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Background: Health literacy is a major determinant of health outcomes, with low literacy correlated with increased risk of postoperative complications and lower patient-reported outcomes. This study sought to increase health literacy in a subset of Los Angeles County patients who would be undergoing total joint arthroplasty (TJA) using a video-based intervention. Methods: We enrolled 51 patients scheduled to undergo TJA. The first 26 patients were allocated into the prevideo group who underwent the typical preoperative visit, and the next 25 patients were enrolled into the video-intervention (postvideo) group. Results: No differences in baseline health literacy based on the Newest Vital Sign survey were noted between the groups (1.88 ± 1.90 vs 1.28 ± 1.24; P = .94). Higher knowledge scores regarding arthritis and TJA were seen in the postvideo group (71.52 ± 24.50 vs 54.92 ± 26.93; P = .01). This finding was consistent in primary Spanish speakers (66.40 ± 24.51 vs 49.60 ± 24.93; P = .04). There were no differences in preoperative anxiety and information requirement between the groups (16.00 ± 6.21 vs 16.88 ± 6.27; P = .31). The total low literacy version of the Decisional Conflict Scale score utilized to quantify patients’ decisional conflict in the setting of TJA were not different between the groups (11.44 ± 14.32 vs 10.40 ± 15.41; P = .40). Conclusions: Patient knowledge about arthritis and TJA significantly improved as measured by the modified arthritis knowledge survey in the postvideo group compared to a discussion with their surgeon.

Background: Multidisciplinary cardiogenic shock (CS) programs have been associated with improved outcomes, yet practical guidance for developing a CS program is lacking. Methods: A survey on CS program development and operational best practices was administered to 12 institutions in diverse sociogeographic regions and practice settings. Common steps in program development were identified. Results: Key steps for program development were identified: measuring baseline outcomes; identifying subspecialty champions; gaining leadership and team buy-in; developing institution-specific CS protocols; educating staff and referring providers; consulting with external experts; and developing quality assessment and process improvement. Conclusions: An assessment of 12 US CS programs highlights a blueprint for establishing and maintaining a successful, multidisciplinary shock program.

Background: Fear of cancer recurrence (FCR), cancer-distress, depression, and anxiety are prevalent concerns among women with gynecologic and other understudied cancers, especially among women of color and lower socioeconomic status (SES). Evidence indicates that mind-body interventions are effective in reducing such distress. This study evaluates (1) proof-of-concept of an integrated group yoga and psychological intervention in alleviating distress among women with gynecologic, gastrointestinal, and thoracic cancers and (2) differences in efficacy across social and economic factors. Methods: One hundred twenty-five participants were enrolled in a 10-week, single-arm, integrated group intervention utilizing mindfulness meditation, psychotherapy skills, and yoga. They completed measures of FCR, cancer-distress, depression, and anxiety at baseline and following intervention. Mixed-linear models evaluated change in outcomes across the intervention and moderating effects of age, minority status, and SES among 51 participants with available data. Results: Reductions in total ( b = −2.06, P = .012) and somatic depressive symptoms ( b = −1.79, P = .002) and state anxiety ( b = −6.21, P = .005) were observed across the sample. Higher SES was associated with greater reductions in psychosocial distress related to FCR ( b = −0.74, P = .050), and in total (b = −1.06, P = .049) and affective depressive symptoms ( b = −0.76, P = .006). Women of color experienced greater declines in somatic symptoms compared to non-Hispanic White women ( b = −2.71, P = .031), with women of color experiencing lower SES exhibiting greatest reduction in these symptoms ( b = 1.73, P = .026). Conclusions: This study demonstrates proof-of-concept that an integrated psychological and yoga intervention may reduce depressive symptoms and state anxiety among women with gynecologic, gastrointestinal, and thoracic cancers, with racial and/or ethnic minority status and SES moderating some of these effects. Future research should examine intervention feasibility and acceptability among diverse women with cancer and evaluate efficacy using a randomized controlled trial design. Trial registration: ClinicalTrials.gov NCT03385577

