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Background: Lateral epicondylitis is the most common cause of lateral elbow pain in adults, and nonoperative treatment is the first-line management modality of choice. Pain refractory to conservative management may improve with surgical interventions involving extensor carpi radialis brevis débridement or denervation. This investigation was conducted to evaluate the long-term analgesic efficacy, incidence of postoperative sensory deficits, and postoperative elbow functionality in patients who underwent a denervation surgery of the posterior branch of the posterior cutaneous nerve of the forearm (PBPCNF) for refractory lateral epicondylitis. Methods: This investigation was an institutional review board–approved, single-center, single-surgeon case series of 22 patients who underwent denervation surgery with an average final follow-up of 4.7 years. Inclusion criteria for surgery were a minimum of 6 months symptom duration refractory to conservative therapies, a minimum of 2 years clinical follow-up, and significant (70-80%) pain relief from the nerve block test. Visual Analog Scale pain and Single Assessment Numeric Evaluation scores were used to assess pain and function, respectively. The incidence of postoperative sensory deficits was evaluated via clinical exam. Results: Compared to the preoperative average, the cohort’s mean Visual Analog Scale pain was significantly decreased at all postoperative follow-up intervals, including 2 weeks, 1 year, and final average follow-up of 4.7 years. At the final follow-up, the mean Single Assessment Numeric Evaluation score was 98.8 ± 2.6, and one patient (4.5%), who reported the same sensory deficit preoperatively, reported postoperative sensory deficits. Conclusion: The PBPCNF denervation procedure is a highly efficacious procedure for achieving long-term pain control in the treatment of refractory lateral epicondylitis. The PBPCNF denervation procedure affords patients a high level of postoperative functionality with a low incidence of sensory deficits.

BACKGROUND:. Early diagnostic uncertainty for infection causes delays in antibiotic administration in infected patients and unnecessary antibiotic administration in noninfected patients. OBJECTIVE:. To develop a machine learning model for the early detection of untreated infection (eDENTIFI), with the presence of infection determined by clinician chart review. DERIVATION COHORT:. Three thousand three hundred fifty-seven adult patients hospitalized between 2006 and 2018 at two health systems in Illinois, United States. VALIDATION COHORT:. We validated in 1632 patients in a third Illinois health system using area under the receiver operating characteristic curve (AUC). PREDICTION MODEL:. Using a longitudinal discrete-time format, we trained a gradient boosted machine model to predict untreated infection in the next 6 hours using routinely available patient demographics, vital signs, and laboratory results. RESULTS:. eDENTIFI had an AUC of 0.80 (95% CI, 0.79–0.81) in the validation cohort and outperformed the systemic inflammatory response syndrome criteria with an AUC of 0.64 (95% CI, 0.64–0.65; p < 0.001). The most important features were body mass index, age, temperature, and heart rate. Using a threshold with a 47.6% sensitivity, eDENTIFI detected infection a median 2.0 hours (interquartile range, 0.9–5.2 hr) before antimicrobial administration, with a negative predictive value of 93.6%. Antibiotic administration guided by eDENTIFI could have decreased unnecessary IV antibiotic administration in noninfected patients by 10.8% absolute or 46.4% relative percentage points compared with clinicians. CONCLUSION:. eDENTIFI could both decrease the time to antimicrobial administration in infected patients and unnecessary antibiotic administration in noninfected patients. Further prospective validation is needed.

Introduction: Emerging literature links fatherhood to men's health but lacks comprehensive assessment of health outcomes, especially among multiethnic populations. This study's objective was to evaluate the associations of fatherhood (age at onset and status) with cardiovascular health scores, incident cardiovascular disease, cardiovascular disease death, and all-cause mortality, examining differences by race/ethnicity. Methods: The study sample included men from Multi-Ethnic Study of Atherosclerosis, prospective cohort study that enrolled adults aged 45–84 years without known cardiovascular disease at baseline. Cardiovascular health was defined using the American Heart Association's Life's Essential 8 scores (0–100), excluding sleep (cardiovascular health score). Results: In this sample of 2,814 men, mean age at cardiovascular health assessment was 62.2 years, 82% were fathers, 24% self-identified as Black, 13% self-identified Chinese, 22% self-identified Hispanic, and 41% self-identified White. Fathers who were aged 35 years (adjusted mean score of 61.1 vs 64.7 [p=0.01] and 61.0 vs 64.7 [p

