Hourglass Ganglion Cyst of the Foot: A Case Report

Ganglion cyst, a common benign soft tissue lesion, is not uncommon in the foot, with the most common location being the dorsal aspect. We describe a case where the ganglion had an unusual radiographic appearance in the form of an hourglass, extending from dorsum into the planter compartments of the foot. A 74-year-old woman presented with longstanding pain in her midfoot. Clinical examination revealed a soft tissue swelling with minimal tenderness in the first webspace of the right foot. The initial radiograph was normal. Ultrasound examination revealed a cystic swelling filled with hemorrhagic fluid with an hourglass appearance. Magnetic resonance imaging examination confirmed the cystic nature of the swelling and depicted the hourglass-shaped ganglion extending from the dorsal to plantar aspect of foot. Complete excision was possible with a combined dorsal and plantar approach. Ganglion cyst can present in the foot in locations other than the dorsum and could have extensions into the plantar aspect. This variation needs to be considered when planning surgical excision, which could be aided by preoperative magnetic resonance imaging.     

Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy

BackgroundFailure of primary bariatric surgery is frequently due to weight recidivism, intractable gastric reflux, gastrojejunal strictures, fistulas, and malnutrition. Of these patients, 10–60% will undergo reoperative bariatric surgery, depending on the primary procedure performed. Open reoperative approaches for revision to Roux-en-Y gastric bypass (RYGB) have traditionally been advocated secondary to the perceived difficulty and safety with laparoscopic techniques. Few studies have addressed revisions after RYGB. The aim of the present study was to provide our experience regarding the safety, efficacy, and weight loss results of laparoscopic revisional surgery after previous RYGB and sleeve gastrectomy procedures.MethodsA retrospective analysis of patients who underwent laparoscopic revisional bariatric surgery for complications after previous RYGB and sleeve gastrectomy from November 2005 to May 2007 was performed. Technical revisions included isolation and transection of gastrogastric fistulas with partial gastrectomy, sleeve gastrectomy conversion to RYGB, and revision of RYGB. The data collected included the pre- and postoperative body mass index, operative time, blood loss, length of hospital stay, and intraoperative and postoperative complications.ResultsA total of 26 patients underwent laparoscopic revisional surgery. The primary operations had consisted of RYGB and sleeve gastrectomy. The complications from primary operations included gastrogastric fistulas, refractory gastroesophageal reflux disease, weight recidivism, and gastric outlet obstruction. The mean prerevision body mass index was 42 ± 10 kg/m². The average follow-up was 240 days (range 11–476). The average body mass index during follow-up was 37 ± 8 kg/m². Laparoscopic revision was successful in all but 1 patient, who required conversion to laparotomy for staple line leak. The average operating room time and estimated blood loss was 131 ± 66 minutes and 70 mL, respectively. The average hospital stay was 6 days. Three patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia. The overall complication rate was 23%, with a major complication rate of 11.5%. No patients died.ConclusionLaparoscopic revisional bariatric surgery after previous RYGB and sleeve gastrectomy is technically challenging but compared well in safety and efficacy with the results from open revisional procedures. Intraoperative endoscopy is a key component in performing these procedures.     

Military cardiology under a tent

As Operation Iraqi Freedom enters its third year, the multinational military force remains engaged in a complex mission based on the military and political climate in the Middle East. As US Navy cardiologists deployed to Kuwait, our experiences proved diverse as we learned to practice in an austere environment. From the evaluation of chest pain to the treatment of coronary artery disease and arrhythmia, patient care was tempered by our ability to use our clinical acumen, physical exam and basic objective data to establish definitive dispositions. Given our younger patient population, involvement in primary prevention efforts was a large focus, allowing us to gain a new perspective on the role of the subspecialist in changing patients' mindsets and lifestyles. By combining the basic tenets of our cardiology training with the practical aspects of diagnosing and treating in a war zone, we developed a great respect for the management of cardiac patients under challenging and often limited conditions. Our experiences as cardiologists in the desert were truly diverse and encompassed virtually every aspect of cardiovascular medicine, involving both current and historic treatment perspectives. Many unique, lifelong lessons were learned.     

Spirituality and medicine: prevalence of spirituality-in-medicine instruction at osteopathic medical schools

CONTEXT: Since the 1990s, there has been a heightened awareness of the value of teaching medical students about how aspects of spirituality and religion may affect patient care. OBJECTIVE: To determine the prevalence of spirituality-in-medicine instruction at colleges of osteopathic medicine (COMs) in the United States. METHODS: Prescreened subjects at 20 COMs were contacted by electronic mail and asked to complete a 25-item Web-based survey. The survey instrument consisted of questions about spirituality-in-medicine instruction at their institutions. If an institution was not represented in our survey results through subject response, we reviewed that institution's Web site to locate material suggestive of an extant spirituality-in-medicine curricula (eg, prospective student information). Results: Surveys were submitted to investigators by representatives of 12 COMs for a response rate of 60%. Subjects from 8 COMs reported a structured spirituality-in-medicine curriculum currently in place at their institutions. Osteopathic medical students generally receive a total of 2 to 20 hours of instruction on spirituality and religion. Of the 10 unrepresented institutions, 4 COMs had material available on their Web sites that suggested spirituality-in-medicine topics were embedded in their curricula. Therefore, approximately 55% of all COMs have some form of spirituality-in-medicine program in place. CONCLUSION: Some form of spirituality-in-medicine instruction is available at slightly more than half the COMs in the United States. As the need for spirituality-in-medicine curricula is increasingly recognized, improved methods of documenting ongoing curricular development and student competency will be required.