Search

In Sierra Leone, the lack of information on pulmonary embolism (PE) limits the access to evidence-based standard of diagnostic work-up and management of the disease. The objective of this study was to describe the clinical characteristics and management of acute pulmonary embolism in our setting and to determine whether the pre-test probability scoring algorithms were used prior to Computed Tomography Pulmonary Angiogram (CTPA) request.This retrospective observational study was conducted on CTPA-confirmed PE patients admitted to the Intensive Care Unit, Choithrams Memorial Hospital, in Freetown, Sierra Leone between July 2014 to June 2019. Clinical data, and pertinent investigations related to PE were determined. CTPA findings were correlated with the patient's hemodynamic status. The calculated pretest clinical probability scores (PCPS) for each patient were compared to the CTPA results.CTPA-confirmed PE in the study cohort was 79, with a rate of 16 new PE per year. The frequency of PE was 1.9% of the total hospital admission per year. The mean age was 64.1 ± 17.9 years, median age was 63.3years (range: 23-89 years), with 55.7% of the cohort being females. Dyspnea (78.5%) and tachycardia (69.6%) were the commonest signs and symptoms documented, with immobilization (34.2%) being the prevalent risk factor, while hypertension (48.1%) was the most common co-morbidity. The PCPS algorithm was underutilized, as "Wells Score" was documented in only 9.5% while "modified Geneva score" was never used by hospital physicians. PE with hemodynamic stability was significantly more common than PE with unstable hemodynamic status [55 (69.6%) vs 24 (30.4%), p=0.015]. All patients were managed only with anticoagulants. The overall in-hospital mortality was 17.7%.Since PCPS was hardly calculated by doctors in the diagnosis of PE, the study showed that the diagnostic algorithm for suspected PE was infrequently used in clinical practice. The use of empirical judgement by doctors in requesting for CTPA may have accounted for low rate in the diagnosis of PE per year. The establishment of P.E registry in Sierra Leone is imperative.En Sierra Leone, le manque d’informations sur l’embolie pulmonaire (EP) limite l’accès à des normes de diagnostic et de prise en charge de la maladie fondées sur des preuves. L’objectif de cette étude était de décrire les caractéristiques cliniques et la prise en charge de l’embolie pulmonaire aiguë dans notre établissement et de déterminer si les algorithmes de notation de la probabilité pré-test étaient utilisés avant la demande d’angiographie pulmonaire par tomodensitométrie (CTPA).Cette étude observationnelle rétrospective a été menée sur des patients atteints d’EP confirmée par CTPA admis à l’unité de soins intensifs, Choithrams Memorial Hospital, à Freetown, Sierra Leone, entre juillet 2014 et juin 2019. Les données cliniques, et les investigations pertinentes liées à l’EP ont été déterminées. Les résultats du CTPA ont été corrélés avec l’état hémodynamique du patient. Les scores de probabilité clinique prétest (PCPS) calculés pour chaque patient ont été comparés aux résultats du CTPA.Le nombre d’EP confirmées par CTPA dans la cohorte étudiée était de 79, avec un taux de 16 nouvelles EP par an. La fréquence de l’EP était de 1,9 % du nombre total d’hospitalisations par an. L’âge moyen était de 64,1 ± 17,9 ans, l’âge médian de 63,3 ans (fourchette : 23-89 ans), 55,7 % de la cohorte étant des femmes. La dyspnée (78,5 %) et la tachycardie (69,6 %) étaient les signes et symptômes les plus fréquemment documentés, l’immobilisation (34,2%) étant le facteur de risque prévalent, tandis que l’hypertension (48,1 %) était la comorbidité la plus courante. L’algorithme PCPS était sous-utilisé, le “ score de Wells “ n’étant documenté que dans 9,5 % des cas, tandis que le “ score de Genève modifié “ n’était jamais utilisé par les médecins hospitaliers. L’EP avec stabilité hémodynamique était significativement plus fréquente que l’EP avec état hémodynamique instable [55 (69,6 %) vs 24 (30,4 %), p=0,015]. Tous les patients ont été traités uniquement par anticoagulants. La mortalité globale à l’hôpital était de 17,7 %.Étant donné que le PCPS était rarement calculé par les médecins pour le diagnostic de l’EP, l’étude a montré que l’algorithme diagnostique pour l’EP suspectée était rarement utilisé dans la pratique clinique. L’utilisation d’un jugement empirique par les médecins pour demander un CTPA peut expliquer le faible taux de diagnostic de l’EP par an. L’établissement d’un registre de l’E.P. en Sierra Leone est impératif.Embolie pulmonaire, caractéristiques cliniques, gestion, Sierra Leone.

