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The authors describe a case of transposition of great arteries with a large atrial septal defect with fusion of tricuspid valve leaflets and severe aortic stenosis. The latter two were likely rheumatic in etiology. The patient’s condition improved after atrial switch and aortic valve replacement surgery. (Level of Difficulty: Intermediate.), Central Illustration

Background and study aims There are limited published data on endoscopic removal of colorectal polyps by endoscopic mucosal resection (EMR) and endoscopic mucosal dissection (ESD) in patients with inflammatory bowel disease (IBD). Patients and methods We performed a retrospective review of patients with colonic IBD and colonic polyps >10mm who underwent EMR and/or ESD at our institution between January 1, 2012 and June 31, 2016. Results Ninety-seven patients with pathology-confirmed IBD (median disease duration 16 years) were included. Mild or moderate active colitis (in background biopsies) was seen in 85 %. Of the total 124 polyps, location was ascending colon in 44 %, transverse in 15 % and sigmoid in 18.5 %; of the total, 55 % were Conclusion This study demonstrates the efficacy and safety of endoscopic resection of large polyps in patients with IBD, making them effective alternatives to colectomy.

Background We sought to estimate the incidence of home parenteral nutrition (HPN) use in a population-based cohort of patients with Crohn disease (CD), and to assess clinical outcomes and complications associated with HPN. Methods We used the Rochester Epidemiology Project (REP) to identify residents of Olmsted County, who were diagnosed with CD between 1970 and 2011, and required HPN. Results Fourteen out of 429 patients (3.3%) with CD received HPN (86% female). Eleven patients (79%) had moderate–severe CD and 12 patients (86%) had fistulizing disease. Thirteen patients (93%) underwent surgery, primarily due to obstruction. Among CD incidence cases, the cumulative incidence of HPN from the date of CD diagnosis was 0% at 1 year, 0.5% at 5 years, 0.8% at 10 years, and 2.4% at 20 years. Indications for HPN included short bowel syndrome in 64%, malnutrition in 29%, and bowel rest in 21%. The median duration of HPN was 2.5 years. There was an average weight gain of 1.2 kg at 6 months, an average weight loss of 1.4 kg at 1 year, and a further weight loss of 2.2 kg at 2 years from the start of HPN. Patients were hospitalized a mean of 5 times after the start of HPN, mainly due to catheter-related bloodstream infections and thrombosis. Conclusions Less than 4% of patients with CD need HPN. Most have moderate to severe disease with short bowel syndrome or malnutrition. Possible reasons for the patients’ weight loss could be noncompliance, and increased metabolic needs because of active disease., Lay Summary A small proportion of patients with Crohn disease need home parenteral nutrition (HPN). When deciding to initiate HPN, providers need to weigh the benefits and risks of HPN, and those who fail conventional therapy with ongoing malnutrition should be considered.

Background: Malaria is a public health problem in more than 90 countries. According to the latest estimates of WHO, released in December 2015, there were 214 million cases of malaria in 2015 and 438 000 deaths . The aim was to study clinical profile and outcome of severe falciparum malaria in patients at tertiary health care centre. Methods: In this prospective study, total 125 clinically diagnosed severe malaria cases admitted during period of November 2013 to October 2015, were enrolled excluding patients below 12 years of age. Detailed history and clinical examination was carried out to assess clinical severity and complications of malaria. Results: Of the 125 cases studied 110 cases were of severe malaria produced by Plasmodium falciparum infection diagnosed on peripheral smear examination or by antigen detection test. The remaining 15 cases were excluded from the study. In this study, seventy six (69.1%) cases were males and thirty four (30.9%) cases were females, with male: female ratio of 2.23:1. Common symptoms found were fever, chills and rigors, altered sensorium, jaundice and nausea or vomiting while most common complication was jaundice, seen in 45.45%. Mortality due to severe falciparum malaria observed was 13.63%. Conclusions: In this study of severe falciparum malaria, most common symptoms found were fever, chills and rigors, altered sensorium, jaundice, nausea and vomiting while most common signs were pallor, splenomegaly, icterus, hepatomegaly, bleeding tendencies and in a few cases neck stiffness and hypotension. Jaundice, renal failure, impaired consciousness and cerebral malaria were most common complications of severe falciparum malaria.

