Could there be light at the end of the tunnel? Mesocaval shunting for refractory esophageal varices in patients with contraindications to transjugular intrahepatic portosystemic shunt.

Cirrhotic patients with recurrent variceal bleeds who have failed prior medical and endoscopic therapies and are not transjugular intrahepatic portosystemic shunt candidates face a grim prognosis with limited options. We propose that mesocaval shunting be offered to this group of patients as it has the potential to decrease portal pressures and thus decrease the risk of recurrent variceal bleeding. Mesocaval shunts are stent grafts placed by interventional radiologists between the mesenteric system, most often the superior mesenteric vein, and the inferior vena cava. This allows flow to bypass the congested hepatic system, reducing portal pressures. This technique avoids the general anesthesia and morbidity associated with surgical shunt placement and has been successful in several case reports. In this paper we review the technique, candidate selection, potential pitfalls and benefits of mesocaval shunt placement

Metastatic Pancreatic Adenocarcinoma During Pregnancy.

We present a rare case of metastatic pancreatic adenocarcinoma diagnosed antepartum. A high index of suspicion must be maintained to diagnose pancreatic cancer during pregnancy. We recommend a thorough history and physical and aggressive pursuit of sensitive imaging in patients with persistent symptoms. If pancreatic adenocarcinoma is diagnosed, a multidisciplinary approach that focuses on patient goals should be undertaken. The effect of pregnancy on tumor growth rates is unknown

Cavernous colorectal hemangioma: A rare cause of lower gastrointestinal bleeding and a review of the literature

Colorectal hemangiomas are rare causes of gastrointestinal bleeding. Most patients present in young adulthood with frequent, recurrent, and occasionally profound bleeding. The reported mortality rate is as high as 40- 50%. Although the need for recognition is accepted, the diagnosis is often missed due to the infrequency of occurrence. It is, therefore, important that hemangiomas be considered in the appropriate clinical circumstances to ensure effective intervention. This report describes the clinical, endoscopic, and radiologic features of a rare case of a cavernous colorectal hemangioma

Breast cancer surveillance: Ambulatory care focus in residency may influence practice patterns

Breast cancer causes significant morbidity and mortality in the United States. Early detection of malignant lesions may increase survival rates. Recommended surveillance techniques include breast self-examination, breast examination by a clinician, and mammography. However, results of research suggest that physicians adhere inconsistently to screening guidelines. Residency training has the potential to impact significantly on future practice patterns. This study evaluated the breast cancer screening patterns in women 50 years of age and older by internal medicine resident physicians in a traditional and a primary care residency program from 1988-1994. A retrospective chart review revealed that resident physicians in the primary care residency performed more breast cancer surveillance than residents in the traditional residency for the following techniques: instructions for breast self-examinations, 10.9% vs. 3.6% (P \u3c 0.0007); breast examinations, 81.3% vs. 39.1% (P \u3c 0.00001); mammographies, 93.8% vs. 37.3% (P \u3c 0.00001). This study suggests that the frequency of breast cancer screening by resident physicians may improve with increased ambulatory care experience. Additional study is necessary to identify other factors that could influence preventive care practices

Physician perception of IBS management in women and men

Irritable bowel syndrome is a common gastrointestinal disorder that is manifested by abdominal pain and an alteration in bowel habits. It is estimated to occur in ∼20% of the US population and is diagnosed more frequently in women compared to men. The principles of management do not differ based upon gender. However, there is not data that has evaluated physician perception of IBS diagnosis and management. This study evaluated internal medicine physicians\u27 perception of IBS in women and men. Sixty internal medicine physicians (30 men, 30 women) completed anonymous surveys evaluating their perception of the ease of diagnosis and management of IBS. A database was created and analyzed using Epi Info. Statistical significance was determined with chi-square tables that generated P values. IBS was more frequently diagnosed in women. There was a Statistically significant difference in women with IBS being not easy to diagnose when compared to men with IBS (P = 0.0003). There was also a statistically significant difference in men with IBS being reported to be not easy to manage when compared to women with IBS (P = 0.0014). This study revealed that physicians perceive a difference in the ease of diagnosis and management of IBS based upon gender. Further research is necessary to gain insight into the influence of patient gender upon this disorder

Impact of two ambulatory care training programs on smoking-cessation activities

Background. Tobacco use causes significant morbidity and mortality. Resident physicians at the George Washington University Medical Center are trained to counsel patients to stop smoking. Methods. I retrospectively reviewed charts of 300 patients treated by resident physicians in the Department of Medicine (200) and the Department of Health Care Sciences (100). Results. In the 200 patients cared for by resident physicians in the traditional internal medicine training program, a smoking history was obtained in 93 (47%). Forty-seven patients (51%) smoked, and 7 smokers (15%) were counseled to stop smoking. In 100 patients cared for by resident physicians in the primary care internal medicine training program, a smoking history was obtained in 94 patients (94%). Twenty-three patients (24%) smoked, and 11 (48%) were counseled to stop smoking. Conclusion. Resident physicians in the primary care training program obtained more smoking histories and counseled more patients to stop smoking. Further study is necessary to evaluate strategies that can be used in residency training to encourage smoking-cessation counseling

Patient and physician gender may influence colorectal cancer screening by resident physicians

Colorectal cancer causes significant morbidity and mortality in the United States. Despite the publication and acceptance of screening guidelines, there is evidence that physicians inconsistently adhere to the recommendations. Recent data also suggest that women may thereby receive inadequate cancer surveillance. This study was designed to evaluate internal medicine residents\u27 performance of colorectal cancer screening at The George Washington University Medical Center during 1989-1994. A retrospective chart review of 200 medical records (110 women, 90 men) revealed that resident physicians performed 85 (42.5%) rectal examinations, 95 (47.5%) fecal occult blood tests, and 21 (10.5%) flexible sigmoidoscopies. Among the 110 female patients, 41 (37.3%) had rectal examinations, 43 (39.1%) had fecal occult blood testing, and 13 (11.8%) had flexible sigmoidoscopies. Among the 90 male patients, 44 (48.9%) had rectal examinations, 52 (57.8%) had fecal occult blood testing, and 8 (8.9%) had flexible sigmoidoscopies. Male patients had significantly more (p \u3c 0.008) fecal occult blood tests than female patients. In addition, female physicians performed more rectal examinations (p \u3c 0.04) and fecal occult blood testing (p \u3c 0.02) on their female patients than did male physicians. Male physicians performed more rectal examinations (p \u3c 0.04) on their male patients than did female physicians. Efforts should be made to improve screening practices by resident physicians. Additional research should be conducted to evaluate the impact of patient and physician gender on the implementation of colorectal cancer screening guidelines