Many countries do not have a newborn screening (NBS) program, and immigrants from such countries are at risk for late diagnosis of phenylketonuria (PKU). In this international survey, 52 of 259 patients (20%) with late diagnosed PKU were immigrants, and 145 of the 259 (55%) were born before NBS or in a location without NBS. ispartof: JOURNAL OF PEDIATRICS vol:239 pages:231-+ ispartof: location:United States status: published

Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years.Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution.Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%).The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.

As the popularity of a laparoscopic Roux-en-Y Gastric Bypass (RYGB) surpassed that of an open approach, practice of concomitant cholecystectomy declined. Low rates of gallbladder disease following RYGB and high complication rates of concomitant cholecystectomy have been published, but these population-based studies have lacked long-term outcomes and survival data. The California Office of Statewide Health Planning and Development longitudinal database was queried for patients who underwent RYGB with or without cholecystectomy between 1995 and 2009. Additionally, patients who underwent cholecystectomy after RYGB were compared to all cholecystectomy patients. Primary outcome was survival; secondary long-term outcomes included cholangitis, common duct stones, dumping syndrome, metabolic derangements, ventral hernia, any hernia, marginal ulcers, and reoperation. Cox proportional hazard analysis was performed to determine adjusted survival and outcomes. Of 134,584 RYGB patients, 21,022 underwent concomitant cholecystectomy. Concomitant cholecystectomy improved both survival (HR[95 % CI] 0.51[.48–.54]) and long-term outcomes (HR 0.84[.77–.91]). Incidence of gallbladder disease following RYGB was 6.8 and 15.2 % at 1 and 5 years. In subsequent analysis of 829,333 cholecystectomy patients, 7,099 underwent prior RYGB with higher risk of conversion to open (HR 1.58[1.41–1.78]), post-operative complication (HR 1.47[1.36–1.6]) and death (HR 1.32[1.17–1.5]). Concomitant cholecystectomy is safe for RYGB patients. Given high rates of gallbladder disease and increased risk when cholecystectomy is performed following RYGB, cholecystectomy should be considered at the time of RYGB.

Background Transanal minimally invasive surgery (TAMIS), an alternative technique to transanal endoscopic microsurgery, was developed in 2009. Herein, we describe our initial experience using TAMIS for benign and malignant rectal neoplasia. Methods This is an institutional review board approved, retrospective case series report. Results TAMIS was performed in 32 patients for rectal adenoma (13), adenocarcinoma (16), and carcinoid (3). There were 14 women, with mean age 62 ± 15 years and body mass index 28 ± 5 kg/m2. Lesion size ranged from .5 to 8.5 cm, distance from the dentate line 1 to 11 cm, and circumference of the lesion 10% to 100%. The mean operative time was 123 ± 62 minutes. Mean hospital length of stay was 2.5 ± 2 days. Complications included urinary tract infection (1), Clostridium difficile diarrhea (1), atrial fibrillation (1), rectal stenosis (1), and rectal bleeding (1). Conclusion TAMIS using a disposable transanal access platform is a safe and effective method to remove rectal lesions in this case series.