Background: Twin pregnancies are associated with higher risks of adverse neonatal outcomes compared to singleton pregnancies. The choice of delivery mode, when twin A presents cephalic, remains a subject of debate. In low- and middle-income countries, where healthcare resources are limited, the decision on the mode of delivery is even more critical. Objective: To evaluate the neonatal outcomes and the hospital costs of planned vaginal delivery compared to cesarean section (CS) in twin pregnancies with twin A presenting cephalic at Tenwek Hospital, Kenya. Study Design: This retrospective cohort study analyzed data from all twin deliveries at Tenwek Hospital, Kenya from, April 1, 2017, to March 30, 2023. Maternal data, mode of delivery, and neonatal data were collected from delivery logs, electronic health records, and neonatal records. Neonatal outcomes were a composite of either Appearance, Pulse, Grimace, Activity, and Respiration score less than seven at 5 minutes, neonatal intensive care unit admission, resuscitation, birth trauma, or neonatal complications, including death before discharge from the hospital. A logistic regression model was created to assess the impact of the planned mode of delivery on neonatal outcomes, controlling for antenatal care clinic visits, noncephalic presentation of twin B, and birth weight category. Results: The study included 177 twin deliveries: 129 (72.9%) were planned as vaginal deliveries and 48 (27.1%) were planned for CS. Among the planned vaginal deliveries, 66 (51.2%) experienced adverse outcomes, compared to 14 (29.2%) in the CS group (P=.009). Logistic regression showed that the odds of adverse outcomes were 0.35 times lower in the CS group compared to the planned vaginal delivery group (95% CI: 0.15–0.83; P=.017). The average total hospital costs for planned vaginal delivery were 104,608 Kenya Shillings (standard deviation 111,761) compared to 100,708 Kenya Shillings (standard deviation 75,468) for CS (P=.82). Conclusion: Planned cesarean deliveries in twin pregnancies with twin A presenting cephalic at Tenwek Hospital were associated with fewer adverse neonatal outcomes compared to planned vaginal deliveries. There was no significant difference in hospital costs. These findings raise the question of the safest mode of delivery for patients in a resource-constrained setting.

Background/Objective: Patients with systemic mastocytosis are at high risk of developing osteoporosis and fractures. Herein, we report a case of hip fragility fracture in a patient with indolent systemic mastocytosis and normal bone density. Case Report: A 48-year-old man experienced a left femoral neck fracture after a fall. After a dose of oxycodone/hydromorphone postoperatively, he developed an anaphylactic reaction. Previously, he experienced a few other episodes of flushing, dizziness, and syncope precipitated by stress and alcohol. His examination was notable for pink and brown macules on his chest, back, arms, and legs. His laboratory test revealed a markedly elevated tryptase level of 171 ng/mL (

