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Background: The oxygenation ratio (ie, [Formula: see text]/[Formula: see text]) remains the most commonly used index for assessing oxygenation and disease severity in patients with acute ARDS. However, the oxygenation ratio does not account for mechanical ventilation settings. We hypothesized that the oxygenation factor (ie, oxygenation ratio/mean airway pressure) is superior to the oxygenation ratio in reflecting oxygenation in patients with ARDS and results in a different classification of ARDS severity., Methods: In 150 subjects with ARDS (50 severe, 50 moderate, and 50 mild), arterial blood gas, mean airway pressure, static lung compliance, driving pressure, and mechanical power were obtained. The oxygenation ratio and the oxygenation factor were then calculated. Receiver operating characteristic curves were constructed for oxygenation ratio and oxygenation factor at lung compliance > 40 mL/cm H 2 O, driving pressure < 15 cm H 2 O, and mechanical power < 17 J/min, thresholds that are known to predict survival in patients with ARDS. Subjects were reclassified for ARDS severity on the basis of the oxygenation factor and compared to classification on the basis of the oxygenation ratio., Results: Areas under the receiver operating characteristic curves for the oxygenation factor were significantly higher than for the oxygenation ratio. Reclassification of ARDS severity using the oxygenation factor did not affect subjects classified as having severe ARDS per the oxygenation ratio. However, 52% of subjects with moderate ARDS per the oxygenation ratio criteria were reclassified as either severe (25 subjects) or mild ARDS (1 subject) on the basis of oxygenation factor criteria. Also, 54% of subjects with mild ARDS per the oxygenation ratio criteria were reclassified as severe (4 subjects), moderate (21 subjects), or non-ARDS (2 subjects) on the basis of oxygenation factor criteria., Conclusions: The oxygenation factor was a superior ARDS oxygenation index compared to the oxygenation ratio and should be considered as a substitute criteria for classification of the severity of ARDS. (ClinicalTrials.gov registration NCT03946189.)., Competing Interests: Mr Chatburn discloses relationships with IngMar Medical and Vyaire Medical. The remaining authors have no conflicts to disclose., (Copyright © 2020 by Daedalus Enterprises.)

Background: Gastrointestinal schwannomas are submucosal tumors accounting for 2-7% of mesenchymal gastro-intestinal neoplasms; the stomach being the most common site. Esophageal schwannomas are more frequent in women, and are usually located in the upper to mid portion. Dysphagia is the main presenting symptom. A definitive diagnosis requires confirmation by histopathological and immunohistochemical studies., Case Presentation: A 50-year-old healthy lady, presented with gradual increasing onset of dyspnea, with minimal dysphagia to solid food, over a period of several years. Enhanced CT scan of the chest revealed a well-defined soft tissue mass arising from the proximal third of the esophagus, measuring 7.8 × 5.4 x 10.5 cm. Esophagogastric endoscopy with ultrasonography showed an elevated, smooth surface lesion, arising from the submucosal layer of the esophagus, with a hypervascular mucosa. Enucleation of this large tumor, with preservation of the overlying mucosa, was difficult to accomplish due to its large size. Making use of a dilated proximal esophageal segment, total en-bloc excision of the mass rendered a 15 cm esophagotomy gap, which was easily closed, in two layers, without affecting the overall caliber thus achieving a good esophagoplasty result. Histologically, abundance of spindle-shaped cells with positive S-100 proteins, confirmed the diagnosis of esophageal schwannoma., Conclusion: Variations in mesenchymal gastrointestinal tumors is vast, rendering diagnosis by radiology alone difficult. As such, characteristic histologic and immunostaining features are cornerstones in precise diagnosis of esophageal schwannomas. Despite being rare in incidence, symptomatic esophageal schwannoma lesions can be excised entirely, with low rate of recurrence and favorable overall outcomes., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Few reports from the medical literature have presented severe mesh-related complications following laparoscopic repair of inguinal hernia. One of these complications is being mesh erosion into bowel, resulting in fistulous tract with subsequent abscess formation., Case Presentation: A 75-year-old patient, status post laparoscopic bilateral inguinal hernia repair, and on anticoagulation for dual prosthetic heart valves, presented with a unique case of sigmoid to scrotal fistula, post mesh erosion, resulting in sepsis. The patient presented in septic shock, necessitating an individualized surgical approach. Given the septic picture of our patient, the surgical approach was truncated. Initially the sepsis from the scrotum was drained and debrided. A watermelon seed was noted in the scrotum. After stabilization, the second stage approach was performed, were a laparotomy was performed, followed by division of the sigmoid to internal ring fistula, and reperitonealization of the mesh. Mesh removal was delayed as the risk of bleeding into the peritoneum was high, once anticoagulation needed to be resumed. Because of a persistent wound sinus tract, several months later, the mesh was removed, in a third stage, from an inguinal incision. Albeit meticulous dissection and homeostasis, a postoperative extraperitoneal inguinal hematoma developed, as expected, on day 2, once anticoagulation was resumed., Conclusion: Sigmoid to inguinoscrotal fistula is a rare, yet serious, complication of mesh infection and erosion. This can be obviated by preventing serosal tear, and proper peritonealization of the mesh. Fistulectomy alone with primary repair turned out to be a valid approach in our patient. Retaining the mesh could be an alternative for avoiding bleeding in patients on anticoagulation; despite that a persistent indolent infection and sinus tract will necessitate mesh removal afterwards.