To demonstrate the feasibility of an innovative technique for the surgical management of rectal cancer, we performed transanal minimally invasive surgery assisted low anterior resection with total mesorectal excision (TAMIS-assisted LAR with TME) in a cadaver model. Transanal LAR via natural orifice transluminal endoscopic surgery has been reported in cadaveric series using rigid transanal platforms. This procedure has not been described using a combination of a single incision laparoscopy and TAMIS transanal endoscopic platform. We describe the first cadaveric series of TAMIS-assisted LAR with TME.TAMIS-assisted LAR with TME was successfully performed in five fresh human cadavers. The procedure was performed using the mini-Gelpoint single incision platform and the Gelpoint Path TAMIS platform (Applied Medical, Rancho Santa Margarita, CA). The variables recorded were age, body mass index (BMI), operative time, complications, and specimen length. The grade of the TME was determined by evaluation of the specimen by photo documentation by a gastrointestinal pathologist.All cadavers were male with a mean age of 71 ± 8 years and mean BMI of 28 ± 3 kg/m(2). The mean operative time was 200 ± 55 min (range 128-249 min). The quality of the TME was grade I (complete) with intact mesorectum in all five cases. The mean specimen length was 36.8 ± 3.4 cm.TAMIS-assisted LAR with TME was feasible. A high-quality TME can be achieved using this innovative technique. Transanal endoscopic total mesorectal dissection may revolutionize the surgical management of rectal cancer. However, multicenter clinical trials are needed to further evaluate the oncologic safety and surgical outcomes of transanal endoscopic TME using various platforms before widespread application of this new technique.

Esophagectomy may lead to impairment in gastric emptying unless pyloric drainage is performed. Pyloric drainage may be technically challenging during minimally invasive esophagectomy and can add morbidity. We sought to determine the effectiveness of intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-assisted esophagectomy as an alternative to surgical pyloric drainage.We performed a retrospective analysis of patients with adenocarcinoma and squamous cell carcinoma of the distal esophagus or gastroesophageal junction who underwent robotic-assisted transhiatal esophagectomy (RATE) without any surgical pyloric drainage. Patients with and without intraoperative endoscopic injection of 200 units of botulinum toxin in 10 cc of saline (BOTOX group) were compared to those that did not receive any pyloric drainage (noBOTOX group). Main outcome measure was the incidence of postoperative pyloric stenosis; secondary outcomes included operative and oncologic parameters, length of stay (LOS), morbidity, and mortality.From November 2006 to August 2014, 41 patients (6 females) with a mean age of 65 years underwent RATE without surgical drainage of the pylorus. There were 14 patients in the BOTOX group and 27 patients in the noBOTOX group. Mean operative time was not different between the comparison groups. There was one conversion to open surgery in the BOTOX group. No pyloric dysfunction occurred in the BOTOX group postoperatively, and eight stenoses in the noBOTOX group (30%) required endoscopic therapy (P .05). There were no differences in incidence of anastomotic strictures or anastomotic leaks. One patient in group noBOTOX required pyloroplasty 3 months after esophagectomy. There was one death in the noBOTOX group postoperatively (30-day mortality 2.4%). Mean LOS was 9.6 days, and BOTOX patients were discharged earlier (7.4 versus 10.7, P .05).Intraoperative endoscopic injection of botulinum toxin into the pylorus during RATE is feasible, safe, and effective and can prevent the need for pyloromyotomy.

Complete duplication of the bladder and urethra is a rare entity. It may occur in the coronal and sagittal planes, and is often associated with other organ system anomalies, in particular of the gastrointestinal tract. We report an unusual variant of sagittal duplication of the bladder, in a male, associated with rudimentary hindgut duplication, and review the literature pertaining to this unusual anomaly.

With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report.A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME.A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes.Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.

Psychiatric stigma is a concept that is often used uncritically by policy-makers to explain the underutilization of professional psychiatric services in non-Western societies. Stigma, however, is a multi-determined process manifestations and effects of which cannot be viewed separately from the larger social and cultural context. The present paper presents the results of a qualitative study of psychiatric stigma in Egypt from the perspective of lay respondents. A vignette method was used to elicit judgments of social distance and qualitative responses to stories depicting psychosis, depression, alcohol abuse and a 'possession state' from 208 respondents recruited through their places of work. The results indicated that while stigma does exist in Egypt, the form that it takes must be understood with reference to Egyptian notions of selfhood that locate behavioral disturbances in the intersubjective rather than intrapsychic realm. On the one hand, individual blame is diffused as responsibility for the illness and its cure is placed in the social, not personal (or biological) realm. On the other, behavioral disorders that threaten the social fabric of society are particularly stigmatized and often met with social rejection.

