Yield of abdominal radiographs in children with suspected intussusception; rate of pneumoperitoneum and other abdominal pathology.

OBJECTIVES: Ultrasound is the criterion standard imaging modality for the diagnosis of intussusception. However, to our knowledge the utility of abdominal radiographs to concurrently screen for pneumoperitoneum or other abdominal pathology that could have a similar presentation has not been studied. Our institutional protocol requires the performance of AP supine and left lateral decubitus views of the abdomen prior to ultrasound evaluation for intussusception, providing an opportunity to examine the yield of abdominal radiographs in this setting. Our primary objective was to determine the rate of pneumoperitoneum on screening abdominal radiographs in children undergoing evaluation for intussusception. Our secondary objective was to determine the rate that other clinically significant pathology is found on these screening abdominal radiographs. METHODS: We performed a retrospective chart review of all patients under 6 years of age who had any imaging ordered in our large urban pediatric emergency department to evaluate for suspected intussusception during the calendar years 2018-2020. RESULTS: 1115 patient encounters met our inclusion criteria. Among 1090 who had screening abdominal radiographs, 82 (8%) had findings concerning for intussusception. Of those not concerning for intussusception, 635 (58%) were read as normal, 263 (24%) showed moderate to large stool burden, 107 (10%) showed generalized bowel distention, and 22 (2%) showed abnormal gastric distention. Individually the remainder of all other findings compromised <1% of encounters and included radiopaque foreign body (8), intraabdominal calcification (4), pneumonia/effusion (3), pneumatosis intestinalis, abdominal mass (2), diaphragmatic hernia (1), rib fracture (1), appendicolith (1), feeding tube malposition (1), and bowel wall thickening (1). In one encounter the patient had a bowel perforation with pneumoperitoneum present secondary to ingestion of multiple magnets. CONCLUSIONS: Our study indicates that radiograph-detected pneumoperitoneum is rare in children with suspected intussusception. Constipation is the most common abnormal finding on screening radiographs. Other findings occur in approximately 15% of total cases, some of which require further workup.

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation.

OBJECTIVES: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. DESIGN: Retrospective case series. SETTING: Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS: Success rate of nonunion surgery. RESULTS: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Association Between Solid Organ Transplant and Recurrence of Acute Diverticulitis: A National Assessment.

OBJECTIVE: Compare rates and severity of recurrent acute diverticulitis in patients with and without solid organ transplant. SUMMARY BACKGROUND DATA: Immunocompromised solid organ transplant recipients have been considered higher risk for both recurrence and severity of acute diverticulitis. Current guidelines recommend an individualized approach for colectomy in these patients, but these are based on single-center data. METHODS: We identified patients with acute diverticulitis using the Merative MarketScan commercial claims data from 2014-2020. Patients were classified by history of solid organ transplant. The primary outcome was recurrence of acute diverticulitis with an associated antibiotic prescription ≥60 days from the initial episode. Secondary outcomes included hospitalization, colectomy, and ostomy in patients with recurrence. Analyses used inverse probability weighting to adjust for imbalances in covariates. RESULTS: Of 170,697 patients with evidence of acute diverticulitis, 442 (0.2%) had a history of solid organ transplantation. In the weighted cohort, among people who had not been censored at one year (n=515), 112 (22%; 95% CI 20%-25%) experienced a recurrence within the first year. Solid organ transplantation was not significantly associated with a risk of recurrence (HR 1.19; 95% CI 0.94-1.50). There was also no statistically significant difference in the hospitalization rate for recurrent diverticulitis. Restricting the analysis to hospitalized recurrences, there was no statistically significant difference observed in either length of stay or discharge status. CONCLUSIONS: In this national analysis of commercially-insured patients with acute diverticulitis we found no statistically significant differences in recurrence between those with and without a history of solid organ transplant. We do not support an aggressive colectomy strategy based on concern for increased recurrence rate and severity in a solid organ transplant population.

An Innovative Polymeric Platform for Controlled and Localized Drug Delivery.

Precision medicine aims to optimize pharmacological treatments by considering patients' genetic, phenotypic, and environmental factors, enabling dosages personalized to the individual. To address challenges associated with oral and injectable administration approaches, implantable drug delivery systems have been developed. These systems overcome issues like patient adherence, bioavailability, and first-pass metabolism. Utilizing new combinations of biodegradable polymers, the proposed solution, a Polymeric Controlled Release System (PCRS), allows minimally invasive placement and controlled drug administration over several weeks. This study's objective was to show that the PCRS exhibits a linear biphasic controlled release profile, which would indicate potential as an effective treatment vehicle for cervical malignancies. An injection mold technique was developed for batch manufacturing of devices, and in vitro experiments demonstrated that the device's geometry and surface area could be varied to achieve various drug release profiles. This study's results motivate additional development of the PCRS to treat cervical cancer, as well as other malignancies, such as lung, testicular, and ovarian cancers.