Background:. Surgical innovation has provided new options for the management of complex peripheral nerve injuries, generating renewed interest in this field. Historic literature may be misinterpreted or misquoted, or create dogma, which is perpetuated in teaching, research publications, and clinical practice. The management of peripheral nerve injuries is based on complex decision-making, with potential lifelong ramifications for patients incorrectly receiving an expectant or surgical management plan. Methods:. This article includes opinion from expert leaders in the field of peripheral nerve surgery and questions some of the current assumptions and preconceptions around nerve surgery based on clinical evidence. There was extensive debate regarding the contents of the final article, and the different opinions expressed represent the uncertainty in this field and the differing levels of confidence in available published evidence. Results:. Individual practices vary and, therefore, absolute consensus is impossible to achieve. The work is presented as 10 myths which are assessed using both historical and emerging evidence, and areas of uncertainty are discussed. Conclusions:. It is important to learn lessons from the past, and scholars of history bear the task of ensuring references are accurately quoted. Expunging myths will enhance care for patients, focus research efforts, and expand on the surgical possibilities within this specialty.

Background/Purpose: Cutaneous squamous cell carcinoma (cSCC) is one of the most common malignancies worldwide. While several environmental risk factors for cSCC are well established, there is conflicting evidence on cigarette smoking (and its potential causal effect) and cSCC risk. Furthermore, it is unclear if these potential associations represent causal, modifiable risk factors for cSCC development. This study aims to assess the nature of the associations between cigarette smoking traits (smoking initiation, amount smoked, and lifetime smoking exposure) and cSCC risk using two-sample Mendelian randomization analyses. Methods: Genetic instruments, based on common genetic variants associated with cigarette smoking traits (P

Background: Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum. Hypothesis/Purpose: The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS. Methods: Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment. Results: All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months). Conclusion: The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

Background:. Plastic and reconstructive surgery is one of the most competitive residency programs, and given the increased number of applicants for a relatively fixed number of positions, successfully matching is a challenge. Match rates have declined since 2018, with a match rate of ~55% in 2022. Two common options before reapplying are a preliminary year of residency (preliminary year) or a research fellowship. This study investigated which option is more beneficial for reapplicants seeking a successful match. Methods:. This retrospective study included all applicants to an integrated plastic and reconstructive surgery residency from 2015 to 2023. Two cohorts based on reapplication strategy (research fellowship or preliminary year) were created. Demographic, applicant, and match data were collected. Pearson chi-squared, Fisher exact, and Wilcoxon rank sum testing were performed. Results:. In total, 125 reapplicants were included. Seventy-one (56.8%) reapplicants pursued a preliminary year, and 29 (23.2%) completed a research fellowship. Research fellowship reapplicants had a greater mean number of first author publications (8.8 versus 3.2, P < 0.001), non-first author publications (11.3 versus 5.9, P = 0.021), poster presentations (9.7 versus 6.0, P = 0.028), and oral presentations (11.8 versus 6.4, P

Balloon entrapment is a rare complication of angioplasty in calcified or recalcitrant lesions. A 65-year-old man with chronic limb-threatening ischemia underwent balloon angioplasty of his heavily calcified tibial arteries with a low-profile, tapered, compliant balloon. The balloon became entrapped within the posterior tibial artery and required multiple endovascular maneuvers to deflate and separate the balloon from the calcified arterial wall. This case report describes several adjunctive techniques for retrieval of an entrapped balloon in small, calcified arteries before consideration of surgical removal. These techniques allow for minimally invasive retrieval and continuation of endovascular treatment thereafter.

Introduction/Purpose: Orthopaedic, vascular, and general surgeons all perform lower extremity amputations. Previous studies have indicated that outcomes may be related surgeon experience or skill, with a similar study indicating that general surgeons experience worst postoperative outcomes than vascular surgeons. In spite of these studies, there is a paucity of literature investigating the difference in outcomes between amputations performed by orthopaedic and vascular surgeons. This study aims to analyze the effect of surgeon specialty on 30-day complication, readmission, reoperation, and mortality rates following below-knee amputation (BKA) procedures between orthopaedic and vascular surgeons. Methods: The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried from 2010-2019 to identify 28,776 patients undergoing BKA by either orthopaedic, general, or vascular surgeons using Current Procedural Terminology (CPT) codes 27880, 27881, and 27882. Patients were stratified into groups based on surgeon specialty with 18,935 (66.4%) cases performed by vascular surgeons, 6,146 (21.6%) cases by general surgeons, and 3,429 (15.3%) cases were performed by orthopaedic surgeons. Demographics, comorbid conditions, hospital length of stay (LOS), and 30-day complications, readmission, reoperation, and mortality rates were compared between groups. Univariate and multivariate analysis were performed to examine the associations between outcomes and surgical specialty, while controlling for comorbid conditions as measured by ASA score and 5-factor modified frailty index (mFI-5) score. Results: The cohort was predominantly male (68.4%), white (61.9%), and the mean age was 63.54 (range, 18-90) years. The cohort of patients treated by vascular and general surgeons had significantly higher rates of numerous comorbidities, including mFI-5 score (p

