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The article focuses on the exploration of the philosophical pedigree and legitimation of ethnomethodology. Sociology has been salvaged at the expense of splitting the pre-empirical transcendental inter-subjectivity into scores of empirically accessible subjectivities. The conduct of ethnomethodology toward existentialist philosophy, source of inspiration, is neither than its behaviour toward phenomenology. Existentialism struggles, in fact, to get rid of the dilemma itself; even of the vocabulary devised to make it utterable. The virtual existence consists in uncompromised liberty from both empirical and introspectional facts. Existentialism is again an invitation to a selfareflection over the residual, irreducible realm of freedom left when everything describable in the language of temporarily anchorable events has been thoroughly culled away. As a consistent system of ideas existentialism seems to be invulnerable unless one resents its voluntary aloofness and sets out to build bridges over the void between the existentialist stance and the empirical, scientific mind.

Background: The Joint Commission reports that at least half of communication breakdowns occur during handovers or transitions of care. There is no consensus on how best to approach the transfer of care within acute care surgery (ACS). We conduct a systematic review and meta-analysis of the current data on handoffs and transitions of care in ACS patients and evaluate the impact of standardization and formalized communication processes., Methods: Clinically relevant questions regarding handoffs and transitions of care with clearly defined patient Population(s), Intervention(s), Comparison(s), and appropriately selected Outcomes were determined. These centered around specific transitions of care within the setting of ACS, specifically perioperative interactions, emergency medical services and trauma team interactions, and intra/interfloor and intensive care unit (ICU) interactions. A systematic literature review and meta-analysis were conducted using the Grading of Recommendations Assessment, Development, and Evaluation methodology., Results: A total of 10 studies were identified for analysis. These included 5,113 patients in the standardized handoff group and 5,293 in the current process group. Standardized handoffs reduced handover errors for perioperative interactions and preventable adverse events for intra/interfloor and ICU interactions. There were insufficient data to evaluate outcomes of clinical complications and medical errors., Conclusion: We conditionally recommend a standardized handoff in the field of ACS, including perioperative interactions, emergency medical services and trauma team interactions, and intra/interfloor and ICU interactions., Level of Evidence: Systematic Review/Meta-analysis; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Traditional rib anatomy and costal margin teaching contends that the costal margin consists of a combined costal cartilage made up of ribs 7 to 10. Variations in 9th and 10th rib anatomy have been observed. We sought to evaluate the variability of interchondral joints and the make-up of the costal margin., Methods: Cadaveric dissections were performed to evaluate the anatomy of the anterior ribs and the composition of the costal margin. Experienced chest wall surgeons evaluated this anatomy through a standardized dissection and assessment. Dissection videos were performed to allow for further review/assessment., Results: Bilateral chest wall anatomy of 30 cadavers was evaluated (15 male, 15 female). The average age was 78 ± 12 years, and all patients were Caucasian. In all patients, the first rib attached to the manubrium, the second rib attached to the manubriosternal junction, and ribs 3 to 6 attached directly to the sternum. Interchondral joints were present between ribs 4/5-3%, 5/6-68%, 6/7-83%, 7/8-72%. Ribs combining to form a common costal cartilage via cartilaginous unions were observed between 6/7-3%, 7/8-45%, 8/9-30%, and 9/10-20%.The 8th rib attached directly to the sternum without joining the 7th rib in 10% of cadavers. The 8th and 9th ribs had free tips in 45% and 60% of evaluations, respectively. The 10th rib was found to have a hooked tip in 25% of cases and was a floating rib without attachment to the 9th rib 52% of the time. Rib tip mobility was noted in ribs 8, 9, and 10 in 52%, 70%, and 90%, respectively., Conclusion: Interchondral joints are common between ribs 5 and 8. Significant variability exists in the chest wall and costal margin compared with traditional teaching. It is important for chest wall surgeons treating diseases of the costal margin to appreciate this anatomic variability., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Classical teaching of rib anatomy contends that the false ribs (7th to 10th) fuse anteriorly to form the costal margin of the chest. Slipped rib syndrome consists of false rib subluxation into the thorax with symptomatic impingement of the intercostal nerve. We sought to determine the incidence of this anatomic finding through anatomic study of the costal margin., Methods: Cadavers were evaluated for mobility and attachment of the ninth and tenth