlusion were observed. This case reminds us of the importance of considering helminthic infections and their atypical manifestations in patients from endemic regions.