Surgeons must be confident that the instruments they use do not pose risk of infection to patients due to bioburden or contamination. Despite this importance, surgeons are not necessarily aware of the steps required to ensure that an instrument has been properly sterilized, processed, and prepared for the next operation. At the end of an operation, instruments must be transported to the sterile processing unit. There, instruments are decontaminated before being sterilized by heat, chemical, or radiation-based methods. Following this, they are stored before being brought back into use. This review highlights the intricacies of the processing of surgical instruments at the conclusion of an operation so that they are ready for the next one.

OBJECTIVES:. To determine the association between spontaneous hypothermia (SH), defined as initial post-resuscitation core body temperature less than 34°C, and diffuse anoxic brain injury (DABI) on initial CT scan of the head (CTH) in post-cardiac arrest patients. DESIGN, SETTING, AND PARTICIPANTS:. This was a retrospective, observational cohort study. This study was performed at the University of Rochester Medical Center Strong Memorial Hospital. All in-hospital and out-of-hospital cardiac arrest patients with return of spontaneous circulation admitted between January 1, 2022, and October 31, 2022, were included. MAIN OUTCOMES AND MEASURES:. The primary outcomes were the odds of DABI on initial CTH for patients with SH compared with patients without SH post-cardiac arrest using a multivariable logistic regression controlling for patient covariates including basic demographics and arrest features. DABI on initial CTH was measured qualitatively and quantitatively using neuroradiologist interpretation and calculated gray-white matter ratio of the basal ganglia, respectively. Secondary outcome measures included length of stay (LOS), inpatient mortality, and those who underwent withdrawal of life-sustaining therapy (WOLST) or progression to brain death. RESULTS:. Out of the observed 150 cases of cardiac arrest, 31 patients (21%) had SH. Of the 128 patients who had an initial CTH performed, 27 (21%) had DABI. The adjusted odds ratio of DABI on initial CTH associated with SH was 3.55 (95% CI, 1.08–11.64; p = 0.036) and 2.18 (95% CI, 0.69–6.91; p = 0.182) when DABI was measured qualitatively and quantitatively, respectively, after controlling for multiple covariates. There was a difference observed in LOS between the groups (3 vs. 10 d; p = 0.0005) and this was driven by early WOLST. CONCLUSIONS AND REVELANCE:. Patients presenting with SH after cardiac arrest may be at greater risk of early DABI on initial CTH compared with those with higher body temperatures in the post-arrest period. Recognition of early SH may help to risk stratify post-cardiac arrest patients at highest risk of DABI.

Background:. Carpal tunnel syndrome affects up to 6% of the general population, and surgical intervention is often required to ameliorate symptoms. Osteoarthritis (OA) is a common condition that often coexists with carpal tunnel syndrome. We hypothesized that patients with preexisting OA use more healthcare resources after carpal tunnel release (CTR) than patients without arthritis. Methods:. This was a retrospective cohort study at a single academic center between January 1, 2018 and November 1, 2021. Patients who underwent CTR were included. Preoperative carpal tunnel symptoms, diagnostic tests, medications, and concomitant OA were abstracted. Hand, wrist, and basal joint arthritis were specified. The primary outcome was healthcare utilization represented by duration and frequency of hand clinic and occupational therapy (OT) follow-up. In total, 312 hands were included. Multivariable analysis was performed. Results:. The average duration of hand clinic follow-up among patients without arthritis was 25.3 days compared with 87.1 days for patients with any arthritis (P = 0.0375) and 172 days for patients with wrist arthritis (P = 0.012). The average number of postoperative surgeon visits was increased in patients with hand arthritis, with an average of 2.3 visits versus 1.34 visits for patients without arthritis (P = 0.003). Both the number of OT visits and the duration of OT follow-up did not differ between cohorts. Conclusion:. After CTR, patients with preexisting OA use more healthcare resources than patients without OA.