Parenteral nutrition (PN) is a life-sustaining therapy in appropriate clinical settings. In the hospital setting, some nondiabetic patients develop hyperglycemia and subsequently require long-term insulin while receiving PN. Whether similar hyperglycemia is seen in the outpatient setting is unclear.We studied patients enrolled in the Mayo Clinic Home Parenteral Nutrition (HPN) program between January 1, 2010, and December 31, 2012. Patients were excluded if they had diabetes mellitus type 2 (DM2), had previously received HPN, had taken corticosteroids, or were at risk for refeeding syndrome.Of 144 enrolled patients, 93 met inclusion criteria with 39 patients requiring the addition of insulin to HPN. The mean age of the insulin-requiring group (IR) was higher than that of the non-insulin-requiring group (NIR) (60.74 ± 13.62 years vs 48.97 ± 17.62 years, P.001). There were 17 (44%) men in the IR group and 26 (48%) men in the NIR group. Mean blood glucose at baseline before starting the infusion was 131.82 ± 49.55 mg/dL in IR patients and 106.16 ± 59.01 mg/dL in NIR patients ( P = .03). In the stepwise multivariate analysis for assessing the risk for developing hyperglycemia, HR for age was 1.020 (1.010-1.031), P.001.Hyperglycemia is a common finding with the use of PN in both the hospital and ambulatory setting in patients without a previous diagnosis of DM2. Age was the most significant predictor of the requirement of insulin in the present study. When hyperglycemia is managed appropriately with insulin therapy, the long-term complications can be minimized.

Objectives To estimate the overall risk of cancer in a population-based cohort of patients with inflammatory bowel disease (IBD) and how IBD-related medications modify this risk. Methods We identified all incident cancers (excluding nonmelanoma skin cancer) after IBD diagnosis in a cohort of 839 patients diagnosed as having IBD from January 1, 1940, through December 31, 2004, in Olmsted County, Minnesota, and followed up for a median 18 years through December 31, 2011 (122 patients taking biologic agents at last follow-up). We calculated standardized incidence ratios (SIRs) with 95% CIs of all cancers and compared cancer risk in patients treated with immunomodulators (IMMs) and biologics with that of patients not exposed to these medications, using an incidence rate ratio (IRR). Results One hundred nine patients developed 135 cancers. The 10-year cumulative probability of cancer was 3.8%. Patients with Crohn disease (SIR, 1.6; 95% CI, 1.2-2.1) but not ulcerative colitis (SIR, 1.1; 95% CI, 0.8-1.4) had an increased overall risk of cancer compared with the general population. Patients treated with IMMs (relative to IMM-naive patients) had an increased risk of melanoma (IRR, 5.3; 95% CI, 1.1-24.8) (and a numerically higher risk of hematologic malignant tumors [IRR, 4.2; 95% CI, 0.9-19.2]), although this risk returned to baseline on discontinuation of IMM treatment. Patients treated with biologics (relative to biologic-naive patients) had a numerically higher risk of hematologic malignant tumors (IRR, 5.3; 95% CI, 0.7-40.5). There was no significant increase in the risk of gastrointestinal malignancies in patients with IBD compared with the general population. Conclusions We observed an increased risk of melanoma in IMM-treated patients with IBD, and this risk returned to baseline after discontinued use of the medications.

Surgery interns' training has historically been weighted toward patient care, operative observation, and sleeping when possible. With more protected free time and less clinical time, real educational hours for trainees in 2013 are precious.We created a 20-session (3 hours each) simulation curriculum (with pre- and post-tests) and a 24/7 online audiovisual (AV) curriculum for surgery interns. Friday morning simulation sessions emphasize operative skills and judgment. AV clips (using operating room, whiteboard, and simulation center videos) take learners through 20 different general surgery operations with follow-up quizzes. We report our early experience with this novel setup.Thirty-two surgical interns (2012-2013) attended simulation sessions on 20 separate subjects (hernia, breast, hepatobiliary, endocrine, etc). Post-test scores improved (P .05) and trainees enjoyed using surgical skills for 3 hours each Friday morning (mean,4.5; Likert scale, 1-5). The AV curriculum feedback is similar (mean,4.3) and usage is available 24/7 preparing learners for both operating room and simulation sessions. Most simulation sessions utilize low-fidelity models to keep costs$50 per session. Scores on our semiannual Surgical Olympics (mean score of 49.6 in July vs 82.9 in January; P .05) improved significantly, suggesting that interns are improving their surgical skills and knowledge.Residents enjoy and learn from the step-by-step, in-house, AV curriculum and both appreciate and thrive on the 'hands-on' simulation sessions mimicking operations they see in real operating rooms. The cost of these programs is not prohibitive and the programs offer simulated repetitions for duty-hour-regulated trainees.

