Unusual Presentation of Bouveret Syndrome Resulting in Both Gastric Outlet Obstruction and Small Bowel Obstruction with Perforation.

Our case describes an 83-year-old female who presented with severe abdominal pain, nausea, and bilious emesis of one day's duration. She had an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and percutaneous transhepatic biliary drainage (PTCD) one year prior for choledocholithiasis with acute cholangitis in her home country, Scotland. Unfortunately, while visiting family in the United States, her PTCD became dislodged, and she developed progressive worsening abdominal pain. Computerized tomography of her abdomen showed pneumobilia, perigastric inflammation, a contracted gallbladder, small bowl inflammation with a likely transition point at the mid-jejunum, and a probable duodenal mass. The patient underwent an exploratory laparotomy with intraoperative findings of choledochoduodenal fistula with coincident gastric and small bowel obstruction (SBO) secondary to three large, mixed gallstones. One 3 cm gallstone was located at the pylorus and two (2.3 and 3 cm) gallstones were isolated in the mid-jejunum, with one of those causing isolated transmural pressure necrosis with subsequent perforation. Bouveret syndrome is a rare cause of gastric outlet obstruction (GOO) that manifests via an acquired cholecystoenteric fistula. Our patient presented with a concomitant GOO and SBO with perforation of the mid-jejunum. Timely diagnosis of Bouveret syndrome is essential, as most causes require emergent surgical intervention.

CT Imaging Findings of Porcelain Gallbladder and Epiploic Appendagitis: Two Rare Abdominal Pathologies in an Asymptomatic Patient.

Porcelain gallbladder (PG) and epiploic appendagitis (EA) are rare imaging findings in an asymptomatic patient. The clinical presentation of PG and EA can vary; however, a common presenting complaint is abdominal discomfort. We describe the case of a 54-year-old male with computerized tomography findings consistent with PG and EA. We also performed a review of the literature to understand the etiology, clinical presentation, and diagnosis and treatment options of both PG and EA.

The aging general surgeon of rural America.

PURPOSE: Nonmetropolitan communities are faced with health care professional shortages and prior reports suggest that general surgeons are no exception. The purpose of this brief is to evaluate the age difference and distribution of rural versus urban general surgeons to highlight the growing need to recruit medical students and residents for rural practice. METHODS: A secondary data analysis of residency graduated general surgeon demographics at the county level was performed using data from the Area Health Resource File. General surgeon demographic data were compared between nonmetropolitan and metropolitan areas. FINDINGS: The number of general surgeons practicing in rural communities is decreasing by a rate of approximately 0.5%-1.0% annually. Moreover, the entry of younger (<35 years of age) general surgeons into rural counties (8.7%) was less than urban regions (12.1%). Rural general surgeons tended to be older than their urban peers, and on average, rural general surgeon age exhibits a negative skewed, platykurtic distribution. CONCLUSIONS: Immediate action must be taken to generate more surgeons for rural practice. A failure to increase recruitment and retention of rural surgeons may have severe consequences on the health status of rural communities.

Assessment of burnout in medical students using the Maslach Burnout Inventory-Student Survey: a cross-sectional data analysis.