Objectives: Tricuspid valve surgery is associated with high rates of shock and in-hospital mortality. Early initiation of venoarterial extracorporeal membrane oxygenation after surgery may provide right ventricular support and improve survival. We evaluated mortality in patients undergoing tricuspid valve surgery based on the timing of venoarterial extracorporeal membrane oxygenation. Methods: All consecutive adult patients undergoing isolated or combined surgical tricuspid valve repair or replacement from 2010 to 2022 requiring venoarterial extracorporeal membrane oxygenation use were stratified by initiation in the operating room (Early) versus outside of the operating room (Late). Variables associated with in-hospital mortality were explored using logistic regression. Results: There were 47 patients who required venoarterial extracorporeal membrane oxygenation: 31 Early and 16 Late. Mean age was 55.6 years (standard deviation, 16.8), 25 (54.3%) were in New York Heart Association class III/IV, 30 (60.8%) had left-sided valve disease, and 11 (23.4%) had undergone prior cardiac surgery. Median left ventricular ejection fraction was 60.0% (interquartile range, 45-65), right ventricular size was moderately to severely increased in 26 patients (60.5%), and right ventricular function was moderately to severely reduced in 24 patients (51.1%). Concomitant left-sided valve surgery was performed in 25 patients (53.2%). There were no differences in baseline characteristics or invasive measurements immediately before surgery between the Early and Late groups. Venoarterial extracorporeal membrane oxygenation was initiated 194 (23.0-840.0) minutes after cardiopulmonary bypass in the Late venoarterial extracorporeal membrane oxygenation group. In-hospital mortality was 35.5% (n = 11) in the Early group versus 68.8% (n = 11) in the Late group (P = .037). Late venoarterial extracorporeal membrane oxygenation was associated with in-hospital mortality (odds ratio, 4.00; 1.10-14.50; P = .035). Conclusions: Early postoperative initiation of venoarterial extracorporeal membrane oxygenation after tricuspid valve surgery in high-risk patients may be associated with improvement in postoperative hemodynamics and in-hospital mortality.

Autogenous arteriovenous fistula (AVF) creation is the preferred method for long-term hemodialysis access. This report describes the novel use of paired brachial veins for the creation of an autogenous AVF in a patient without a traditional superficial venous conduit available. Application of this general concept might serve to expand the options for autogenous AVF creation.

Introduction: An extracranial carotid artery aneurysm (ECAA) is a rare pathology comprising

Over the past decade, medical education has shifted from a time-based approach to a competency-based approach for surgical training. This transition presents many new systemic challenges. The Society for Improving Medical Professional Learning (SIMPL) was created to respond to these challenges through coordinated collaboration across an international network of medical educators. The primary goal of the SIMPL network was to implement a workplace-based assessment and feedback platform. To date, SIMPL has developed, implemented, and sustained a platform that represents the earliest and largest effort to support workplace-based assessment at scale. The SIMPL model for collaborative improvement demonstrates a potential approach to addressing other complex systemic problems in medical education.

Mitral valve replacement in the setting of extensive mitral annular calcification is technically challenging and associated with high mortality and morbidity, including stroke. This is the first published report of direct surgical transcatheter valve implantation with use of a cerebral embolic protection device. (Level of Difficulty: Intermediate.)

Objective: To study the outcomes of noninvasive ventilation (NIV) administered through a tabletop device for coronavirus disease 2019 acute respiratory distress syndrome in the respiratory intermediate care unit (RIMCU) at a tertiary care hospital in India. Patients and Methods: We retrospectively studied a cohort of hospitalized patients deteriorating despite low-flow oxygen support who received protocolized management with positive airway pressure using a tabletop NIV device in the RIMCU as a step-up rescue therapy from July 30, 2020 to November 14, 2020. Treatment was commenced on the continuous positive airway pressure mode up to a pressure of 10 cm of H2O, and if required, inspiratory pressures were added using the bilevel positive air pressure mode. Success was defined as weaning from NIV and stepping down to the ward, and failure was defined as escalation to the intensive care unit, the need for intubation, or death. Results: In total, 246 patients were treated in the RIMCU during the study period. Of these, 168 received respiratory support via a tabletop NIV device as a step-up rescue therapy. Their mean age was 54 years, and 83% were men. Diabetes mellitus (78%) and hypertension (44%) were the commonest comorbidities. Treatment was successful with tabletop NIV in 77% (129/168) of the patients; of them, 41% (69/168) received treatment with continuous positive airway pressure alone and 36% (60/168) received additional increased inspiratory pressure via the bilevel positive air pressure mode. Conclusion: Respiratory support using the tabletop NIV device was an effective and economical treatment for coronavirus disease 2019 acute respiratory distress syndrome. Further studies are required to assess the appropriate time of initiation for maximal benefits and judicious utilization of resources.

