Malik Elharram

Management of esophageal perforation in the endoscopic era: Is operative repair still relevant?

BACKGROUNDnWith the introduction of new treatment paradigms for esophageal perforation, the management of this highly morbid condition is evolving. We reviewed our experience to investigate the modern management and outcomes of esophageal perforations with a focus on operatively repaired patients.nnnMETHODSnA retrospective review of all esophageal perforations was conducted between August 2003 and Januaryxa02016.nnnRESULTSnA total of 48 patients were identified, with iatrogenic injury in 19 (40%), spontaneous perforation in 18 (38%), and traumatic/foreign body causes in 11 (23%). The distal esophagus was the site of perforation in 63% of the patients, and the duration of time between perforation and treatment was <24xa0hours in 60%. Nonoperative management was employed in 18 (38%) and operative repair in 30 (primary operative repairxa0=xa020, drainagexa0=xa04, esophagectomyxa0=xa06). Iatrogenic and traumatic perforations were more likely to be treated nonoperatively (68%), while all spontaneous perforations were treated by operative intervention. There were no complications or mortalities in the nonoperative group and only a 5% reintervention rate. In the operative group, complications occurred in 10 (33%), reinterventions in 13 (43%), and mortality in 2 (7%) patients.nnnCONCLUSIONnOur study highlights the importance of considering the etiology of a perforation when planning management and the success of nonoperative treatment with careful patient selection. In addition, operative repair in septic patients yielded excellent outcomes and should be the standard for comparison in future studies exploring endoscopic approaches.

Myocardial Infarction With No Obstructive Coronary Artery Disease: Angiographic and Clinical Insights in Patients With Premature Presentation

BACKGROUNDnPremature myocardial infarction (MI) is an increasingly prevalent cause of morbidity and mortality worldwide. A subset of patients, predominantly young women, present with MI with no obstructive coronary artery disease (MINOCA), a nomenclature gaining recognition. However, few data exist on presentation and prognosis according to the severity of coronary artery disease (CAD).nnnMETHODSnWe studied patients with premature (younger than 55 years of age) acute MI enrolled in a large cohort in 24 centres across Canada. Baseline clinical, psychosocial, and coronary anatomy characteristics as well as 12-month outcomes were compared between patients with MINOCA (< 50% stenosis) and patients with MI with obstructive CAD (≥ 50% stenosis; MICAD).nnnRESULTSnFrom a cohort of 1210 patients with acute coronary syndrome, we examined 998 MI patients with available angiography core lab readings: 82 (8.2%) had a MINOCA and 916 (91.8%) had a MICAD. Forty percent of patients with MINOCA were women compared with one-third with MICAD. The prevalence of traditional risk factors and chest pain at presentation was lower in MINOCA patients, yet 37% had a ST-elevation MI and 10% presented with a cardiac arrest. No evident etiology was detected in > 70% of MINOCA, but 10% presented with either spontaneous coronary dissection or Takotsubo cardiomyopathy. Although combined major adverse cardiovascular events and all-cause readmission rate was lower in the MINOCA group (14% vs 25%; adjusted hazard ratio, 0.51; 95% confidence interval, 0.28-0.93), it was not negligible.nnnCONCLUSIONSnPatients with MINOCA present with high-risk features despite the absence of obstructive CAD. A search for etiology and eventual treatment provides a rich avenue for improving prognosis in young women with premature MI.

Global Health Values of a Multidirectional Near Peer Training Program in Surgery, Pathology, Anatomy, Research Methodology, and Medical Education for Haitian, Rwandan, and Canadian Medical Students

BACKGROUNDnAs health care delivery increasingly requires providers to cross international borders, medical students at McGill University, Canada, developed a multidirectional exchange program with Haiti and Rwanda. The program integrates surgery, pathology, anatomy, research methodology, and medical education.nnnOBJECTIVEnThe aim of the present study was to explore the global health value of this international training program to improve medical education within the environment of developing countries, such as Haiti and Rwanda, while improving sociocultural learning of Canadian students.nnnMETHODSnStudents from the University of Kigali, Rwanda and Université Quisqueya, Haiti, participated in a 3-week program at McGill University. The students spanned from the first to sixth year of their respective medical training. The program consisted of anatomy dissections, surgical simulations, clinical pathology shadowing, and interactive sessions in research methodology and medical education. To evaluate the program, a survey was administered to students using a mixed methodology approach.nnnFINDINGSnCommon benefits pointed out by the participants included personal and professional growth. The exchange improved career development, sense of responsibility toward ones own community, teaching skills, and sociocultural awareness. The participants all agreed that the anatomy dissections improved their knowledge of anatomy and would make them more comfortable teaching the material when the returned to their university. The clinical simulation activities and shadowing experiences allowed them to integrate the different disciplines. However, the students all felt the research component had too little time devoted to it and that the knowledge presented was beyond their educational level.nnnCONCLUSIONnThe development of an integrated international program in surgery, pathology, anatomy, research methodology, and medical education provided medical students with an opportunity to learn about differences in health care and medical education between the 3 countries. This exchange demonstrated that a crosscultural near-peer teaching environment can be an effective and sustainable method of medical student-centered development in global health.