A Mysterious Cause of Gastrointestinal Bleeding Disguising Itself as Diverticulosis and Peptic Ulcer Disease: A Review of Diagnostic Modalities for Aortoenteric Fistula

An 81-year-old male with a history of hypertension, hyperlipidemia, smoking, and peptic ulcer disease (PUD) presented with 2 episodes of maroon stools for 3 days and was found to be orthostatic. His PUD was thought to have accounted for a previous upper gastrointestinal (GI) bleed. A colonoscopy revealed 3 polyps and a few diverticuli throughout the colon that were considered to be the source of the bleeding. Two months later, the patient had massive lower GI bleeding and developed hypovolemic shock with a positive bleeding scan in the splenic flexure; however, angiography was negative. A repeat colonoscopy revealed transverse/descending colon diverticular disease and the patient was scheduled for a left hemicolectomy for presumed diverticular bleeding. Intraoperatively, an aortoenteric (AE) fistula secondary to an aorto-bi-iliac bypass graft placed during an abdominal aortic aneurysm (AAA) repair 14 years prior was discovered and was found to be the source of the bleeding. The patient had an AE fistula repair and did well postoperatively without further bleeding. AE fistulas can present with either upper GI or lower GI bleeding, and are universally deadly if left untreated. AE fistulas often present with a herald bleed before life-threatening bleeding. A careful history should always be elicited in patients with risk factors of AAAs such as hypertension, hyperlipidemia and a history of smoking. Strong clinical suspicion in the setting of a scrupulous patient history is the most important factor that allows for the diagnosis of an AE fistula. There are numerous diagnostic modalities for AE fistula, but there is not one specific test that universally diagnoses AE fistulas. Nuclear medicine scans and angiography should not be completely relied on for the diagnosis of AE fistulas or other lower GI bleeds for that manner. Although the conventional paradigm for evaluating lower GI bleeds incorporates nuclear medicine scans and angiography, there is evidence that early endoscopy with enteroscopy may have a better role in severe lower GI bleeding

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Design for Indigenisation of the IT Curriculum

Following an institution-wide mandate by the University of Canberra to Indigenize the curriculum in all courses, this descriptive case study reports on a pilot redesign of the subject unit outline of an Information Technology (IT) unit that previously had no Indigenous-related content. The study experimented with different designs to embed Indigenisation holistically in a unit that is mandatory for students undertaking IT Degrees at the University of Canberra, Australia. With support from educational design specialists, the curriculum was redesigned to integrate Yankaporta’s (2009) 8 Ways of Indigenous learning framework into the content, teaching methods, and assessment as expressed in the unit outline to integrate Indigenisation and build a design that can be adapted applied in other IT units over time. The study applied a Design Science Research (DSR) methodology to evaluate the previous unit outline, design its replacement and observe and reflect on the successes and challenges of its implementation over one semester with one cohort of students. This methodology can also be applied in future iterative cycles of continuous adjustment and improvement of the unit’s curriculum by designers such as conveners, lecturers and program directors, to inform the designs for other units that have no Indigenous-related content

The LEGS Score: A Proposed Grading System to Direct Treatment of Chronic Lower Extremity Ischemia

OBJECTIVE: To prospectively compare the Lower Extremity Grading System (LEGS)-derived “recommended treatment” to the actual treatment performed and to analyze LEGS intergrader scoring consistency by comparing blinded scoring results between physician graders. SUMMARY BACKGROUND DATA: Due to technical advances and the increased medical complexity of the aging population, the most appropriate treatment for chronic lower extremity ischemia—open surgery versus endovascular—is again in flux. In an attempt to standardize management, the LEGS score, based on the best available outcomes data, was devised by the physicians of an established vascular service. METHODS: From March to June 2002, all chronically ischemic lower extremities that met standard indications for revascularization were prospectively enrolled and independently graded with the LEGS score by an “endovascular surgeon” and an “open surgeon” for comparative analysis. The results were then blindly evaluated to determine whether the LEGS-derived “recommended treatment” agreed with the actual treatment rendered and to assess for intergrader consistency. Agreement was assessed using kappa statistical analysis. RESULTS: Of the 137 presenting limbs (mean patient age 66.4 yo; 43% claudication, 57% limb-threatening ischemia), 107 were treated (65% endovascular, 30% open surgery, 5% amputation), 16 were pending treatment, and 14 were not treated because of patient refusal (n = 13) or death (n = 1). The LEGS score predicted the actual or offered clinical treatment in 90% of cases. The LEGS score comparison between physician graders resulted in identical “recommended treatment” in 116 of 128 cases for a 90.6% agreement. CONCLUSIONS: A reproducible scoring system to guide the treatment of patients with chronic lower extremity ischemia is possible. While systems like the LEGS score may have potential clinical application, their use as a treatment standardization tool for future prospective outcomes comparisons between open and endovascular surgery will be essential

Science Educational Outreach Programs That Benefit Students and Scientists

<div><p>Both scientists and the public would benefit from improved communication of basic scientific research and from integrating scientists into education outreach, but opportunities to support these efforts are limited. We have developed two low-cost programs—"Present Your PhD Thesis to a 12-Year-Old" and "Shadow a Scientist”—that combine training in science communication with outreach to area middle schools. We assessed the outcomes of these programs and found a 2-fold benefit: scientists improve their communication skills by explaining basic science research to a general audience, and students' enthusiasm for science and their scientific knowledge are increased. Here we present details about both programs, along with our assessment of them, and discuss the feasibility of exporting these programs to other universities.</p></div