Objective: To investigate the impact of corneal photograph quality on convolutional neural network (CNN) predictions. Design: A CNN trained to classify bacterial and fungal keratitis was evaluated using photographs of ulcers labeled according to 5 corneal image quality parameters: eccentric gaze direction, abnormal eyelid position, over/under-exposure, inadequate focus, and malpositioned light reflection. Participants: All eligible subjects with culture and stain-proven bacterial and/or fungal ulcers presenting to Aravind Eye Hospital in Madurai, India, between January 1, 2021 and December 31, 2021. Methods: Convolutional neural network classification performance was compared for each quality parameter, and gradient class activation heatmaps were generated to visualize regions of highest influence on CNN predictions. Main Outcome Measures: Area under the receiver operating characteristic and precision recall curves were calculated to quantify model performance. Bootstrapped confidence intervals were used for statistical comparisons. Logistic loss was calculated to measure individual prediction accuracy. Results: Individual presence of either light reflection or eyelids obscuring the corneal surface was associated with significantly higher CNN performance. No other quality parameter significantly influenced CNN performance. Qualitative review of gradient class activation heatmaps generally revealed the infiltrate as having the highest diagnostic relevance. Conclusions: The CNN demonstrated expert-level performance regardless of image quality. Future studies may investigate use of smartphone cameras and image sets with greater variance in image quality to further explore the influence of these parameters on model performance. Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Category: Hindfoot; Ankle Introduction/Purpose: Insertional Achilles Tendinopathy (IAT) is a degenerative process at the insertion of Achilles tendon onto the calcaneal tuberosity that often coexists with retrocalcaneal bursitis and Haglund’s deformity. The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with IAT that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT. Methods: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95% confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). Results: Ten studies with 232 patients were included. The AOFAS (American Orthopaedic Foot and Ankle Society) Ankle- Hindfoot Score and the VISA-A score (Victorian Institute of Sports of Australia-Achilles score) were significantly improved after the Zadek osteotomy (p < 0.00001). Pain levels were also significantly reduced (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia. Conclusion: The Zadek osteotomy is a safe and effective procedure for patients with IAT. The osteotomy improves pain levels and functions and is associated only with minor complications and a low complication rate. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.

OBJECTIVES:. While opioids are part of usual care for analgesia in the ICU, there are concerns regarding excess use. This is a systematic review of nonsteroidal anti-inflammatory drugs (NSAIDs) use in postoperative critical care adult patients. DATA SOURCES:. We searched Medical Literature Analysis and Retrieval System Online, Excerpta Medica database, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, trial registries, Google Scholar, and relevant systematic reviews through March 2023. STUDY SELECTION:. Titles, abstracts, and full texts were reviewed independently and induplicate by two investigators to identify eligible studies. We included randomized control trials (RCTs) that compared NSAIDs alone or as an adjunct to opioids for systemic analgesia. The primary outcome was opioid utilization. DATA EXTRACTION:. In duplicate, investigators independently extracted study characteristics, patient demographics, intervention details, and outcomes of interest using predefined abstraction forms. Statistical analyses were conducted using Review Manager software Version 5.4. (The Cochrane Collaboration, Copenhagen, Denmark). DATA SYNTHESIS:. We included 15 RCTs (n = 1,621 patients) for admission to the ICU for postoperative management after elective procedures. Adjunctive NSAID therapy to opioids reduced 24-hour oral morphine equivalent consumption by 21.4 mg (95% CI, 11.8–31.0 mg reduction; high certainty) and probably reduced pain scores (measured by Visual Analog Scale) by 6.1 mm (95% CI, 12.2 decrease to 0.1 increase; moderate certainty). Adjunctive NSAID therapy probably had no impact on the duration of mechanical ventilation (1.6 hr reduction; 95% CI, 0.4 hr to 2.7 reduction; moderate certainty) and may have no impact on ICU length of stay (2.1 hr reduction; 95% CI, 6.1 hr reduction to 2.0 hr increase; low certainty). Variability in reporting adverse outcomes (e.g., gastrointestinal bleeding, acute kidney injury) precluded their meta-analysis. CONCLUSIONS:. In postoperative critical care adult patients, systemic NSAIDs reduced opioid use and probably reduced pain scores. However, the evidence is uncertain for the duration of mechanical ventilation or ICU length of stay. Further research is required to characterize the prevalence of NSAID-related adverse outcomes.

