HCA healthcare journal of medicine最新文献

Background: This article provides surgical trainees with a ranked list of the foundational literature that guides the contemporary surgical management of colorectal cancer and shows the evolution of surgical techniques in the field.

Methods: We assessed the surgical literature using the Web of Science and other ranking systems to create a ranked list of published articles on colorectal cancer surgery.

Results: We compiled a ranked list of the top 25 articles in the surgical management of colorectal cancer, based on the citation density score (mean number of citations per year) and the individual author H-index. The mean density score of the 25 papers was 29.9, and the journal most frequently represented on our list was the Annals of Surgery (36% of top papers). The Web of Science (primary) and alternative databases (secondary) H-index values for each author were identified. The range, mean, and median of the primary H-index values were 7.0-84.0, 31.8, and 29.0, respectively. The range, mean, and median of secondary H-index values were 4.0-108.0, 48.6, and 45.0, respectively. A 2-tailed, unpaired t-test was used to determine whether a significant difference existed between the primary and secondary H-index values for primary authors; P = .0376 (95% confidence interval, 1.02-32.58). A citation density score was calculated for each article, which represented the mean number of citations per year.

Conclusion: We provided a ranked list (citation density score) of the top-cited 25 articles in colorectal cancer surgery, a ranking of the associated primary authors by H-index, and a comparison of H-index scores between primary and secondary database sources. We believe this list is a useful resource for surgical trainees and researchers in colorectal cancer field and provides easy access to the top papers in this discipline.

Description This poem explores the complex intersection of memory, identity and the challenges imposed by Lewy body dementia, using the metaphor of a lost expedition traversing an isolated icy landscape. A profound sense of solitude reflects the disconnection that accompanies the dementia and tremors that follow, while also highlighting the danger of memory loss with mythological sirens representing its perilous allure (with some inspiration from The Odyssey). Through vivid imagery and lyrical language, it delves into the complexities of cognitive decline, providing an artistic reflection on dementia and offering a unique view of the emotional landscape of those affected by this condition.

Description Raindrops, ripples, and a moonlit sky evoke not just poetic imagery but also profound physiological and psychological responses from deep inside. In a kaleidoscope of colors, rain flakes spiral down like whispers from the cosmos, each droplet a tiny universe reflecting the dreams of wandering souls. They dance upon the surface of puddles, sending ripples that shimmer like liquid silver, weaving a tapestry of sound that resonates with the heartbeat of the earth. As moonlight drips softly from the sky, each moondrop creates a symphony of luminescent echoes, cascading through the air like stardust, inviting us to lose ourselves in the enchantment of this vibrant, surreal symphony. In this trippy embrace of nature, time melts away, and we are suspended in a dreamscape where the ordinary transforms into the surreal.

Background: Lichen planus pigmentosus inversus (LPPI) is a rare variant of lichen planus pigmentosus (LPP), characterized by sharply defined violaceous-brown to gray macules, papules, patches, or plaques primarily affecting the intertriginous and flexural areas. Unlike LPP, which predominantly affects Fitzpatrick skin types III to IV in sun-exposed areas, LPPI spares these regions and has been predominantly reported in White and Asian patients.

Case presentation: We discuss a 66-year-old man with Fitzpatrick skin type III who presented with a year-long history of mildly itchy, hyperpigmented plaques on the inframammary folds. These plaques developed after being hospitalized for a chronic urinary tract infection that was treated with antibiotics. He felt self-conscious and anxious due to the changes in skin, which affected his quality of life. His medical history included controlled diabetes and dyslipidemia, and he reported no systemic symptoms or prior topical medication use. A physical examination revealed well-demarcated, violaceous-brown plaques without scaling. Tests for fungal organisms, antinuclear antibodies, thyroid function, and hepatitis C were negative, and routine blood work was normal. A biopsy confirmed LPPI. Initial treatments with triamcinolone were ineffective, and hydroquinone was discontinued after 2 weeks due to irritation. The patient improved with tacrolimus 0.1% ointment twice daily, showing significant reduction in hyperpigmentation and improvement in skin texture at 4 and 8 weeks, with no side effects noted.

Conclusion: This case report highlights the diagnostic and therapeutic challenges associated with LPPI and discusses its potential response to topical tacrolimus. Our findings indicate that tacrolimus 0.1% ointment provides a safe and effective nonsteroidal treatment alternative for LPPI. Given the possible impact of LPPI on quality of life, timely diagnosis and appropriate management are crucial. Due to the absence of established treatment protocols for LPPI, further studies are necessary to better understand treatment responses and guide therapeutic strategies, particularly for individuals with darker skin tones.