Amyloidosis is a rare condition on its own but finding localized amyloidosis of a site such as the nasopharynx is an extremely rare condition with very few cases described in the literature. The condition occurs due to the accumulation of misfolded proteins in the extracellular space disrupting the cell architecture and causing eventual dysfunction. In this case report we discuss the pathophysiology, symptoms, and imaging findings of a patient initially thought to have giant cell arteritis, but who was found on CT to have a mass later determined to be localized nasopharyngeal amyloidosis. Evaluation will require biopsy as it is the gold standard, but there are many other tests and even reasons to consider the use of interventional radiology to sample other tissues rather than the primary target site for amyloid deposition in conjunction with nuclear imaging.

Objectives: There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair. Methods: Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n = 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n = 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n = 620); and ascending aortic replacement with distal and proximal extension (n = 334). “Eventful recovery,” defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference. Results: Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P

Aberrant coagulation in sickle cell disease (SCD) is linked to extracellular vesicle (EV) exposure. However, there is no consensus on the contributions of small EVs (SEVs) and large EVs (LEVs) toward underlying coagulopathy or on their molecular cargo. The present observational study compared the thrombin potential of SEVs and LEVs isolated from the plasma of stable pediatric and adult SCD patients. Further, EV lipid and protein contents were analyzed to define markers consistent with activation of thrombin and markers of underlying coagulopathy. Results suggested that LEVs—but not SEVs—from pediatrics and adults similarly enhanced phosphatidylserine (PS)-dependent thrombin generation, and cell membrane procoagulant PS (18:0;20:4 and 18:0;18:1) were the most abundant lipids found in LEVs. Further, LEVs showed activated coagulation in protein pathway analyses, while SEVs demonstrated high levels of cholesterol esters and a protein pathway analysis that identified complement factors and inflammation. We suggest that thrombin potential of EVs from both stable pediatric and adult SCD patients is similarly dependent on size and show lipid and protein contents that identify underlying markers of coagulation and inflammation.

The collapse of an abdominal aortic endograft is a rare event. We present the case of a 60-year-old man with an abdominal endograft who came to the emergency department with chest, back, abdominal, and lower extremity pain in addition to a cool left foot. On imaging, he was found to have a type B aortic dissection and a collapsed abdominal endograft. Subsequently, the patient was taken to the operating room and treated with a thoracic endovascular aortic repair, abdominal aortic cuff, and an iliac stent. Our study details this case and thoroughly reviews similar cases in the literature.

Objectives:. This study tests the null hypotheses that overall sentiment and gendered words in verbal feedback and resident operative autonomy relative to performance are similar for female and male residents. Background:. Female and male surgical residents may experience training differently, affecting the quality of learning and graduated autonomy. Methods:. A longitudinal, observational study using a Society for Improving Medical Professional Learning collaborative dataset describing resident and attending evaluations of resident operative performance and autonomy and recordings of verbal feedback from attendings from surgical procedures performed at 54 US general surgery residency training programs from 2016 to 2021. Overall sentiment, adjectives, and gendered words in verbal feedback were quantified by natural language processing. Resident operative autonomy and performance, as evaluated by attendings, were reported on 5-point ordinal scales. Performance-adjusted autonomy was calculated as autonomy minus performance. Results:. The final dataset included objective assessments and dictated feedback for 2683 surgical procedures. Sentiment scores were higher for female residents (95 [interquartile range (IQR), 4–100] vs 86 [IQR 2–100]; P < 0.001). Gendered words were present in a greater proportion of dictations for female residents (29% vs 25%; P = 0.04) due to male attendings disproportionately using male-associated words in feedback for female residents (28% vs 23%; P = 0.01). Overall, attendings reported that male residents received greater performance-adjusted autonomy compared with female residents (P < 0.001). Conclusions:. Sentiment and gendered words in verbal feedback and performance-adjusted operative autonomy differed for female and male general surgery residents. These findings suggest a need to ensure that trainees are given appropriate and equitable operative autonomy and feedback.