Background: Multi-ligament knee injuries and knee dislocations are potentially devastating injuries that typically result in injury to both cruciate ligaments and variable injury to collateral ligament complexes. Indications: Surgical intervention typically leads to better patient outcomes than nonoperative management. We describe our preferred technique for bicruciate ligament reconstruction with a focus on double-bundle posterior cruciate ligament (PCL) reconstruction. Technique Description: A transtibial approach is used to drill the PCL tibial tunnel. A safety incision on the proximal medial tibia, which may incorporate the distal aspect of a medial-sided incision for medial collateral ligament (MCL) reconstruction, allows palpation of the PCL fovea for anatomic tunnel placement, protection of the posterior neurovascular structures, and egress of arthroscopic fluid during the case. This technique uses an inside-out approach for creation of the 2 femoral sockets to recreate the 2 PCL bundles. The grafts are passed in antegrade fashion, with passage and femoral fixation of the posteromedial (PM) bundle followed by the anterolateral (AL) bundle. After passage of the anterior cruciate ligament (ACL) graft and fixation on the femur in standard fashion, attention is turned to PCL tibia-sided fixation. We use a screw and spiked washer to fix the AL bundle at 90° of flexion with an anterior drawer maneuver. The PM bundle is then fixed with a polyetheretherketone (PEEK) interference screw in near full extension. Fixation of the ACL on the tibia in standard fashion completes the bicruciate ligament reconstruction. Results: In biomechanical cadaveric studies, double-bundle PCL reconstruction has been shown to more closely approximate native knee kinematics, with more restraint to posterior translation at all knee flexion angles and less internal rotation laxity at higher knee flexion angles. In clinical results, both single-bundle and double-bundle reconstructions improve knee stability and patient-reported outcomes. Double-bundle PCL reconstruction may provide improved objective posterior tibial stability and objective International Knee Documentation Committee (IKDC) scores. Discussion: Double-bundle PCL reconstruction can be performed efficiently with good outcomes and potentially less residual posterior translation or internal rotation laxity than single-bundle PCL reconstruction. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: There is debate regarding the efficacy of intra-articular (IA) hyaluronic acid (HA) injections for the management of knee osteoarthritis (OA). This study aimed to determine if IA HA utilization and payer coverage of viscosupplementation affected the prevalence of total knee arthroplasty (TKA) procedures and the age of TKA patients. Methods: We performed a retrospective analysis from 2014 to 2020 using a large national commercial claims data set. We analyzed the number of TKA procedures and the age of the patients in states that covered IA HA vs those with limited coverage. Mixed random effects and slopes models were used to identify the impact of the IA HA injections. Results: Of 7,335,301 patients with knee OA, 440,606 (6.0%) received a TKA procedure at an average age of 59 years. The rate of TKA procedures increased by 0.56% per year (95% confidence interval [CI] 0.46-0.66; P < .001). Payer coverage of IA HA injections had no effect on TKA prevalence (P = .926). The age of surgical patients increased yearly by 0.15 years (95% CI 0.12-0.18; P < .001), regardless of IA HA injections (P = .990). After controlling for demographics and comorbidities, patients that received an IA HA injection had a higher probability of receiving a subsequent TKA (odds ratio = 2.83; 95% CI 2.80-2.87; P < .001); this finding was conditional of patients' age at the first diagnosis of knee OA. Conclusions: Additional clinical trials should be employed to identify the role of HA injections in the treatment armamentarium for knee OA.

Background: Nonalcoholic fatty liver disease (NAFLD) is the most common liver disorder in Western industrialized countries and may progress to liver injury. Cortisol is thought to play a role in the pathogenesis of NAFLD, and cortisol modulation has shown efficacy in preclinical models. However, published reports on the clinical effects of glucocorticoid receptor antagonism in these patients are limited. Case Report: Two women (aged 66 and 60 years) with endogenous hypercortisolism presented with a history of hepatic steatosis, hypertension, type 2 diabetes mellitus, and dyslipidemia. Both patients declined adrenalectomy or pituitary tumor surgery, and treatment with mifepristone 300 mg daily was initiated. During mifepristone treatment (follow up durations ranging from 10 months to 5 years), improvements in hypercortisolism-related cardiometabolic abnormalities were observed, including the normalization of lipid levels and improvement of hyperglycemia. In both cases, findings on follow-up imaging revealed resolution of fatty liver, which was supported by a decrease in liver enzymes on liver function tests. No adverse events were reported. Discussion: NAFLD is frequently observed in patients with endogenous hypercortisolism. Improvement in liver function tests has previously been demonstrated in patients with hypercortisolism treated with mifepristone. The present cases showed, for the first time, radiological improvement of liver steatosis following mifepristone use in patients with hypercortisolism and NAFLD. Conclusion: This case series demonstrated improvements in biochemical and imaging parameters of NAFLD in patients with hypercortisolism treated with mifepristone. Further research is needed to investigate the effects of glucocorticoid receptor modulation in fatty liver disease.