ribs. Experienced anatomists and chest wall surgeons conducted a standardized dissection and assessed rib tip mobility using predefined criteria. Videos of dissections were submitted to a single investigator who reviewed the findings., Results: Costal margins of 40 cadavers (45% male) were evaluated bilaterally. The average age was 83 years ± 11 years. The ninth rib was found to be attached to the eighth rib 100% of the time by an interchondral cartilaginous attachment along the body of the eighth and ninth ribs. Internal subluxation was noted in 19% (15 of 80), and the tip of the rib was mobile in 86% (69 of 80) evaluations. The tenth rib was attached to the ninth rib in 18%(14/80). A "floating" 10th rib was noted in 59% (47 of 80) of specimens. Subluxation was noted in 33% (26 of 60). Half of the ribs that subluxed moved medially to the ninth rib and half moved externally. An upwardly hooked tip was noted in 10% (8 of 80). Ribs with a hooked tip subluxed in 63% (5 of 8), and all of these ribs (5 of 5) moved to the interior of the chest ( p = 0.020)., Conclusion: The ninth rib is commonly attached to the eighth rib, but the tenth rib is often not attached to the ninth rib. Most commonly, the tenth rib is a "floating" rib. Internal subluxation of the tenth rib as well as the presence of a hooked tip may predispose individuals to the development of "slipped rib syndrome.", Level of Evidence: Diagnostic Tests or Criteria; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Prospective studies of surgical stabilization of rib fractures (SSRF) have excluded elderly patients, and no study has exclusively addressed the ≥80-year-old subgroup. We hypothesized that SSRF is associated with decreased mortality in trauma patients 80 years or older., Methods: Multicenter retrospective cohort study involving eight centers. Patients who underwent SSRF from 2015 to 2020 were matched to controls by study center, age, injury severity score, and presence of intracranial hemorrhage. Patients with chest Abbreviated Injury Scale score less than 3, head Abbreviated Injury Scale score greater than 2, death within 24 hours, and desire for no escalation of care were excluded. A subgroup analysis compared early (0-2 days postinjury) to late (3-7 days postinjury) SSRF. Poisson regression accounting for clustered data by center calculated the relative risk (RR) of the primary outcome of mortality for SSRF versus nonoperative management., Results: Of 360 patients, 133 (36.9%) underwent SSRF. Compared with nonoperative patients, SSRF patients were more severely injured and more likely to receive locoregional analgesia. There were 31 hospital deaths among the entire sample (8.6%). Multivariable regression demonstrated a decreased risk of mortality for the SSRF group, as compared with the nonoperative group (RR, 0.41; 95% confidence interval, 0.24-0.69; p < 0.01). However, SSRF patients were more likely to develop pneumonia, and had an increased duration of both mechanical ventilation and intensive care unit stay. There were no differences in discharge destination, although the SSRF group was less likely to be discharged on narcotics (RR, 0.66; 95% confidence interval, 0.48-0.90; p = 0.01). There was no difference in adjusted mortality between the early and late SSRF subgroups., Conclusion: Patients selected for SSRF were substantially more injured versus those managed nonoperatively. Despite this, SSRF was independently associated with decreased mortality. With careful patient selection, SSRF may be considered a viable treatment option in octogenarian/nonagenarians., Level of Evidence: Therapeutic, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Youth are tragically affected by violence. Justice-involved youth are at elevated risk for the effects of violence, as incarceration serves as a risk factor. The objective of this study is to explore the risks and needs of justice-involved youth and identify channels for future hospital-based programming., Methods: Four weekly focus groups were conducted by a credible messenger at the Douglas County Youth Center with former participants of Dusk 2 Dawn, a youth violence prevention program delivered at the Douglas County Youth Center. Eight participants were prompted with preset interview questions. All focus groups were recorded and transcribed by a professional transcription service. A thematic analysis was performed by 2 independent coders to identify themes using Dedoose software., Results: The 3 most frequently occurring themes involved topics on protection, identified 40 times; family, identified 36 times; and the challenge of overcoming violence, identified 31 times. These themes often overlapped with one another, demonstrating the complexity of youth violence., Conclusion: Providing a safe and judgement-free space for the youth to discuss issues of violence was beneficial for 3 reasons: (1) inclusion of youth perspectives allows violence prevention programs to be tailored to specific needs, (2) participants were able to deeply reflect on violence in their own lives and consider steps toward positive change, and (3) open communication encourages trust building and collaborative prevention efforts between the hospital and community., (© 2021 The Authors.)