BACKGROUND: Medical student burnout can cause emotional and physical exhaustion and detachment. The objectives of this study were to evaluate burnout using the Maslach Burnout Inventory-Student Survey (MBI-SS), identify factors that may predict burnout, and assess wellness initiatives effectiveness at reducing burnout. METHODS: The MBI-SS was administered to all medical students (Classes 2019 to 2022) at the University of Illinois College of Medicine (UICOM) from February to May 2019. Factor analysis and internal consistency of the MBI-SS were assessed. Mean MSBI-SS subscale scores for burnout were calculated for cynicism (CY), emotional exhaustion (EE), and academic efficacy (AE). Multiple regression analysis was used to identify student factors that may predict burnout. RESULTS: A total of 273 (21.6%) UICOM students completed the survey and 110 (40.3%) respondents reported self-perceived burnout. MBI-SS subscale scores were significantly higher for CY and EE, and significantly lower for AE in students who reported suffering from burnout versus students who did not report burnout. Mean ± SD subscale scores for CY, EE, and AE in burnout students were 14.44 ± 5.59, 23.23 ± 4.74, and 24.81 ± 5.35, respectively. In comparison, mean ± SD subscale scores for CY, EE, and AE in non-burnout students were 7.59 ± 5.16, 14.96 ± 5.71, and 28.74 ± 3.21, respectively. Regression analysis denoted significant associations between burnout and being out-of-phase in the curriculum, the effectiveness of wellness initiatives, and strength of motivation for medical school (SMMS) in both the two- and three-dimensional MBI-SS models. Gender was significantly associated with burnout in only the two-dimensional model. CONCLUSIONS: Self-reported burnout in medical students at UICOM was validated using the MBI-SS. Being out-of-phase in the curriculum, being female, rating wellness initiatives as less effective, and demonstrating lower motivation for continued medical school education may be used as predictors of medical student burnout. This investigation may act as a guide for measuring burnout in medical student populations and how the implementation of wellness initiatives may ameliorate burnout.

Factors Influencing a Medical Student's Decision to Pursue Surgery as a Career.

BACKGROUND: Recent match trends from the National Resident Matching Program suggest that the number of allopathic medical students (MD) pursuing general surgery is declining. This decline may have profound consequences given the surgeon shortage predicted by the Association of American Medical Colleges. Early exposure to surgery opportunities may increase a student's desire to pursue the specialty as a career. The aim of this study was to evaluate the effect surgical activities have on promoting student interest in surgery. METHODS: Medical students (years 1-3) at the University of Illinois at Rockford completed a two-component activity: a questionnaire and laparoscopic box activity. Differences in lifestyle factors, psychomotor aptitude, and future career interests were compared. RESULTS: A total of 64 medical students completed the activity. 45.3% of students reported that the activity positively influenced their decision to pursue a career in surgery. Rating of the importance of living in a rural versus urban community was an important lifestyle factor (p = 0.01) for students without rather than with an interest in surgery, 3.95 and 3.19, respectively. No differences were observed in other lifestyle factors. CONCLUSION: Early exposure to surgical activities may foster interest in students who lacked previous intention to pursue the specialty.

Chronic temporal lobe epilepsy is associated with enhanced Alzheimer-like neuropathology in 3×Tg-AD mice.

The comorbidity between epilepsy and Alzheimer's disease (AD) is a topic of growing interest. Senile plaques and tauopathy are found in epileptic human temporal lobe structures, and individuals with AD have an increased incidence of spontaneous seizures. However, why and how epilepsy is associated with enhanced AD-like pathology remains unknown. We have recently shown ß-secretase-1 (BACE1) elevation associated with aberrant limbic axonal sprouting in epileptic CD1 mice. Here we sought to explore whether BACE1 upregulation affected the development of Alzheimer-type neuropathology in mice expressing mutant human APP, presenilin and tau proteins, the triple transgenic model of AD (3×Tg-AD). 3×Tg-AD mice were treated with pilocarpine or saline (i.p.) at 6-8 months of age. Immunoreactivity (IR) for BACE1, ß-amyloid (Aß) and phosphorylated tau (p-tau) was subsequently examined at 9, 11 or 14 months of age. Recurrent convulsive seizures, as well as mossy fiber sprouting and neuronal death in the hippocampus and limbic cortex, were observed in all epileptic mice. Neuritic plaques composed of BACE1-labeled swollen/sprouting axons and extracellular AßIR were seen in the hippocampal formation, amygdala and piriform cortices of 9 month-old epileptic, but not control, 3×Tg-AD mice. Densities of plaque-associated BACE1 and AßIR were elevated in epileptic versus control mice at 11 and 14 months of age. p-Tau IR was increased in dentate granule cells and mossy fibers in epileptic mice relative to controls at all time points examined. Thus, pilocarpine-induced chronic epilepsy was associated with accelerated and enhanced neuritic plaque formation and altered intraneuronal p-tau expression in temporal lobe structures in 3×Tg-AD mice, with these pathologies occurring in regions showing neuronal death and axonal dystrophy.