Background & Aims Patients with inflammatory bowel disease (IBD) may be at higher risk for hidradenitis suppurativa (HS). We studied the risk and clinical characteristics of HS in a population-based cohort of patients with IBD. Methods We identified all cases of HS (confirmed by biopsy and/or dermatologic evaluation) in a population-based inception cohort of Olmsted County, Minnesota, residents diagnosed with IBD between 1970 and 2004 and followed up through August 2013. We estimated the incidence rate ratio of HS in patients with IBD compared with the general population, and described the clinical characteristics, risk factors, and management of HS. Results In 679 IBD patients followed up over a median of 19.8 years, we identified 8 patients with HS (mean age, 44.4 ± 8.3 y; 7 women; 6 obese). Compared with the general population, the incidence rate ratio of HS in IBD was 8.9 (95% confidence interval, 3.6–17.5). The 10- and 30-year cumulative incidence of HS was 0.85% and 1.55%, respectively. Five patients had Crohn's disease, 4 of whom had perianal disease; of 3 patients with ulcerative colitis, 2 had undergone ileal pouch–anal anastomosis. Axillae, groin, and thighs were the most common sites of involvement. Six patients had Hurley stage 2 disease (recurrent abscesses with sinus tracts and scarring, involving widely separated areas), and required a combination of antibiotics and surgery; none of the patients were treated with anti–tumor necrosis factor-α agents. Conclusions In this population-based study, patients with IBD were approximately 9 times more likely to develop HS than the general population, with a female predisposition.

Background & Aims Little is known about progression of ischemic colitis (IC) among unselected patients. We aimed to estimate the incidence, risk factors, and natural history of IC in a population-based cohort in Olmsted County, Minnesota. Methods We performed a retrospective population-based cohort and nested case-control study of IC. Each IC case was matched to 2 controls from the same population on the basis of sex, age, and closest registration number. Conditional logistic regression, the Kaplan–Meier method, and proportional hazards regression were used to assess comorbidities, estimate survival, and identify characteristics associated with survival, respectively. Results Four hundred forty-five county residents (median age, 71.6 years; 67% female) were diagnosed with IC from 1976 through 2009 and were matched with 890 controls. The age-adjusted and sex-adjusted incidence rates of IC nearly quadrupled from 6.1 cases/100,000 person-years in 1976–1980 to 22.9/100,000 in 2005–2009. The odds for IC were significantly higher among subjects with atherosclerotic diseases; odds ratios ranged from 2.6 for individuals with coronary disease to 7.9 for individuals with peripheral vascular disease. Of IC cases, 59% survived for 5 years (95% confidence interval, 54%–64%), compared with 90% of controls (95% confidence interval, 88%–92%). Age >40 years, male sex, right-sided colon involvement, concomitant small bowel involvement, and chronic obstructive pulmonary disease were all independently associated with mortality ( P Conclusions The incidence of IC increased during the past 3 decades in a population-based cohort in Minnesota. IC typically presents in older patients with multiple comorbidities and is associated with high in-hospital mortality (11.5%) and rates of surgery (17%).

Background We sought to identify clinical and demographic features influencing hospitalization and colectomy in a population-based inception cohort of ulcerative colitis. Methods Between 1970 and 2004, a total of 369 patients (58.5% males) from Olmsted County, MN, were followed from diagnosis for 5401 person-years. The cumulative probability of hospitalization and colectomy were estimated using the Kaplan-Meier method. Cox proportional hazards regression was used to identify factors associated with hospitalization and colectomy. Results The cumulative probability of first hospitalization was 29.4% at 5 years (95% confidence interval [CI], 24.5%-34.1%), 38.7% at 10 years (33.1%-43.8%), 49.2% at 20 years (42.7%-55.2%), and 52.3% at 30 years (45.1%-59.7%). The incidence rate of hospitalizations decreased over the last 4 decades, although cumulative probability of first hospitalization increased with successive decades of diagnosis. Early need for corticosteroids (hazard ratio [HR], 1.8; 95% CI, 1.1%-2.7%) and early need for hospitalization (HR, 1.5; 95% CI, 1.02-2.4) were independent predictors of hospitalization after 90 days of illness. The cumulative probability of colectomy from the time of diagnosis was 13.1% at 5 years (95% CI, 9.4%-16.6%), 18.9% at 10 years (95% CI, 14.4%-23.2%), and 25.4% at 20 years (95% CI, 19.8%-30.8%). Male gender (HR, 2.1; 95% CI, 1.3-3.5), diagnosis in the 1990s (HR, 2.0; 95% CI, 1.01-4.0), and diagnosis in 2000 to 2004 (HR, 3.7; 95% CI, 1.7-8.2) were significantly associated with colectomy risk. Conclusions Colectomy rates were comparable to reports from northern Europe. The numbers of hospitalizations show a decreasing trend. Male gender and being diagnosed in the 2000 to 2004 period predicted colectomy while extensive colitis predicted future hospitalizations.