The patient was a 58-year-old man with a history of hypertension who had incidentally been found to have a 2.7-cm dissecting fusiform superior mesenteric artery aneurysm involving a long segment of a proximal to distal superior mesenteric artery. Double-lumen anatomy was present, with the true lumen perfusing the proximal and mid-small bowel and the false lumen perfusing the distal small bowel and the ileocolic artery. The patient elected to undergo endovascular repair using double-barrel stenting with self-expanding and balloon-expandable covered stents, as described. Computed tomography angiography after 1 year demonstrated patent stents.

Background:. Seroma formation is the most common complication after mastectomy. While the exact pathophysiology behind seroma development has not been entirely elucidated, seromas are associated with negative outcomes in breast reconstruction. The utilization of drains is one method to combat seroma. However, the current state of plastic surgery is divided as to whether one drain or two drains is optimal in reducing seroma formation. We hypothesized that using two drains instead of one drain would reduce the risk of seroma more so than one drain. Methods:. This was a retrospective cohort study of patients who underwent prepectoral direct to implant reconstruction at a single institution by a single surgeon. Each patient underwent reconstruction with either one or two drains. Patients were followed postoperatively for rates of seroma formation. Seroma were classified as either minor or major. Secondary variables including drain duration, infection, and necrosis were also analyzed. Results:. A total of 99 breasts and 71 patients experienced breast reconstruction with two drains, and 163 breasts corresponding to 135 patients received reconstruction with one drain. In the two drain cohort, 14 (14.1%) developed a seroma, with 11 (11.1%) being minor seromas and three (3.03%) being major seromas. In comparison, out of the one drain cohort, 41 (25.2%) developed a seroma, with 35 (21.5%) being a minor seroma and six (3.68%) being classified as major. Conclusion:. This study suggests that two drains decreases the rate and risk of seroma formation compared to one drain in prepectoral breast reconstruction with an acellular dermal matrix.

Background:. Negative-pressure wound therapy (NPWT) has improved split-thickness skin graft (STSG) survival rates, but prolonged application increases bacterial bioburden. Antimicrobial NPWT adjuncts have demonstrated efficacy, but strong evidence is lacking. We hypothesized that simultaneously replacing NPWT dressings within 48–72 hours and cleansing with Dakin's solution—a well-known antimicrobial agent—would increase STSG take. Methods:. We performed a controlled retrospective case series on three groups of STSG patients treated between January 2014 and December 2020: bolster dressings, continuous NPWT (C-NPWT), and Dakin's NPWT (D-NPWT). Patients with documented measurements of STSG survival were included. The primary outcome was the percentage of STSG take calculated by survival area using surgical tape measures 2 weeks after surgery. Results:. Fifty-nine patients were followed up for greater than or equal to 3 months. Average wound size for bolsters was smaller than that for D-NPWT (83 cm2 versus 204 cm2; P < 0.05). Average treatment time was 6.4 ± 2.4 days (bolsters), 6.5 ± 0.9 days (C-NPWT), and 2.8 ± 0.9 days (D-NPWT; P < 0.01). Average percentage of STSG take was 92% ± 0% (bolsters), 82% ± 0% (C-NPWT), and 99% ± 0% (D-NPWT; P < 0.01); there were significant differences between bolsters versus C-NPWT (P < 0.05) and C-NPWT versus D-NPWT (P < 0.05), but not between bolsters and D-NPWT. Conclusions:. Interrupting NPWT with 0.125% Dakin’s solution cleansing is associated with increased STSG survival compared with standard NPWT protocols, but not bolster dressings. These findings warrant further investigation due to limitations of this retrospective case series.

