Search

Gastric cancer is the fifth most common cancer in the world and the third leading cause of cancer-related deaths. Signet-ring cell type is the most malicious subtype. We report a case of advanced stage gastric adenocarcinoma case post-radical gastrectomy who presented with nausea, vomiting, and diarrhea. Though there were no signs of bowel obstruction on abdominal CT and PET imagine studies, and the cytology of body fluid was initially negative, the patient had unilateral malignant pleural effusion, a moderate amount of ascites and bilateral hydronephrosis. After laparoscopic surgery, the patient was diagnosed with local cancer relapse causing jejunojejunal anastomosis obstruction and peritoneal carcinomatosis causing hydronephrosis. We urge broadening the indication of EGD in the evaluation of advanced stage gastric carcinoma to include mechanic bowel obstruction.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged from Wuhan, China in December 2019 and is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19). Approximately one-third of the patients with COVID-19 require intensive care unit (ICU) admission, and almost 30% of the patients develop acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used as salvage therapy for severe ARDS. The role of ECMO in the treatment of COVID-19 remains unclear, although there is emerging evidence that this approach may be an effective salvage therapy for severe ARDS. Case Presentation: We present a case of a previously healthy 39-year-old Hispanic male who presented to the hospital with flu-like symptoms, including headache, fatigue, and myalgia for 8 days in late April 2020. He denied dyspnea on exertion. The patient’s symptoms progressed, resulting in pneumonia and acute respiratory distress syndrome (ARDS). The patient was managed with prone positioning, convalescent plasma and veno-venous extracorporeal membrane oxygenation (VV-ECMO) for 35 days. The patient successfully recovered and was able to ambulate independently and was discharged home from an acute care hospital without oxygen supplementation on hospital day 63. Conclusion: We present one of the first few documented cases of ECMO for severe ARDS due to COVID-19. After a prolonged hospital course requiring VV-ECMO, the patient was discharged home from an acute care hospital without oxygen requirement and ambulated independently, likely as a result of daily aggressive mobility-focused rehabilitation.

Introduction: Little is known about adult intussusception, but current evidence suggests that malignancy, polyps, and diverticula are usual etiologies. We present a case of adult ileoceccal intussusception secondary to carcinoid tumor. Case Presentation: A 53-year-old African American male presented with hematochezia and non-radiating constant left upper quadrant pain accompanied by nausea and vomiting. CT of the pelvis demonstrated a pathognomic ‘target’ sign, consistent with ileoceccal intussusception and early small bowel obstruction. Two years prior to this current presentation, the patient had experienced an episode of hematochezia for which he underwent colonoscopy and polypectomy, with subsequent pathology results negative for colon cancer. He denies diarrhea, constipation, weight loss, decreased appetite or skin flushing. Due to persistent symptoms of bowel obstruction, he underwent exploratory laparotomy. During the surgery a white-colored, chalky mass indicative of penetrating tumor was noted 13 cm proximal to the ileocecal valve. An extended right hemi-colectomy followed the discovery of the mass. Pathology showed a well-differentiated neuroendocrine tumor consistent with carcinoid tumor. Evaluation for metastatic disease using 5-HIAA and chromogranin A was unremarkable, and the resection of the right colon carcinoid tumor was felt to be curative. Conclusion: It is uncommon for adults to present with intussusception; in such cases, malignancy should be ruled out as an underlying cause. Carcinoid should be listed among the other secondary causes, which include inflammatory bowel disease, diverticulitis, polyps, scar tissue, adhesions, and lipomas. Abbreviation: CT (Computer tomography), 5-HIAA (5-hydroxyindole acetic acid), NCCN (National Comprehensive Cancer Network)

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the diagnosis of gout.This guideline is based on a systematic review of published studies on gout diagnosis, identified using several databases, from database inception to February 2016. Evaluated outcomes included the accuracy of the test results; intermediate outcomes (results of laboratory and radiographic tests, such as serum urate and synovial fluid crystal analysis and radiographic or ultrasonography changes); clinical decision making (additional testing and pharmacologic or dietary management); short-term clinical (patient-centered) outcomes, such as pain and joint swelling and tenderness; and adverse effects of the tests. This guideline grades the evidence and recommendations by using the ACP grading system, which is based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.The target audience for this guideline includes all clinicians, and the target patient population includes adults with joint inflammation suspected to be gout.ACP recommends that clinicians use synovial fluid analysis when clinical judgment indicates that diagnostic testing is necessary in patients with possible acute gout. (Grade: weak recommendation, low-quality evidence).

Hospitals that provide post-graduate medical education have a unique role in the American healthcare system. These hospitals provide a large portion of healthcare for populations that are poor and chronically ill. With few exceptions, these institutions are responsible for training all physicians who practice in the United States. Teaching hospitals receive funding for providing graduate medical education through the Medicare program, Medicaid program, Health and Human Services, the Veterans Administration, Department of Defense, and private funding from individual hospitals. Payment for training of postgraduate physicians consists of direct costs for maintaining residency training programs and indirect medical expenses related to the increased costs associated with having residency training programs in a hospital. Funding for individual residency training programs is determined by complex formulas which are reviewed.