Background Chronic groin discomfort is an undesired complication of laparoscopic totally extraperitoneal (TEP) inguinal hernia repairs. We examined whether perioperative factors may be associated with an increased risk of developing this problem and if their recognition could lead to preventive strategies. Study Design We performed a retrospective review of 1 surgeon's experience with 1,479 TEP repairs on 976 patients from 1995 to 2009. A mailed survey, which included a groin discomfort questionnaire (Carolinas Comfort Scale), was distributed to all patients. Symptom severity grading (range 0, none to 5, severe) was used to sort individual responses. Perioperative factors were compared between asymptomatic and symptomatic patients with varying levels of discomfort. Results There were 691 patients (71%) who provided complete responses to the questionnaire. Median follow-up was 5.7 years (range 0 to 14.4 years). The majority (n = 543, 79%) denied any symptoms of mesh sensation, pain, or movement limitation. In the remaining 148 (21%) patients, symptoms were most often mild (n = 108), followed by mild but bothersome (n = 25), and 15 patients (2%) had moderate or severe symptoms. Symptomatic patients were younger (median age 52 vs 57 years, p = 0.002) and were more likely to have had the TEP repair for recurrent hernias (24% vs 17%, p = 0.035). Operative diagnosis, bilateral exploration, mesh fixation techniques, perioperative complications, American Society of Anesthesiologists grade, and length of hospital stay were not associated with chronic groin discomfort. Conclusions The majority of patients are asymptomatic after a laparoscopic TEP inguinal hernia repair. Most of the symptomatic patients do not have any bothersome symptoms. Given that younger age and a repair for recurrent hernia were predictors of chronic groin discomfort, we counsel these patients about their increased risks.

15 (51.7%) F; mean age 55.8 (SD 16.9) years, BMI 23.9 (3.3)). Patients diagnosed with CSS often had other vascular diseases. 8% was diagnosed with cerebrovascular disease, 13.3% with coronary arterial disease, 24% with peripheral vascular disease and 2.7% with renal disease. Furthermore, 26.7% were diagnosed with GI disease, p.e. non-healing ulcera or an ischemic colon, before mesenteric vascular disease was diagnosed. The adherence area of our referral centre is estimated at 264000 inhabitants. The incidence of CSS was therefore calculated at 2.84 per 100.000 inhabitants. CSS was more often based on multiple vessel disease than CSD (52% vs 10%). In total, 155 patients had stenoses of mesenterial arteries and as high as 48.4% of these patients had proven GI ischemia. Furthermore, we calculated the incidence of NOMI at 1.10 per 100.000 inhabitants. Conclusion: This is the first study that assessed the incidence of chronic splanchnic syndrome, or chronic gastrointestinal ischemia, in the general population at 2.8 per 100.000.

Background: Gastroparesis can have varied clinical presentation. There are no well defined clinical parameters for predicting gastroparesis in patients presentingwith different gastrointestinal symptoms. Aims: To assess clinical predictors of gastroparesis in a large cohort of patients undergoing gastric emptying test Methods: A retrospective chart review of patients referred to our tertiary care center with presumed diagnosis of gastroparesis and various combinations of abdominal symptoms (nausea, vomiting, abdominal pain, bloating, post parandial fullness and early satiety) were included. All patients underwent a standardized 4-hrs scintigraphic gastric emptying test (GET) consisting of low-fat (2%) isotope labeled egg beaters meal of 250 kcal at our center. Patient demographics, medical/surgical history, drug use (affecting gastric/GI motility), proton pump inhibitor (PPI) use, endoscopic findings and results of hydrogen breath test were noted. Patients with previous history of gastric or small bowel resection, IBD, significant co-morbidities (end stage liver, kidney disease) were excluded. A univariate analysis was performed using Fisher's exact to evaluate predictors of gastroparesis, variables with a significance (p