الملخص: يعتبر فرط نشاط جارة الدرقية الأولي الناجم عن ورم غدد جارات الدرقية خارج مكانها المعتاد في منطقة المنصف اكتشافا نادرا. نقدم هنا حالة من فرط نشاط جارة الدرقية الأولي الناجم عن ورم غدد جارات الدرقية خارج مكانها المعتاد يقع في منطقة المنصف لرجل يبلغ من العمر ٧٥ عاما. بداية تمت إحالة هذا المريض إلى العيادة للتحقيق في ارتفاع نسبة الكالسيوم في الدم الذي تم تشخيصه صدفة. وأظهر تصويره الأولي غدتين مشبوهتين، واحدة مجاورة للغدة الدرقية والأخرى في منطقة المنصف. عند التحقق بدراسات متكررة وإضافية، تم تحديد الغدة المنصفية لوحدها فقط باعتبارها الغدة المشبوهة المحتملة لورم غدة جارة الدرقية وتم التأكيد على ذلك بعد اعتدال مستويات هرمون الغدة جارة الدرقية بعد الاستئصال الجراحي. يمكن أن يكون التشخيص الدقيق لمثل هذه الحالات أمرا صعبا؛ واستخدام دراسة أشعة واحدة مثل التصوير بالموجات فوق الصوتية أو التصوير المقطعي المحوسب أو التصوير النووي وحده قد لا يؤدي إلى نتائج قاطعة أو يمكن أن يعطي نتائج إيجابية خاطئة. توضح حالتنا أن طرق التصوير المتعددة المستخدمة مجتمعة يمكن أن تؤدي إلى تشخيص دقيق لسبب فرط نشاط جارات الدرقية الأولي. وبالتالي يؤدي ذلك إلى تجنيب المرضى إجراءات استئصال جراحية إضافية غير ضرورية أو من ناحية أخرى، تقليل فرص نسيان مصادر أخرى للإفراز خارج مكانها المعتاد. Abstract: Primary hyperparathyroidism caused by an ectopic parathyroid adenoma in the mediastinum is a rare clinical condition. We present a 75-year-old male with primary hyperparathyroidism caused by an ectopic parathyroid adenoma in the mediastinum. This patient was initially referred to the clinic for suspected incidental hypercalcemia. Initial imaging showed two suspicious lesions: one adjacent to the thyroid gland and another in the mediastinum. Further investigations identified a sole mediastinal adenoma. The diagnosis was confirmed by normalization of parathyroid hormone levels after its surgical resection. Thoroughly diagnosing such cases can prove challenging and using a single modality such as ultrasonography, computed tomography, or nuclear imaging alone may not yield conclusive findings or can give false positive results. Our case demonstrates that a combination of several imaging modalities can lead to accurate localization of the cause of primary hyperparathyroidism. This will obviate the performance of unnecessary surgical procedures. In addition, the possibility of missing additional sources of ectopic secretions of the parathyroid hormone will be reduced.

A 66-year-old man with refractory multiple myeloma presented with acute severe aortic insufficiency leading to cardiogenic shock and multiorgan failure. After comprehensive heart team evaluation, he underwent successful JenaValve transcatheter aortic valve (JenaValve Technology, Inc., Irvine, California) implantation resulting in resolution of his aortic insufficiency and improvement in his clinical status. (Level of Difficulty: Advanced.)

Aortic intramural hematoma accounts for 5% to 20% of patients with acute aortic syndrome. Endovascular grafts have evolved as minimally invasive alternatives for treatment in some highly selected patients. We present the case of a patient who had late complications of a chronic Stanford type A intramural hematoma requiring thoracic endovascular aortic repair. (Level of Difficulty: Beginner.)

In select patients, transcatheter pulmonary valve replacement through a percutaneous approach can be challenging because of complicated anatomy or small patient size. In these patients, especially those weighing

Purpose: Radiation of the draining lymph node basin remains controversial for Merkel cell carcinoma, particularly in the era of sentinel lymph node biopsy (SLNB). Methods and Materials: Based on a 20-year experience using SLNB-guided adjuvant radiation therapy (RT), we conducted a retrospective review of clinically node-negative patients testing 2 hypotheses: (1) whether nodal RT could be safely omitted in SLNB-negative Merkel cell carcinoma and (2) whether the excised primary site should always be radiated. Clinically node-positive patients were excluded. Results: Among 57 clinically node-negative patients who underwent SLNB and wide local excision (WLE), 42 (74%) had a negative SLNB, and 15 (26%) had a positive SLNB. At a median follow-up of 43 months (range, 5-182), SLNB-negative patients irradiated to the primary site had improved 4-year disease-specific survival (100% vs 65%, P = .008), local recurrence-free survival (100% vs 76%, P = .009), and distant recurrence-free survival (100% vs 75%, P = .008), but not overall survival (87.5% vs 57.7%, P = .164) compared with SLNB-positive patients receiving comprehensive RT. Among SLNB-negative patients treated with WLE only, 67% (6/9) had a disease relapse, half of which were local relapses (33%). Conclusions: In this single-institution retrospective review, after negative SLNB and WLE, RT given only to the primary site provided 100% disease control without a need for nodal RT. Among SLNB-negative patients who had WLE, omission of postoperative primary-site RT was associated with 67% cancer relapse, of which half was local.