Background: The efficacy of surgical stabilization of rib fracture (SSRF) in patients without flail chest has not been studied specifically. We hypothesized that SSRF improves outcomes among patients with displaced rib fractures in the absence of flail chest., Methods: Multicenter, prospective, controlled, clinical trial (12 centers) comparing SSRF within 72 hours to medical management. Inclusion criteria were three or more ipsilateral, severely displaced rib fractures without flail chest. The trial involved both randomized and observational arms at patient discretion. The primary outcome was the numeric pain score (NPS) at 2-week follow-up. Narcotic consumption, spirometry, pulmonary function tests, pleural space complications (tube thoracostomy or surgery for retained hemothorax or empyema >24 hours from admission) and both overall and respiratory disability-related quality of life (RD-QoL) were also compared., Results: One hundred ten subjects were enrolled. There were no significant differences between subjects who selected randomization (n = 23) versus observation (n = 87); these groups were combined for all analyses. Of the 110 subjects, 51 (46.4%) underwent SSRF. There were no significant baseline differences between the operative and nonoperative groups. At 2-week follow-up, the NPS was significantly lower in the operative, as compared with the nonoperative group (2.9 vs. 4.5, p < 0.01), and RD-QoL was significantly improved (disability score, 21 vs. 25, p = 0.03). Narcotic consumption also trended toward being lower in the operative, as compared with the nonoperative group (0.5 vs. 1.2 narcotic equivalents, p = 0.05). During the index admission, pleural space complications were significantly lower in the operative, as compared with the nonoperative group (0% vs. 10.2%, p = 0.02)., Conclusion: In this clinical trial, SSRF performed within 72 hours improved the primary outcome of NPS at 2-week follow-up among patients with three or more displaced fractures in the absence of flail chest. These data support the role of SSRF in patients without flail chest., Level of Evidence: Therapeutic, level II.

Background: The aim of this study was to evaluate the related change in outcomes (mortality, complications) in patients undergoing trauma laparotomy (TL) with the implementation of damage control resuscitation (DCR). We hypothesized that the implementation of DCR in patients undergoing TL is associated with better outcomes., Methods: We analyzed 1,030 consecutive patients with TL. Patients were stratified into three phases: pre-DCR (2006-2007), transient (2008-2009), and post-DCR (2010-2013). Resuscitation fluids (crystalloids and blood products), injury severity score (ISS), vital signs, and laboratory (hemoglobin, international normalized ratio, lactate) parameters were recorded. Regression analysis was performed after adjusting for age, ISS, laboratory and vital parameters, comorbidities, and resuscitation fluids to identify independent predictors for outcomes in each phase., Results: Patient demographics and ISS remained the same throughout the three phases. There was a significant reduction in the volume of crystalloid (p = 0.001) and a concomitant increase in the blood product resuscitation (p = 0.04) in the post-DCR phase compared to the pre-DCR and transient DCR phases. Volume of crystalloid resuscitation was an independent predictor of mortality in the pre-DCR (OR [95% CI]: 1.071 [1.03-1.1], p = 0.01) and transient (OR [95% CI]: 1.05 [1.01-1.14], p = 0.01) phases; however, it was not associated with mortality in the post-DCR phase (OR [95% CI]:1.01 [0.96-1.09], p = 0.1). Coagulopathy (p = 0.01) and acidosis (p = 0.02) were independently associated with mortality in all three phases., Conclusion: The implementation of DCR was associated with improved outcome in patients undergoing TL. There was a decrease in the use of damage control laparotomy, with a decrease in the use of crystalloid and an increase in the use of blood products., Level of Evidence: Prognostic study, level III.

Purpose: Point-of-care ultrasound evaluates inferior vena cava (IVC) and internal jugular vein (IJV) measurements to estimate intravascular volume status. The reliability of the IVC and IJV collapsibility index during increased thoracic or intra-abdominal pressure remains unclear., Methods: Three phases of sonographic scanning were performed: spontaneous breathing phase, increased thoracic pressure phase via positive pressure ventilation (PPV) phase, and increased intra-abdominal pressure (IAP) phase via laparoscopic insufflation to 15 mmHg. IVC measurements were done at 1-2 cm below the diaphragm and IJV measurements were done at the level of the cricoid cartilage during a complete respiratory cycle. Collapsibility index was calculated by (max diameter - min diameter)/max diameter × 100 %. Chi square, t test, correlation procedure (CORR) and Fisher's exact analyses were completed., Results: A total of 144 scans of the IVC and IJV were completed in 16 patients who underwent laparoscopic surgery. Mean age was 46 ± 15 years, with 75 % female and 69 % African-American. IVC and IJV collapsibility correlated in the setting of spontaneous breathing (r (2) = 0.86, p < 0.01). IVC collapsibility had no correlation with the IJV in the setting of PPV (r (2) = 0.21, p = 0.52) or IAP (r (2) = 0.26, p = 0.42). Maximal IVC diameter was significantly smaller during increased IAP (16.5 mm ± 4.9) compared to spontaneous breathing (20.6 mm ± 4.8, p = 0.04) and PPV (21.8 mm ± 5.6, p = 0.01)., Conclusion: IJV and IVC collapsibility correlated during spontaneous breathing but there was no statistically significant correlation during increased thoracic or intra-abdominal pressure. Increased intra-abdominal pressure was associated with a significant smaller maximal IVC diameter and cautions the reliability of IVC diameter in clinical settings that are associated with intra-abdominal hypertension or abdominal compartment syndrome.