The organizing goal of the present study was to analyze and understand the 'discursive presentation' of the Egyptian psychiatric patient through the texts, or narratives, contained within the patient medical charts. It is argued that the medical record, as a written document blending overt medical imperatives with more unexamined cultural assumptions about self-hood and abnormality, is an unusually rich source of discursive data concerning the 'cultural negotiations' implicit in the construction of the patient according to the two (often competing) world views represented by western biomedicine and traditional Egyptian culture. Psychiatry in Egypt is much more than a 'foreign transplant'; to assume this is to deny the culturally constructed nature of western biomedicine and psychiatry, which have their roots in historical and cultural notions of self, society, the individual, and normality versus abnormality (Transcultural Psychiat. 35(3) (1998) 352). Egyptian psychiatry is the product of an ongoing active blending of two very different conceptualizations of these issues.

Laparoscopic and endoluminal surgical techniques have evolved and allowed improvements in the methods for treating benign and malignant gastrointestinal diseases. To date, only case reports have been reported on the application of a laparo-endoscopic approach for resecting gastric submucosal tumors (SMT). In this study, we aimed to evaluate the efficacy, safety, and oncologic outcomes of a laparo-endoscopic transgastric approach to resect tumors that would traditionally require either a laparoscopic or open surgical approach. Herein, we present the largest single institution series utilizing this technique for the resection of gastric SMT in North America.We performed a retrospective review of a prospectively collected patient database. Patients who presented for evaluation of gastric SMT were offered this surgical procedure and informed consents were obtained for participation in the study.Fourteen patients were included in this study between August/2010 and January/2013. Eight (8) patients (57.1 %) were female and the median age was 56 years (range 29-78). Of the 14 cases, 8 patients (57.1 %) underwent laparo-endoscopic resection of SMTs with transgastric extraction, 5 patients (35.7 %) had conversions to traditional laparoscopic surgery, and 1 patient (7.2 %) was abandoned intraoperatively. The median operative time for this cohort was 80 min (range 35-167). Ten patients (71.4 %) had GISTs, 3 (21.4 %) had leiomyomas, and 1 (7.1 %) had schwannoma. There were no intraoperative complications. Two patients had postoperative staple line bleeding that required repeat endoscopy. The median hospital stay was 1 day (range 1-6) and there were no postoperative mortalities. At 12-month follow-up visit, only one GIST patient (10 %) had tumor recurrence.Our experience suggests that this surgical approach is safe and efficient in the resection of gastric SMT with transgastric extraction. This study found no intraoperative complications and optimal oncologic outcomes during the follow-up period. Minimally invasive surgical approaches are emerging as a valid and potentially better approach for resecting malignancies; however, continued investigation is underway to further validate this data.

There are few options for the treatment of fistulas, leaks, and perforations endoscopically. Here we describe our experience with an endoscopic clipping system. A retrospective review of all cases using the Over-The-Scope-Clip system (Ovesco Endoscopy AG, Tuebingen, Germany) was performed. The system was utilized in ten patients with gastrointestinal surgical complications. Four patients had gastric leaks following sleeve gastrectomy, one had a post-operative colonic leak, two had gastro-gastric fistulas following gastric bypass, and three had esophageal perforations. Two leak patients had complete resolution, one had a contained leak following clip placement that was clinically insignificant, and the fourth patient had a persistent leak despite two clipping procedures. Two patients had gastro-gastric fistulas following roux-en-y gastric bypass surgery and, while they both had initial success, the fistulas recurred. One patient presented with anastomotic leak following colon resection but the system was unable to reach the treatment site. Three patients were successfully treated for esophageal perforation. There were no complications. This over-the-scope endoscopic clip system is simple to use, safe, and successful in approximating tissue to treat traditionally difficult surgical complications. Further experience and longer follow-up are needed to assess its indications as related to defect size and location.