Objective:. We aimed to determine the impact of a standardized curriculum on learning outcomes for surgical trainees in East, Central, and Southern Africa (ECSA). Background:. As surgical education expands throughout ECSA, there is a recognized need for a standardized curriculum. We previously described the design of a novel, large-scale, flipped-classroom, surgical curriculum for trainees in ECSA. Methods:. In January 2020, the first year of curricular content for trainees of the College of Surgeons of ECSA was released, containing 11 monthly thematic topics, each with 2 to 5 weekly modular subtopics. We aimed to evaluate 3 outcomes utilizing data sources incorporated into the curriculum structure. Learner engagement was assessed by the number of trainees completing curriculum topics. User experience was evaluated using quantitative and qualitative feedback responses to embedded surveys for each content week. Curriculum impact on trainee examination performance was assessed by comparing certification examination scores stratified by the number of curricular topics each trainee completed. Results:. Two hundred seventy-one trainees (96%) in 17 countries accessed at least 1 weekly module. Trainees completed a median of 9 topics (interquartile range: 6–10). The feedback survey response rate was 92% (5742/6233). Quantitative and qualitative responses were positive in overall module value (93.7% + 2.6%), amount of learning experienced (97.9% + 1.4%), confidence in achieving learning objectives (97.1% + 2.4%), and ease of use of the module (77.6% + 5.98%). Topic-related certification examination performance improved significantly with increased completion of thematic topics. Conclusions:. A standardized surgical curriculum in ECSA demonstrated excellent trainee usage, positive feedback, and improved examination scores.

Objective:. We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data:. Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods:. We utilized Kern’s 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results:. Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions:. We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

A preadolescent female presented to the emergency department with an acute asthma exacerbation. Chest radiograph and computed tomography scan showed extensive pneumomediastinum with a small pneumopericardium without a distinct source for this air leak. The patient was admitted for noninvasive monitoring, analgesia, and high concentration oxygen. Serial chest radiographs showed marked improvement following high concentration oxygen, and she was discharged on hospital day 3. Spontaneous pneumomediastinum and pneumopericardium are rare complications of asthma that can often be managed conservatively but should be considered on the differential for this patient population, and may be a complication of COVID-19.

Background: Climate change is broadly affecting human health, with grave concern that continued warming of the earth’s atmosphere will result is serious harm. Since the mid-20th century, skin cancer incidence rates have risen at an alarming rate worldwide. Objective: This review examines the relationship between climate change and cutaneous carcinogenesis. Methods: A literature review used the National Institutes of Health databases (PubMed and Medline), the Surveillance, Epidemiology, and End Results and International Agency for Research on Cancer registries, and published reports by federal and international agencies and consortia, including the Australian Institute of Health and Welfare, Climate and Clean Air Coalition, U.S. Environmental Protection Agency, Intergovernmental Panel on Climate Change, National Aeronautics and Space Administration, National Oceanic and Atmospheric Administration, United Nations Environment Programme, World Health Organization, and World Meteorological Organization. Results: Skin cancer risk is determined by multiple factors, with exposure to ultraviolet radiation being the most important. Strong circumstantial evidence supports the hypothesis that factors related to climate change, including stratospheric ozone depletion, global warming, and ambient air pollution, have likely contributed to the increasing incidence of cutaneous malignancy globally and will continue to impose a negative on influence skin cancer incidence for many decades to come. Conclusion: Because much of the data are based on animal studies and computer simulations, establishing a direct and definitive link remains challenging. More epidemiologic studies are needed to prove causality in skin cancer, but the evidence for overall harm to human health as a direct result of climate change is clear. Global action to mitigate these negative impacts to humans and the environment is imperative.