We encountered a rare case of gastroschisis associated with jejunal atresia and colonic atresia. In our case, the jejunal atresia was not discovered for 27 days after the initial abdominal wall closure. The colonic atresia was not discovered for 48 days after initial repair of the gastroschisis secondary to the rarity of the disorder. Both types of atresia were repaired with primary hand-sewn anastomoses. Other than the prolonged parenteral nutrition and hyperbilirubinemia, our patient did very well throughout his hospital course. Based on our case presentation, small bowel atresia and colonic atresia must be considered in patients who undergo abdominal wall closure for gastroschisis with prolonged symptoms suggestive of bowel obstruction. Our case report also demonstrates primary enteric anastomosis as a safe, well-tolerated surgical option for patients with types of intestinal atresia.

We encountered a case of gallbladder volvulus in an 88-year-old thin female in which the initial presentation was more consistent with that of acute appendicitis. After complete work-up, including physical exam, lab work, and computed tomography, the definite diagnosis of gallbladder volvulus was not made until intraoperative visualization was obtained. Gallbladder volvulus is a rare but serious condition, which requires a high clinical suspicion so prompt surgical intervention can be undertaken.

Background: Cardiac output (CO) measurement in the intensive care unit (ICU) requires invasive devices such as the pulmonary artery (PA) catheter or arterial waveform pulse contour analysis (PCA). This study tests the accuracy and feasibility of point of care ultrasound (POCUS) of the common carotid artery to estimate the CO non-invasively and compare it to existing invasive CO measurement modalities., Methods: Patients admitted to the surgical and cardiothoracic ICU in a tertiary university-affiliated academic center during a 4-month period, with invasive hemodynamic monitoring devices for management, were included in this cohort study. Common carotid artery POCUS was performed to measure the CO and the results were compared to an invasive device., Results: Intensivists and ICU fellows, using ultrasound of the common carotid artery, obtained the CO measurements. Images of the Doppler flow and volume were obtained at the level of the thyroid gland. Concurrent CO measured via invasive devices was recorded. The patient cohort comprised 36 patients; 52 % were females. The average age was 59 ± 13 years, and 66 % were monitored via PCA device and 33 % via PA catheter. Intraclass correlation coefficient (ICC) analysis demonstrated almost perfect correlation (0.8152) between measurements of CO via ultrasound vs. invasive modalities. The ICC between POCUS and the invasive measurement via PCA was 0.84 and via PA catheter 0.74, showing substantial agreement between the ultrasound and both invasive modalities., Conclusions: Common carotid artery POCUS offers a non-invasive method of measuring the CO in the critically ill population.

