Mental health disease is under recognized in medical professionals. To screen medical students (MS), residents and fellows for major depressive disorder (MDD) and generalized anxiety disorder (GAD) under the new era of work hour reform with age-matched controls from a large representative cross-sectional survey. We conducted an anonymous online survey at a medical university in 2013–2014. We incorporated the Patient Health Questionnaire 2 (PHQ-2) to screen for MDD and the generalized anxiety disorder scale (GAD-7) to screen for GAD, along with additional questions on life stressors and academic performance. We compared these results to age-matched controls from the National Health and Nutrition Examination Survey (NHANES) database. 126 residents/fellows and 336 medical students participated voluntarily. 15.1% and 15.9% of postgraduates as well as 16.4% and 20.3% of MS screened positive for MDD and GAD, respectively. When compared to national estimates, the prevalence of a positive screen for MDD was over five-fold higher in medical trainees compared to age-matched controls (16% vs. 2.8%, p<0.0001). Similarly, the prevalence of a positive screen for GAD was over eight-fold higher in medical trainees (19% vs. 2.3%, p<0.0001).The prevalence was consistently higher within age strata. 33.3% of postgraduates and 32% of MS believe there is a significant impact of depression or anxiety on their academic performance. For stress relief, one fifth of residents/fellows as well as MS reported alcohol use. The stresses of medical education and practice may predispose trainees to psychopathological consequences that can affect their academic performance and patient care. The current study showed a significantly higher rate of MDD and GAD positive screens in medical trainees than the prevalence in an age-matched U.S. population, despite significant work hour reform for medical trainees. Increased awareness and support services are required at all levels of medical training. We propose that the ACGME and the Institute of Medicine may consider these findings when implementing future changes to work hour regulations.

The clinical manifestations of hyperammonemia are usually easily identifiable to the clinician when associated with liver disease and lead to prompt diagnosis and treatment. However, hyperammonemia-induced encephalopathy is rare in adults in the absence of overt liver disease, thus diagnosis is often delayed or missed leading to potentially life threatening complications. Without proper treatment, such patients can decompensate rapidly with poor outcomes including seizures, coma, and death. Early assessment of plasma ammonia levels in patients with normal hepatic function and characteristic symptoms of encephalopathy can lead to early intervention while investigating the underlying etiology. We describe a patient who presented with a 2-year progression of waxing and waning acute mental status changes after a Roux-en-Y gastric bypass surgery. He was found to have elevated ammonia level as well as orotic aciduria; results consistent with a urea cycle disorder. After consulting neurology as well as toxicology, he ultimately improved after dietary protein restriction, sodium benzoate and lactulose therapy. While rare, clinicians should have a high index of suspicion for late onset urea cycle disorders in symptomatic patients presenting with encephalopathy secondary to hyperammonemia.

Background/Objectives: Studies have suggested that smokers may have a lower risk of primary sclerosing cholangitis (PSC) although the results have been inconsistent. This systematic review and meta‐analysis was conducted to summarize all available data to better characterize this association.Methods: A comprehensive literature review was conducted using Medline and Embase databases through January 2018 to identify all studies that compared the risk of PSC among current/former smokers versus nonsmokers. Effect estimates from each study were extracted and combined using the random‐effect, generic inverse variance method of DerSimonian and Laird.Results: Seven case‐control studies with 2,307,393 participants met the eligibility criteria and were included in the meta‐analysis. The risk of PSC among current smokers and former smokers was significantly lower than nonsmokers with the pooled odds ratio of 0.31 (95% CI, 0.18–0.53) and 0.52 (95% CI, 0.44–0.61), respectively. The risk remained significantly lower among current smokers and former smokers compared with nonsmokers even when only patients with PSC without inflammatory bowel disease were included.Conclusions: A significantly decreased risk of PSC among current and former smokers was demonstrated in this study.

Background: With longer survival of patients with PSC undergoing liver transplantation (LT), the frequency and risk factors associated with vascular and biliary complications in the allograft and the impact on long-term outcomes are poorly understood. Aim: To assess frequency and risk factors for long term outcomes in patients post-LT for PSC. Methods: All LT recipients for advanced stage PSC for non-cholangiocarcinoma indication from 1984-2012, with follow-up through March 2022 (>10+year followup) were idenitfied. 1-, 5-, and 10-yr cumulative risks of complications were estimated using the Aalen-Johansen method, where death was considered a competing risk. Results: Two hundred ninety-three patients (mean age, 47.3±12 y), formed our study cohort. One hundred and thirty-four patients received LT before 1995 and the 159 were transplanted after 1995. Over a median (interquartile range) follow-up of 15.0 (10.3-22.1) years, LT was complicated by hepatic artery thrombosis (N=30), portal vein stenosis/thrombosis (N=48), biliary leak (N=47), biliary strictures (N=87), rPSC (N=107), and graft failure (N=70). The 1-, 5-, 10-, and 15-year cumulative incidence of rPSC was 1.0%, 8.0%, 23.5%, and 34.3% respectively. Type of donor and older donor age were associated with increased risk of biliary strictures. Donor age >60 years was associated with increased risk of rPSC. Conclusion: Long-term patient and graft-survival have not changed significantly for patients transplanted for PSC. Controlling transplant related factors such as donor age, prompt identification of vascular and biliary complications early and long-term rigorous followup is recommended to continue to improve on these outcomes. Export

The National Cancer Institute reports high incidence of renal cell carcinoma (RCC) in the US compared to other regions. However, pancreatic and periampullary metastasis are uncommon when only 17% of the RCC cases metastasize overall. We herein present a case series of four patients with periampullary or pancreatic metastatic disease following complete resection of RCC, evaluating their occurrences and outcomes. We reviewed the cases of four male patients retrospectively, mean age 75 years (range 65 - 87) who had a previous history of nephrectomy for RCC. They experienced recurrence with periampullary (two patients) or pancreatic (two patients) metastatic disease between 0 and 108 months (mean time 41.5 months) following primary tumor resection. In patients with periampullary metastasis, one had asymptomatic presentation with progressive dilatation of the pancreatic duct noted on surveillance CT scans. The other patient had iron deficiency anemia and melena with esophagogastroduodenoscopy (EGD) findings of large fungating infiltrative ulcerating mass in the area of the duodenal papilla (the only patient with metastasis to other sites: lungs and colon). As for those with pancreatic metastasis, one patient presented with hematuria and abdominal pain and was found to have pancreatic metastasis at the time of RCC diagnosis. The other patient was admitted for further workup of a mass in the pancreatic tail upon surveillance. Pathologic findings included high grade RCC in the metastatic foci. Management of such patients included: distal pancreatectomy in two patients without chemoradiation, one was awaiting Whipple procedure and received four cycles of sunitinib, while the last was a poor surgical candidate and received aminocaproic acid. Three patients are still alive to date. Optimal management is challenging given the very high risk of delayed relapse following tumor resection of the localized disease, leaving such cases with a very poor prognosis. Therefore to enhance survival, it is imperative to have careful stage-dependent surveillance in patients who have undergone a prior resection of RCC. We emphasize the importance of raising awareness for this unusual presentation. Disease recurrence as a pancreatic mass or hepatobiliary ductal dilatation might be more frequent than previously reported.World J Oncol. 2015;6(3):378-380doi: http://dx.doi.org/10.14740/wjon911w