In laparoscopy, it often is the case that port sites are enlarged for specimen extraction. This leads to higher risk of trocar site complications, such as infection or incisional hernia. Natural orifice surgery (NOTES) is beneficial for minimizing these complications, and this is emphasized when the extracted specimen is of large volume. We have been using transgastric technique for appendectomy, cholecystectomy, and laparoscopic sleeve gastrectomy (LSG). Of these transgastric operations, we focus on the one with relatively large-organ extraction: LSG with transoral remnant extraction (TORE). We describe the details and feasibility of this procedure and compare the outcomes to conventional LSG. All patients undergoing LSG were considered candidates for TORE and were consented for this procedure if interested after an informed discussion. Eighteen LSGs with TORE (TORE group) and ten conventional LSGs (non-TORE group) were performed from August 2010 to March 2011. We retrospectively compared these two groups for the age, sex, preoperative body mass index, operating room time, hospital stay, excess weight loss (EWL), and trocar site complications. Laparoscopic sleeve gastrectomy with TORE consists of conventional LSG and transgastric retrieval of the resected stomach. The procedure exceeds exactly the same manner as conventional LSG until the initial stapling of the stomach. For TORE, the gastrectomy is initiated 5 cm proximal to the pylorus than usual LSG to save the space for the gastrotomy used for specimen retrieval. After the gastrectomy is completed, the full thickness of the distal most part of the staple line is incised open as wide as 2 cm by using electric cautery or ultrasonic dissector. A flexible upper endoscope, which has been in the stomach already as a bougie for gastrectomy, is then guided into the peritoneal cavity through the gastrotomy. The specimen is grasped endoscopically with a snare and extracted transorally. Following this, the gastrotomy is closed laparoscopically. The final shape of the gastric sleeve is identical to the one of conventional LSG. There was no significant difference between the TORE and the non-TORE group for patients’ profile, operating room time, hospital stay, and EWL. Neither group has experienced perioperative complications. All specimens were extracted readily and safely in the TORE group. Of the ten cases in the non-TORE group, four required extension of the trocar site. No trocar site complications were found in the TORE group, whereas the extended trocar site developed panniculitis in two cases of the non-TORE group; one required panniculectomy for refractory induration. TORE can be safely and easily performed by surgeons with laparoscopic and endoscopic skill, and with commonly available instruments. While producing identical outcomes, our initial experience with the TORE technique demonstrates an advantage over traditional LSG, because it minimizes trocar site complications. Transgastric organ extraction is potentially applicable to other large-organ extractions in laparoscopic surgery without excessive risk or resources. Larger case volume and longer follow-up period is awaited.

This study was designed to compare growth parameters, biochemical indices of protein metabolism and serum amino acid patterns in newborn infants fed either human milk (n: 22) or formula with protein and amino acid concentrations similar to human milk (n: 19) during the first two months of life. Growth parameters were normal and similar in all infants. Serum levels of transferrin and IgG were not significantly different, whereas prealbumin concentrations were found to be significantly higher in infants fed formula compared to those fed human milk. In the formula group, glutamic acid and cystine levels were significantly lower while phenylalanine and proline were significantly higher compared to the breastfed group. It was observed that feeding a formula with an amino acid pattern similar to that of human milk does not necessarily give rise to identical patterns of amino acids or indices of protein metabolism.

Screening of 2234 primary and secondary school students in a rain-forest area with endemic onchocerciasis showed that the percentage of students with positive skin snips increased with school age: from 0.7% in class 1 to 23% in form 5. Visual acuity of 6/12 or more in both eyes was found in 98% of the students. Students with an intraocular pressure higher than 21 mm showed a higher percentage of positive skinsnips than those with an intraocular pressure of 21 mm or less. The results of health education and treatment with diethylcarbamazine were better than those obtained in outpatients of the eye hospital in the same town. The possibilities of mass school screening in the Northern Province of Sierra Leone are discussed.

One hundred and forty eight patients (69 women and 79 men) with often recurring genital herpes were observed for two months. Men had 119 observed recurrences and women 104. The attacks were significantly longer in men than women (8.7 days v 6.6 days, p = 0.005). Significantly more women complained of symptoms, however, and when symptoms occurred they were more severe. Other significant differences between men and women included age (men were older than women); more men had previously had sexually transmitted diseases; more men had infected a sexual partner, but fewer knew the source of their infection; and men had more lesions at each attack. Positive viral culture results were shown to depend on the amount of erythema, the number of lesions, and the presence of vesicles.