Context Cultural competency is a cornerstone of patient-centered health care. Religious doctrines may define appropriate consumption or use of certain animals and forbid use of others. Many medications contain ingredients that are animal-derived; these medications may be unacceptable to individual patients within the context of their religious beliefs and lifestyle choices. Knowledge of animal-derived medications as a component of cultural competency can facilitate a dialogue that shifts focus from the group to the individual, away from cultural competency toward cultural humility, and away from a paternalistic provider/patient dynamic toward one of partnership. Objectives To explore how animal-derived drug components may impact medication selection and acceptability from the perspective of patients, physicians, and religious leaders as evidenced by studies that explore the question via survey or questionnaire. A secondary objective is to use the context of animal-derived drug products as a component of cultural competency to build a framework supporting the development of cultural humility. Methods A systematic search was performed in the PubMed, CINAHL, Cochrane, and ProQuest databases using combinations of the following terms: “medication selection,” “medication,” “adherence,” “pharmaceutical preparations,” “religion and medicine,” “religion,” “animal,” “dietary,” “porcine,” and “bovine.” Studies that reported using surveys or questionnaires to examine patient, physician, or religious leader perspective on animal-derived medications published in English between 1990 and 2020 were included. Review articles, opinion pieces, case reports, surveys of persons other than patients, religious leaders, or physicians, and studies published in languages other than English were excluded. Three authors independently reviewed articles to extract information pertaining to perspectives on animal-based medication ingredients. Results Eight studies meeting the described criteria were found that queried beliefs or knowledge of patients, religious leaders, or physicians regarding medications and medical products of biologic origin. Those studies are described in full in this review. Conclusions Knowledge of animal-derived ingredients may help open conversations with patients around spiritual history and cultural competency, particularly for those patients belonging to religious sects with doctrines that define appropriate use of human- or animal-derived products. Further formal study is needed to explore more fully the extent to which religious beliefs may impact selection of animal- or human-derived medications. Guidelines developed from this knowledge may aid in identifying individual patients with whom the discussion may be particularly relevant. More studies are needed to quantify and qualify beliefs regarding animal-derived medication constituents.

after overnight fasting and again at specified timepoints after iron ingestion. The patients received one 30 mg iron tablet/capsule, and blood draws were performed after 60 and 120 min. After patients had consumed a very low-iron lunch (potato soup, bread), the same protocol was repeated. The area under the curve [AUC] for iron absorption at 60 and 120 min was calculated with regard to a.m./p.m. baselines. The blood samples were analyzed at Immundiagnostik AG, Bensheim, Germany, by LC/MS/MS. Results: Thirty patients with IBD were enrolled (17 f/13 m; 13 CD/17 UC; 37.6 6 13.6 y). Of these, 5/30(%) had inflammatory disease activity. The first administration of both ferrous sulphate and iron maltol led to a significant increase in plasma iron compared to baseline (P , 0.001), regardless of the presence of inflammation. After the second iron dose (p.m.), plasma iron fell insignificantly in both groups (P 5 0.011 and P 5 0.538, respectively, for the iron maltol and iron sulphate groups). Iron absorption capacity was higher in the iron maltol group in the morning, but did not differ after the second iron dose p.m. (P 5 0.280). Serum hepcidin values were significantly increased in both groups at afternoon baseline, i.e., prior to the second iron dose (P , 0.001), and serum hepcidin increase occurred independent of the type of iron. Conclusion(s): Hepcidin levels increased after intake of both ferrous sulphate and iron maltol, thus impairing iron absorption from the second daily dose. Intake of oral iron supplements by patients with IDA results in an acute increase of serum hepcidin levels over approximately 24 hours, regardless of whether ferric (III) or ferrous (II) iron is ingested and in spite of strong suppression of hepatic hepcidin expression due to iron deficiency and erythropoietic drive. Our data suggest that alternate day dosing of oral iron supplements may be appropriate in patients with IBD and anemia.

Bouveret syndrome is ectopic gallstone impaction and obstruction of the duodenum or pylorus affecting a small minority of gallstone ileus cases. There have been advances in its endoscopic management, but this remains a challenging condition to treat successfully. We present a patient with Bouveret syndrome who required open surgical extraction and gastrojejunostomy after attempts of endoscopic retrieval and electrohydraulic lithotripsy (EHL). A 79-year-old man with a medical history of gastroesophageal reflux disease, chronic obstructive pulmonary disease on 5 liters of oxygen at baseline, and coronary artery disease with recent stenting presented to the hospital with three days of abdominal pain and vomiting. CT of the abdomen/pelvis demonstrated gastric outlet obstruction, a 4.5 cm gallstone in the proximal duodenum, cholecystoduodenal fistula, gallbladder wall thickening, and pneumobilia. Esophagogastroduodenoscopy (EGD) demonstrated a black pigmented stone impacted in the duodenal bulb with ulceration of the inferior wall. Repeated Roth net retrieval attempts of the stone were unsuccessful even after biopsy forceps were used to trim the stone’s margins. The next day, EGD with EHL used 20 shocks of 200 watts, allowing for partial stone removal and fragmentation, but the majority of the stone remained stuck to the wall. Laparoscopic cholecystectomy was attempted but was converted to an open extraction of the gallstone from the duodenum, pyloric exclusion, and gastrojejunostomy. The gallbladder remained in place, and the cholecystoduodenal fistula was not surgically repaired. The patient experienced significant postoperative pulmonary insufficiency and remained on the ventilator with failure of multiple spontaneous breathing trials. Postoperative imaging showed resolution of pneumobilia but a small amount of contrast leaked from the duodenum revealing the fistula's persistence. After 14 days of unsuccessful ventilator weaning, the family opted for palliative extubation. Advanced endoscopic techniques have been regarded as the first-line intervention for Bouveret syndrome as there is low morbidity and mortality associated with them. However, there is a reduced success rate compared to surgical intervention. Open surgical management has high morbidity and mortality in the elderly and comorbid patients commonly affected by this condition. Thus, the risks and benefits must be weighed and individualized for each patient with Bouveret syndrome before therapeutic intervention.

some rare cases abscess formation has also been associated with colon cancer in up to 0.3 to 4% of patients that can lead to even more diagnostic challenges. In these situations, reviewing the imaging with your Radiologist might be helpful to further strengthen your diagnosis and to possibly avoid a colonoscopy that can have an increased risk of perforation in acute diverticulitis.[1976] Figure 1. A) Coronal view of splenic flexure exophytic mass B) Sigmoid area with congestion, erythema and drainage of pus C) Transverse view of residual splenic flexure mass.