A 50-year-old male presented with atrial flutter 25 days after heart and kidney transplantation. Rejection was excluded, but he developed severe COVID-19 infection with cardiac allograft dysfunction. Despite continued corticosteroid and tacrolimus therapy, he remained aviremic. Respiratory and myocardial functions recovered after a week of mechanical ventilation. The cardiomyopathy was stress induced. (Level of Difficulty: Advanced.)

Meningioma represents the most frequently diagnosed primary brain tumor, accounting for over one-third of central nervous system neoplasms. The majority of tumors are categorized as benign. However, albeit rarely, meningiomas may metastasize to distant sites. We describe a 78-year-old man with a history of recurrent World Health Organization grade I meningioma managed who presented for evaluation of weakness and urinary retention. A computed tomography scan obtained in the emergency department revealed multiple scattered low-density liver lesions. Subsequent magnetic resonance imaging showed a 5.5-centimeter heterogeneous enhancing mass with 2 smaller enhancing lesions suspicious for a primary or secondary malignant neoplasm. Microscopic examination of a tissue sample obtained via liver biopsy demonstrated a metastatic spindle cell neoplasm with histologic features compatible with a diagnosis of World Health Organization grade I transitional meningioma. The patient was referred to hematology/oncology for systemic therapy. Keywords: Meningioma, Meningioma staging, Metastatic meningioma, Liver metastases, Central nervous system neoplasms, WHO grade I meningioma

OBJECTIVES:. Current guidance recommends initiation of early enteral nutrition (early EN) within 24–36 hours of ICU admission in critically ill COVID-19 patients. Despite this recommendation, there is quite limited evidence describing the effect of early EN on outcomes in COVID-19 patients. The association between early EN (within 3 d post intubation) and clinical outcomes in adult COVID-19 patients requiring mechanical ventilation (within 2 d post ICU admission) was evaluated. DESIGN:. We performed a nationwide observational cohort study using a nationwide administrative-financial database (Premier) in United States. SETTING:. Information pertaining to all COVID-19 patients admitted to ICU from 75 hospitals between April and December 2020 was analyzed. PATIENTS:. A total of 861 COVID-19 patients were included. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Clinical outcomes were assessed via regression models to control for patient and hospital characteristics. We identified 513 COVID-19 ICU patients (59.2%) requiring mechanical ventilation who received early EN and had similar baseline characteristics to late EN group. Compared with late EN group, the early EN group had shorter ICU (hazard ratio [HR], 1.39; 95% CI, 1.15–1.68) and hospital length of stays (LOS) (HR, 1.53; 95% CI, 1.23–1.91), fewer mechanical ventilation days (HR, 1.25; 95% CI, 1.01–1.54), and lower cost (–$22,443; 95% CI, –$32,342 to –$12,534). All comparisons were statistically significant (p < 0.05). CONCLUSIONS:. In patients with COVID-19 requiring mechanical ventilation, early EN is associated with earlier liberation from mechanical ventilation, shorter ICU and hospital LOS, and decreased cost. Our results are among the first to support guideline recommendations for initiation of early EN in COVID-19 ICU patients. Further, our data show nearly 40% of critically ill COVID-19 patients fail to have early EN initiated, even at 3 d post initiation of mechanical ventilation. These results emphasize the need for targeted strategies promoting initiation of early EN, as this may lead to improved clinical and economic outcomes in severe COVID-19 patients.

Aspirin overdose is still a common cause of presentation to the emergency department and is commonly seen in the setting of one-time, accidental or intentional ingestion of large amounts of salicylate-containing compounds, though can occur with long-term ingestion of super-therapeutic doses of medications. Salicylate toxicity has a predictable progression from early respiratory alkalosis to late metabolic acidosis. We present the case of a 14-year-old girl who intentionally ingested a handful of Aspirin and despite appropriate therapy, developed transient proximal tubule dysfunction. This case highlights the need for a change in the short-term medical management of children presenting with salicylate toxicity.