Background: Pessaries are commonly used to treat pelvic organ prolapse. While these devices generally pose negligible risk, serious morbidity can be associated with neglected use.

Case presentation: A 91-year-old woman began to experience acute pain related to an impacted pessary. An Exam in the operating room under anesthesia revealed that the pessary was deeply embedded within the vaginal canal and was noted to have a hard metal wire under a rubber exterior. An intraoperative orthopedic consult was obtained to facilitate discussion and selection of tools outside the typical gynecological scope to remove the pessary. A combination of bolt cutters and rongeur forceps were used to successfully remove the pessary.

Conclusion: Consideration of instruments outside traditional gynecology including bolt cutters may be considered when faced with a difficult removal of foreign bodies embedded in gynecological tissues.

Description This photo, taken in June 2024 at the Northern Bulgarian Black Sea Coast, captures our fleeting time against that of ocean and rocks. Cape Kaliakra ("Beautiful Headland") has been fought over by various tribes and groups across centuries. Succession included the Dacians, Greeks, Ottoman Turks, the Russian Navy, and in the last century, the communist government of Bulgaria. Now a nature reserve, dolphins play off the coast and cormorants seek its updrafts. Cape Kaliakra sits on the Via Pontica, an ancient Greek road and major bird migration route from Africa into Eastern and Northern Europe. Its beauty and its importance in controlling the shoreline propelled men to capture it as a status and military vantage point, as if the awe and wonder it engenders could ever be fully owned.

Description Spontaneous coronary artery dissection (SCAD) is a rare nonatherosclerotic cause of myocardial infarction among young women, particularly during pregnancy. As the name suggests, SCAD is caused by the spontaneous formation of the false lumen within the coronary artery wall, thus compromising the blood flow to the myocardium. Unlike atherosclerotic acute coronary syndromes, SCAD is not directly associated with diabetes or hypertension; moreover, underlying connective tissue defects and inflammation are considered more contributory towards its etiology. Although its pathophysiology is not well understood, multiple theories have been proposed. Clinically, SCAD has a similar presentation to acute coronary syndromes, including substernal chest pain, elevated cardiac enzymes, ST-segment elevation myocardial infarction, and T wave changes on the ECG. Due to its elusive etiology, variable clinical presentation, and potential for catastrophic outcomes, it is essential to make a proper diagnosis using tools such as coronary angiography, optical coherence tomographic imaging, intravascular ultrasound, and cardiac magnetic resonance imaging. In this article, we review the current understanding of SCAD, encompassing its epidemiology, pathophysiology, clinical presentation, and diagnostic and management options.

Background: Pediatric appendicitis (PA) is the most frequent cause of pediatric emergency surgery. Standard PA scoring systems incorporate inflammatory biomarkers (white blood cell count [WBC] or C-reactive protein [CRP]); however, the individual biomarker sensitivities have not been reported beyond single-center sites. We aimed to measure the individual and combined sensitivities of WBC and CRP to rule out PA in a large multicenter hospital system.

Methods: We did a retrospective study of pediatric emergency department patients (age <18) with abdominal pain, using a deidentified electronic health database from a 175-hospital system in the United States, comparing PA versus non-PA patients. Pediatric appendicitis patients were identified by ICD-10 diagnosis codes and had advanced imaging, whereas non-PA patients had advanced imaging and were discharged home with the ICD-10 code for abdominal pain. Using matched propensity matching, we calculated receiver operator characteristics and Youden's index to find the optimal cutpoints. Sensitivity was calculated at the optimal and traditional cutpoints for each biomarker, also combined in parallel fashion.

Results: We identified 7414 subjects (3707 PA matched to 3707 controls). The WBC in PA patients was 14.99 ± 5.00 k/mm³ versus 9.63 ± 3.83 k/mm³ in non-PA patients (P < .001). The CRP in PA patients was 5.13 ± 6.43 mg/dL versus 1.22 ± 2.17 mg/dL in controls (P < .001). The optimal cutpoints (Youden's index) were 11.5 k/mm³ for WBC and 1.11 mg/dL for CRP. The sensitivity of WBC to rule out PA varied between 75.6%-83.9%, depending on the cutpoint (10.0-11.5 K/mm³). Similarly, the sensitivity of CRP to rule out PA varied from 64.9%-66.7%, depending on the cutpoint (1.0-1.11 mg/dL). Combined analysis showed that low WBC and CRP had a sensitivity of 90.0%-93.0%, yielding a negative predictive value of 99.2%-99.4% to rule out PA.