Background: The objective of this study was to assess differences in hemodynamic stability for patients undergoing carotid endarterectomy (CEA) under general anesthesia (GA) as compared with cervical block anesthesia (CBA)., Methods: An institutional review board-approved, retrospective review of 651 patients from 1998 to 2012 undergoing CEA was performed: 254 patients underwent CEA under CBA and 397 under GA. Comprehensive chart review including preoperative, postoperative, and 30-day follow-up was conducted. Patients were monitored continuously intraoperatively and for 24 hr after surgery. All intraoperative vasoactive and antihypertensive medications administered were recorded., Results: Both groups were similar in age, incidence of coronary artery disease, hypertension, and renal failure. There was a preponderance of female patients, with a high incidence of chronic obstructive pulmonary disease, diabetes mellitus, and nicotine abuse in the GA group. Symptomatic patients predominated the GA group (54% vs. 41%; P = 0.0018). Of the symptomatic patients, 78% experienced transient ischemic attacks in the GA group vs. 64% in the CBA group. Evaluation of hemodynamic stability under GA versus CBA revealed that no significant hemodynamic changes occurred in 34.5% of CBA patients vs. only 14.4% in the GA group. Under GA, incidence of hypotension was 17.84% as compared with 0.52% under CBA (P < 0.001). Under GA, patients had far more hemodynamic fluctuations with 41% of patients demonstrating >3 intraoperative fluctuations in mean arterial pressure of >20% vs. 20% in the CBA group (P < 0.001). Under GA, 51% of patients required vasopressors alone vs. 36% under CBA (P < 0.0002). Antihypertensive medications alone were required in 63% of patients in the GA group vs. 73% in the CBA group (P = 0.0085). Thirty percent of all patients required both vasopressors and antihypertensives during surgery; 23% under CBA vs. 34% under GA (P = 0.0457). There were two postoperative hematoma's CBA cohort. The GA cohort developed postoperative complications (myocardial infarction, 4; stroke, 6; and hematoma, 9), however, these complications were not statistically significant compared with the CBA group., Conclusions: For patients undergoing CEA, CBA resulted in less hemodynamic fluctuations and fewer intraoperative vasoactive medication requirements as compared with GA., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Clearance of homocysteine via the transsulfuration pathway provides an endogenous route for cysteine synthesis and represents a quantitatively significant source of this amino acid needed for glutathione synthesis. Men have higher plasma levels of total homocysteine than do women, but the mechanism of this sex-dependent difference is not known. In this study, we investigated regulation by testosterone of cystathionine beta-synthase (CBS), which catalyzes the committing step in the transsulfuration pathway. We report that testosterone downregulates CBS expression via a posttranscriptional mechanism in the androgen-responsive prostate cancer cell line, LNCaP. This diminution in CBS levels is accompanied by a decrease in flux through the transsulfuration pathway and by a lower intracellular glutathione concentration. The lower antioxidant capacity in testosterone-treated prostate cancer cells increases their susceptibility to oxidative stress conditions. These results demonstrate regulation of the homocysteine-clearing enzyme, CBS, by testosterone and suggest the potential utility of targeting this enzyme as a chemotherapeutic strategy.

The transsulfuration pathway converts homocysteine to cysteine and represents the metabolic link between antioxidant and methylation metabolism. The first and committing step in this pathway is catalyzed by cystathionine beta-synthase (CBS), which is subject to complex regulation, including allosteric activation by the methyl donor, S-adenosylmethionine (AdoMet). In this study, we demonstrate that methionine restriction leads to a >10-fold decrease in CBS protein levels, and pulse proteolysis studies reveal that binding of AdoMet stabilizes the protein against degradation by approximately 12 kcal/mol. These observations predict that under pathological conditions where AdoMet levels are diminished, CBS, and therefore glutathione levels, will be reduced. Indeed, we demonstrate this to be the case in a mouse model for spontaneous steatohepatitis in which the gene for the MAT1A isoenzyme encoding AdoMet synthetase has been disrupted, and in human hepatocellular carcinoma, where MAT1A is silenced. Furthermore, diminished CBS levels are associated with reduced cell viability in hepatoma cells challenged with tert-butyl hydroperoxide. This study uncovers a mechanism by which CBS is allosterically activated by AdoMet under normal conditions but is destabilized under pathological conditions, for redirecting the metabolic flux toward methionine conservation. A mechanistic basis for the coordinate changes in redox and methylation metabolism that are a hallmark of several complex diseases is explained by these observations.

Methionine metabolism provides two key cellular reagents: S-adenosylmethionine and glutathione, derived from the common intermediate, homocysteine. A majority of cancer cells exhibit a methionine-dependent phenotype whereby they are unable to grow in medium in which methionine is replaced by its precursor, homocysteine. Additionally, CpG island hypermethylation of tumor suppressor gene promoters is observed in a background of global hypomethylation in cancerous cells. In this study, we have profiled the expression levels of the homocysteine junction enzymes, methionine synthase (MS), MS reductase (MSR), and cystathionine beta-synthase (CBS) in the NCI60 panel of cancer cell lines. The doubling time of non-small lung cell cancer lines, which exhibit the lowest levels of MS within the panel, was significantly correlated with expression of MS. The ratio of MS to MSR varied over a 5-fold range in the different cell types, which may modulate methionine synthesis. Interestingly, markedly reduced CBS expression was seen in the methionine-dependent prostate cancer cell line, PC-3, but not in the methionine-independent cell line, DU-145. However, neither provision of the transsulfuration pathway product, cysteine, nor overexpression of CBS rescued the growth impairment, indicating that reduced CBS was not responsible for the methionine-dependent phenotype in this cell line.