Objectives:. Since the beginning of the coronavirus disease 2019 pandemic, hundreds of thousands of patients have been treated in ICUs across the globe. The severe acute respiratory syndrome–associated coronavirus 2 virus enters cells via the angiotensin-converting enzyme 2 receptor and activates several distinct inflammatory pathways, resulting in hematologic abnormalities and dysfunction in respiratory, cardiac, gastrointestinal renal, endocrine, dermatologic, and neurologic systems. This review summarizes the current state of research in coronavirus disease 2019 pathophysiology within the context of potential organ-based disease mechanisms and opportunities for translational research. Data Sources:. Investigators from the Research Section of the Society of Critical Care Medicine were selected based on expertise in specific organ systems and research focus. Data were obtained from searches conducted in Medline via the PubMed portal, Directory of Open Access Journals, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, and Web of Science from an initial search from December 2019 to October 15, 2020, with a revised search to February 3, 2021. The medRxiv, Research Square, and clinical trial registries preprint servers also were searched to limit publication bias. Study Selection:. Content experts selected studies that included mechanism-based relevance to the severe acute respiratory syndrome–associated coronavirus 2 virus or coronavirus disease 2019 disease. Data Extraction:. Not applicable. Data Synthesis:. Not applicable. Conclusions:. Efforts to improve the care of critically ill coronavirus disease 2019 patients should be centered on understanding how severe acute respiratory syndrome–associated coronavirus 2 infection affects organ function. This review articulates specific targets for further research.

Schwannomas and Perineuromas are rare findings in the GI tract, especially in pediatric patients. They typically present in the fifth to sixth decade of life with a female predominance. In this case, we describe a 13-year-old female who presented with multiple GI complaints including weight loss and anemia. She was found to have an umbilicated mass in the lesser curvature of the stomach suspicious of a gastrointestinal stromal tumor (GIST). The mass was resected via a laparoscopic partial gastrectomy. The pathology report confirmed the diagnosis of a gastric hybrid schwannoma and perineuroma staining for EMA and S-100 protein.

Liposarcoma of the larynx is a rare entity, typically well differentiated with a good prognosis. We present a patient who presented to ENT clinic with a 3-month history of hoarseness. Contrast-enhanced computed tomography of the neck demonstrated a 2.5-cm mass of the true vocal cord, which biopsy demonstrated to be dedifferentiated liposarcoma of the larynx. The patient went on to total laryngectomy with planned adjuvant radiation therapy. The presentation and imaging findings of laryngeal liposarcoma are nonspecific, but this neoplasm should be considered in the differential of masses in the head and neck. Keywords: Liposarcoma, Larynx

Pneumocephalus and pneumorrhachis are related to transgression of the barriers to the central nervous system. We present a patient with a Pancoast tumor treated with palliative chemoradiation who developed symptomatic spinal and intracranial air caused by spontaneous bronchopleurodurosubarachnoid fistula secondary to direct tumor invasion into the thecal sac.

Background:. Complication rates following immediate breast reconstruction range from 4% to 60%. Mastectomy skin flap necrosis (MSFN) is often the sentinel event leading to secondary complications. Methods:. All patients undergoing immediate reconstruction were enrolled. Upon mastectomy completion, the surgeon visually interpreted the skin flaps, performed laser-assisted indocyanine green angiography (LAIGA), and intervened if needed. Patients were followed for 90 days, documenting skin necrosis, infection, seroma, hematoma, implant loss, and reoperation. Results:. There were 126 patients who had 206 immediate breast reconstructions. The complication rate was 22.3%. The incidence of MSFN was 14.1%. The reoperation rate was 8.7%. There was 1 necrosis-related implant loss. Postoperative surveys were completed on 193 breasts: 137 had visual and LAIGA interpretation of well or adequately perfused, resulting in 5.8% rate of necrosis, 2 reoperations, and no implant losses. Twenty breasts had visual and LAIGA interpretation of marginal or poor perfusion. Sixteen of these underwent intervention. The necrosis rate in this group was 35% with no implant losses. A third group with 26 breasts had adequate visual interpretation with marginal or poor perfusion on LAIGA. Ten breasts had no intervention, and 16 received intervention. The overall necrosis rate in this group was 42.3%, with 4 reoperations for necrosis and 1 implant loss. Conclusions:. LAIGA can more accurately predict complications from MSFN than surgeon assessment alone. When surgeon decision making is supplemented with LAIGA, it reduces the incidence of MSFN, infection, implant loss, and overall unexpected reoperation rate. LAIGA is a valuable adjunct for intraoperative decision making.