Conclusion: The PA patients in our study had significantly higher inflammatory biomarkers than the non-PA patients. Combining WBC less than 10.0 k/mm³ and CRP less than 1.0 mg/dL was 93.0% sensitive to rule out PA. Researchers should consider this combination of biomarkers to rule out PA in future prospective studies.

Introduction: The use of topical hemostatic agents has become common during surgical interventions. There is a wide variety of substances available to augment clotting, ranging from physical agents to topical thrombin combinations. Application of these agents in gynecologic surgery in patients with existing coagulopathies has not been studied.

Case presentation: A 62-year-old woman with an inferior vena cava filter and a history of multiple deep vein thromboses presented to the clinic with pelvic pain, stress urinary incontinence, and uterovaginal prolapse. She underwent a total vaginal hysterectomy, sacral colpopexy, tension-free vaginal tape sling, and cystourethroscopy. Warfarin was cross titrated to enoxaparin prior to surgery. Patient had a 10-week sized uterus, normal appearing adnexa, and postoperatively bleeding was identified at the vaginal cuff. Preoperative hemoglobin was 9.0, and postoperative hemoglobin was 8.0 with normal coagulation factors. Several hemostatic techniques were used intraoperatively including combined gelatin-thrombin and gelatin-based agents. The procedure was complicated by a cystotomy which was repaired intraoperatively. The patient had postoperative bleeding from the incision site within the first 2 hours of recovery requiring a revision procedure. Exploration laparotomy was performed identifying the source of hemorrhage as a vaginal cuff hematoma. Suture and additional gelatin-thrombin sealant was applied to the pedicles and thrombin-soaked packing was placed in the vagina. Total estimated blood loss was 800 mL. The patient was transfused 2 units of packed red blood cells, 1 unit of platelets, and 1 unit of fresh frozen plasma. The patient made an uneventful recovery, and routine follow-up was conducted with no apparent complications.

Conclusion: This case illustrates special considerations for intraoperative topical hemostatic agent use for gynecologic patients taking chemoprophylaxis for history of thrombosis and the value of the material composition for timely activity. Fibrin sealants have more rapid hemostasis than an oxidized regenerated dry matrix of cellulose. Because of the proximity of the reproductive organs to the bladder and urinary system, procedures complicated by cystotomy may result in mild leakage of sanguineous urine. This leakage can reduce the efficacy of combined gelatin-thrombin spray by disrupting its chemical components, compared with other hemostatic agents.

Background: We present a rare case of Sweet syndrome with underlying monoclonal gammopathy of unknown significance (MGUS) which initially presented as upper respiratory tract infection.

Case presentation: A 52-year-old woman presented with a complaint of sore throat for 6 days, productive cough and fever for 5 days, and red, pruritic, circular, tender rashes on face, arms and trunk for 2 days. There was a past history of similar self-limiting rashes presenting intermittently for 1.5 years. She also reported to be taking tablet ibuprofen, as required for the past 1-2 years, for cervical spondylosis. On integumentary examination, widespread, red, tender, annular plaques (2.5-5 cm in diameter) were noted over the face, back, and arms, with old, healed lesions having hyper-pigmented margins. A blood test revealed leukocytosis (13.6 x 10⁹/L), high neutrophil count (9.6 x 10⁹/L), elevated C-reactive protein of 108.7 mg/dL, abnormal monoclonal protein level (1.9 g/dL), high immunoglobulin G count (19.78 g/L) and high erythrocyte sedimentation rate (64 mm/hr). A histological examination showed skin with hyperkeratosis, parakeratosis and acanthosis of the epidermis, and scattered intra-epidermal neutrophils with occasional eosinophils and florid interstitial infiltrate of neutrophil in dermis. A diagnosis of Sweet syndrome due to possible use of ibuprofen and underlying MGUS was suspected, and the patient was started on a tapering dose of prednisolone. At a 2-week follow-up, the patient reported significant improvement in her health, which confirmed our diagnosis of Sweet syndrome.

Conclusion: It is crucial to investigate Sweet syndrome patients for malignant and premalignant conditions due to their common association. In this case, the patient was diagnosed with MGUS, a clinical condition with 1% risk of conversion into lymphoma or myeloma.