Coinfection can markedly alter the response to a pathogen, thereby changing its clinical presentation. For example, non-typhoidal Salmonella (NTS) serotypes are associated with gastroenteritis in immunocompetent individuals. In contrast, individuals with severe pediatric malaria can develop bacteremic infections with NTS, during which symptoms of gastroenteritis are commonly absent. Here we report that, in both a ligated ileal loop model and a mouse colitis model, malaria parasites caused a global suppression of gut inflammatory responses and blunted the neutrophil influx that is characteristic of NTS infection. Further, malaria parasite infection led to increased recovery of Salmonella enterica serotype Typhimurium from the draining mesenteric lymph node (MLN) of mice. In the mouse colitis model, blunted intestinal inflammation during NTS infection was independent of anemia but instead required parasite-induced synthesis of interleukin (IL)-10. Blocking of IL-10 in coinfected mice reduced dissemination of S. Typhimurium to the MLN, suggesting that induction of IL-10 contributes to development of disseminated infection. Thus IL-10 produced during the immune response to malaria in this model contributes to suppression of mucosal inflammatory responses to invasive NTS, which may contribute to differences in the clinical presentation of NTS infection in the setting of malaria.

Chest pain is commonly reported in emergency departments, and a thorough clinical history is important in distinguishing the etiology. This case highlights Kounis syndrome, a histamine-mediated coronary vasospasm leading to myocardial injury, due to scombroid fish poisoning. (Level of Difficulty: Beginner.)

Transradial access has been used for percutaneous coronary interventions with success; however, there is limited literature on its use for visceral stenting in the setting of complex endovascular aneurysm repair. We present a case of transradial left renal salvage after renal artery thrombosis in the setting of complex endovascular aneurysm repair. Keywords: Transradial, Endovascular, Aortic, Renal

OBJECTIVES:. We sought to validate prognostic scores in coronavirus disease 2019 including National Early Warning Score, Modified Early Warning Score, and age-based modifications, and define their performance characteristics. DESIGN:. We analyzed prospectively collected data from the Adaptive COVID-19 Treatment Trial. National Early Warning Score was collected daily during the trial, Modified Early Warning Score was calculated, and age applied to both scores. We assessed prognostic value for the end points of recovery, mechanical ventilation, and death for score at enrollment, average, and slope of score over the first 48 hours. SETTING:. A multisite international inpatient trial. PATIENTS:. A total of 1,062 adult nonpregnant inpatients with severe coronavirus disease 2019 pneumonia. INTERVENTIONS:. Adaptive COVID-19 Treatment Trial 1 randomized participants to receive remdesivir or placebo. The prognostic value of predictive scores was evaluated in both groups separately to assess for differential performance in the setting of remdesivir treatment. MEASUREMENTS AND MAIN RESULTS:. For mortality, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.60–0.68), and improved with addition of age (c-index, 0.66–0.74). For recovery, baseline National Early Warning Score and Modified Early Warning Score demonstrated somewhat better prognostic ability (c-index, 0.65–0.69); however, National Early Warning Score+age and Modified Early Warning Score+age further improved performance (c-index, 0.68–0.71). For deterioration, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.59–0.69) and improved with addition of age (c-index, 0.63–0.70). All prognostic performance improvements due to addition of age were significant (p < 0.05). CONCLUSIONS:. In the Adaptive COVID-19 Treatment Trial 1 cohort, National Early Warning Score and Modified Early Warning Score demonstrated moderate prognostic performance in patients with severe coronavirus disease 2019, with improvement in predictive ability for National Early Warning Score+age and Modified Early Warning Score+age. Area under receiver operating curve for National Early Warning Score and Modified Early Warning Score improved in patients receiving remdesivir versus placebo early in the pandemic for recovery and mortality. Although these scores are simple and readily obtainable in myriad settings, in our data set, they were insufficiently predictive to completely replace clinical judgment in coronavirus disease 2019 and may serve best as an adjunct to triage, disposition, and resourcing decisions.