Perforation in a patient with stercoral colitis and diverticulosis: who did it?

Stercoral colitis with perforation of the colon is an uncommon, yet life-threatening cause of the acute abdomen. No one defining symptom exists for stercoral colitis; it may present asymptomatically or with vague symptoms. Diagnostic delay may result in perforation of the colon resulting in complications, even death. Moreover, stercoral perforation of the colon can also present with localized left lower quadrant abdominal pain masquerading as diverticulitis. Diverticular diseases and stercoral colitis share similar pathophysiology; furthermore, they may coexist, further complicating the diagnostic dilemma. The ability to decide the cause of perforation in a patient with both stercoral colitis and diverticulosis has not been discussed. We, therefore, report this case of stercoral perforation in a patient with diverticulosis and include a discussion of the epidemiology, clinical presentation, and a review of helpful diagnostic clues for a rapid differentiation to allow for accurate diagnosis and treatment

The Far Ultraviolet Spectroscopic Explorer Survey of OVI Absorption in the Disk of the Milky Way

To probe the distribution and physical characteristics of interstellar gas at temperatures T ~ 3e5 K in the disk of the Milky Way, we have used the Far Ultraviolet Spectroscopic Explorer (FUSE) to observe absorption lines of OVI toward 148 early-type stars situated at distances 1 kpc. After subtracting off a mild excess of OVI arising from the Local Bubble, combining our new results with earlier surveys of OVI, and eliminating stars that show conspicuous localized X-ray emission, we find an average OVI mid-plane density n_0 = 1.3e-8 cm^-3. The density decreases away from the plane of the Galaxy in a way that is consistent with an exponential scale height of 3.2 kpc at negative latitudes or 4.6 kpc at positive latitudes. Average volume densities of OVI along different sight lines exhibit a dispersion of about 0.26 dex, irrespective of the distances to the target stars. This indicates that OVI does not arise in randomly situated clouds of a fixed size and density, but instead is distributed in regions that have a very broad range of column densities, with the more strongly absorbing clouds having a lower space density. Line widths and centroid velocities are much larger than those expected from differential Galactic rotation, but they are nevertheless correlated with distance and N(OVI), which reinforces our picture of a diverse population of hot plasma regions that are ubiquitous over the entire Galactic disk. The velocity extremes of the OVI profiles show a loose correlation with those of very strong lines of less ionized species, supporting a picture of a turbulent, multiphase medium churned by shock-heated gas from multiple supernova explosions.Comment: Accepted for publication in ApJS. Preprint with full resolution images and all 148 spectra available at http://www.astro.princeton.edu/~dvb/o

Continental-scale temperature variability in PMIP3 simulations and PAGES 2k regional temperature reconstructions over the past millennium

Estimated external radiative forcings, model results, and proxy-based climate reconstructions have been used over the past several decades to improve our understanding of the mechanisms underlying observed climate variability and change over the past millennium. Here, the recent set of temperature reconstructions at the continental-scale generated by the PAGES 2k project and a collection of state-of-the-art model simulations driven by realistic external forcings are jointly analysed. The first aim is to estimate the consistency between model results and reconstructions for each continental-scale region over the time and frequency domains. Secondly, the links between regions are investigated to determine whether reconstructed global-scale covariability patterns are similar to those identified in model simulations. The third aim is to assess the role of external forcings in the observed temperature variations. From a large set of analyses, we conclude that models are in relatively good agreement with temperature reconstructions for Northern Hemisphere regions, particularly in the Arctic. This is likely due to the relatively large amplitude of the externally forced response across northern and high-latitude regions, which results in a clearly detectable signature in both reconstructions and simulations. Conversely, models disagree strongly with the reconstructions in the Southern Hemisphere. Furthermore, the simulations are more regionally coherent than the reconstructions, perhaps due to an underestimation of the magnitude of internal variability in models or to an overestimation of the response to the external forcing in the Southern Hemisphere. Part of the disagreement might also reflect large uncertainties in the reconstructions, specifically in some Southern Hemisphere regions, which are based on fewer palaeoclimate records than in the Northern Hemisphere

Is there a place for medical students as teachers in the education of junior residents?

BACKGROUND: The aim of this study was to investigate a novel resident education model that turns the traditional surgical hierarchy upside down, termed a reverse peer-assisted learning curriculum. METHODS: Thirty surgical topics were randomized between medical students and chief residents on each clinical team, with 1 topic being presented briefly during morning rounds. An exam evaluating junior residents\u27 knowledge of these topics was administered before and after 1 month of presentations. A questionnaire was distributed to evaluate the junior residents\u27 perceptions of this teaching model. RESULTS: Thirty-four residents participated. There was a significant improvement in the mean examination score (54 vs 74, P \u3c .05). No significant difference was noted in the mean score differentials of topics presented by either the medical students or the chief resident (21 vs 18, P = .22). More than 80% of the residents responded positively about the effectiveness of this exercise and agreed that they would like to see this model used on other services. CONCLUSIONS: This study confirms the hypothesis that medical students can teach surgical topics to junior residents at least as effectively as their chief residents

Work Hours Assessment and Monitoring Initiative (WHAMI) under resident direction: A strategy for working within limitations

A review of surgical residents’ duty-hours prompted a Work Hours Assessment and Monitoring Initiative (WHAMI) that preemptively limits residents from violating “duty-hours rules.” Work hours data for the Department of Surgery were reviewed over 8-months at New York Presbyterian Hospital-Columbia Campus. This ongoing review is performed by a work-hours monitoring team, which supervises residents’ hours for the initial 5-days of each week. As residents approach work-hours limits for the week, they are dismissed from duty for appropriate time periods in the remaining 2 days of the week. The work-hours data entry compliance for 52 residents was increased from 93% to 99% after creation of the WHAMI. Before the new system, a mean of 9.5 residents per month (19%) worked an average of 7.3 ± 6.4 hours over the 80-hour limit. Averaged monthly compliance with the 80-hour work limit was increased to 98% with introduction of the WHAMI. A review of on-call duty hours revealed a mean of 7 (14%) residents per month who worked an average of 2.4 hours beyond 24-hour call limitations including “sign-out” time imposed by the ACGME. New monitoring procedures have improved compliance to 100% with 24-hour call limitations imposed by the ACGME. Compliance with the more stringent New York State (NYS) guidelines has approached 94% with noncompliant residents extending on-call hours by an average of 1.5 hours over the 24-hour limitations, most on “off General Surgery” rotations or out-of-state rotations. Review of mandatory rest periods contributed to an increase in mean “time off” between work periods, thereby increasing compliance with ACGME guidelines and NYS regulations from 75% to 88%, and 90% to 98%, respectively. Residents reporting less than 10 hours rest reported increased “time off” from 6.2 ± 2.0 to 7.9 ± 1.3 hours (p < 0.001). Internal review of surgical resident’s duty-hours at a large university hospital revealed that despite strict scheduling and the requirement of mandatory duty-hours entry, achieving the goals of meeting the duty-hours requirements and of ongoing data entry required the creation of a resident enforced, real-time Work Hours Assessment and Monitoring Initiative