Background. Rabbit antithymocyte globulin (rATG) is the most widely used kidney transplant induction immunotherapy in the United States. It was recently Food and Drug Administration approved for this indication with typical dose recommendations of 1.5 mg/kg for up to 7 days given via a central line. Methods. We theorized that reduced rATG dosing when compared with conventional dosing (6-10.5 mg/kg) is safe and effective, leading to development of a risk-stratified treatment protocol. Five-year data from a retrospective cohort of 224 adult kidney transplants (2008-2013) with follow-up through 2015 is presented. Cumulative rATG doses of 3 mg/kg were administered peripherally to nonsensitized living donor recipients, 4.5 mg/kg to nonsensitized deceased donor recipients. A subset of higher immunologic risk recipients (defined as history of prior transplant, panel reactive antibody greater than 20%, or flow cytometry crossmatch positivity) received 6 mg/kg. Results. There were no differences in patient or graft survival between the 3 groups. One-year rejection rates in the first 2 groups were 8.3% and 8.8%, respectively, comparable to contemporaneous rates reported to the Scientific Registry of Transplant Recipients. Dose tailoring permitted substantial cost savings estimated at US $1 091 502. Mean length of stay fell by almost 3 days as the protocol was refined. There were no episodes of phlebitis. Infection rates were comparable with those reported to the Scientific Registry of Transplant Recipients. Conclusions. The novel findings of the current study include peripheral administration, reduced dosing, favorable safety, excellent allograft outcomes, and clear associative data regarding reduced costs and length of stay.

Introduction: Conditions mimicking penile fracture are extremely rare and have been seldom described. Aim: To describe a patient with false penile fracture who presented with superficial dorsal vein injury/thrombosis managed with ligation. Methods: A 33‐year‐old male presented with penile swelling and ecchymosis after intercourse. A penile ultrasound demonstrated a thrombosed superficial dorsal vein but also questionable fracture of the tunica albuginea. As the thrombus was expanding, he was emergently taken to the operating room for exploration and required only dorsal venous ligation. Results: Postoperatively, patient's Sexual Health Inventory for Men score was 23, and he had no issues with erections or sexual intercourse. Conclusion: Early exploration of patients with suspected penile fracture provides excellent results with maintenance of erectile function. Also, in the setting of dorsal vein thrombosis, ligation preserves the integrity of the penile tissues and avoids unnecessary complications from conservative management. Rafiei A, Hakky TS, Martinez D, Parker J, and Carrion R. Superficial dorsal vein injury/thrombosis presenting as false penile fracture requiring dorsal venous ligation. Sex Med 2014;2:182–185.

Cholestasis is a general feature of intrahepatic or extrahepatic biliary obstruction by various mechanisms including cirrhosis, stricture, choledocholithiasis, hepatitis, and neoplasms. Neoplasms can directly impinge on the hepatobiliary tree resulting in bile stasis. Stauffer’s syndrome is another variant of this neoplastic process that can cause cholestasis and liver enzyme elevation without any direct hepatobiliary obstruction, and is thus categorized as a paraneoplastic syndrome of unclear pathophysiology. We report a first case of metastatic prostate adenocarcinoma with features of Stauffer’s syndrome that reversed completely on androgen deprivation therapy. This is in contrast to a previously reported case of Stauffer’s syndrome due to metastatic prostate adenocarcinoma, which reversed partially to androgen deprivation therapy. Our case demonstrates the importance of early recognition of Stauffer’s syndrome and underlying neoplasms in patients who present with cholestasis without clear evidence of intrahepatic or extrahepatic biliary obstruction, which may lead to early initiation of treatment.