Comparing and Contrasting the Experiences of U.S. Medical Students During the COVID-19 and 1918 Influenza Pandemics.

In March 2020, medical students across the United States were pulled from their in-person responsibilities and learning in response to COVID-19. Leaders in the U.S. medical education system then began the arduous task of determining when, and how, to restore their full scope of training. This challenge was complicated by a paucity of readily available historical information about U.S. medical students in pandemics. To fill this knowledge gap, the authors collaborated with a medical history archivist to describe the experience of U.S. medical students during the 1918 influenza pandemic and compare it with the modern day. The experiences and responsibilities of medical students differed tremendously between the 2 pandemics. In 1918, U.S. medical students typically were conscripted into clinical service if they did not volunteer, assuming the roles of physicians, physician assistants, and nurses, often with atypically high levels of autonomy. Medical students were at great risk during the 1918 pandemic; multiple medical schools recorded students dying from influenza. In contrast, during the early COVID-19 pandemic, U.S. medical students were removed from the clinical environment, even if they wanted to volunteer, assuming ancillary roles instead. Upon returning to the clinical environment, most were not permitted to care for COVID-19 patients. The few medical students who recorded personal narratives about 1918 felt that caring for patients with influenza significantly influenced their growth and development as future physicians. One of the few things U.S. medical education had in common between the 1918 and COVID-19 pandemics was a lack of preparedness that impaired readiness and increased confusion among medical students. As U.S. medical education reflects on its response to COVID-19, the authors hope that their findings will provide context for future discussions and decisions about the role of medical students in pandemics.

Cardiolipin, and not monolysocardiolipin, preferentially binds to the interface of complexes III and IV.

The mitochondrial electron transport chain comprises a series of protein complexes embedded in the inner mitochondrial membrane that generate a proton motive force via oxidative phosphorylation, ultimately generating ATP. These protein complexes can oligomerize to form larger structures called supercomplexes. Cardiolipin (CL), a conical lipid, unique within eukaryotes to the inner mitochondrial membrane, has proven essential in maintaining the stability and function of supercomplexes. Monolysocardiolipin (MLCL) is a CL variant that accumulates in people with Barth syndrome (BTHS). BTHS is caused by defects in CL biosynthesis and characterised by abnormal mitochondrial bioenergetics and destabilised supercomplexes. However, the mechanisms by which MLCL causes pathogenesis remain unclear. Here, multiscale molecular dynamics characterise the interactions of CL and MLCL with yeast and mammalian mitochondrial supercomplexes containing complex III (CIII) and complex IV (CIV). Coarse-grained simulations reveal that both CL and MLCL bind to sites at the interface between CIII and CIV of the supercomplex. Free energy perturbation calculations show that MLCL interaction is weaker than that of CL and suggest that interaction with CIV drives this difference. Atomistic contact analyses show that, although interaction with CIII is similar for CL and MLCL, CIV makes more contacts with CL than MLCL, demonstrating that CL is a more successful "glue" between the two complexes. Simulations of the human CIII2CIV supercomplex show that this interface site is maintained between species. Our study suggests that MLCL accumulation in people with BTHS disrupts supercomplex stability by formation of relatively weak interactions at the interface lipid binding site.

Collection and Utilization of Patient-Reported Outcome Measures in a Colorectal Surgery Clinic.

INTRODUCTION: The routine collection of patient-reported outcome measures (PROMs) promises to improve patient care. However, in colorectal surgery, PROMs are uncommonly collected outside of clinical research studies and rarely used in clinical care. We designed and implemented a quality improvement project with the goals of routinely collecting PROMs and increasing the frequency that PROMs are utilized by colorectal surgeons in clinical practice. METHODS: This mixed-methods, quality improvement project was conducted in the colorectal surgery clinic of a tertiary academic medical center. Patients were administered up to five PROMs before each appointment. PROM completion rates were measured. Additionally, we performed two educational interventions to increase utilization of our electronic health record's PROM dashboard by colorectal surgeons. Utilization rates and attitudes toward the PROM dashboard were measured. RESULTS: Overall, patients completed 3600 of 3977 (90.9%) administered PROMs during the study period. At baseline, colorectal surgeons reviewed 6.7% of completed PROMs. After two educational interventions, this increased to 39.3% (P = 0.004). Colorectal surgeons also felt that the PROM dashboard was easier to use. Barriers to greater PROM dashboard utilization included poor user interface/user experience and a perceived lack of knowledge, time, and relevance. CONCLUSIONS: The collection of PROMs in colorectal surgery clinics is feasible and can result in high PROM completion rates. Educational interventions can improve the utilization of PROMs by colorectal surgeons in clinical practice. Our experience collecting PROMs through this quality improvement initiative can serve as a template for other colorectal surgery clinics interested in collecting and utilizing data from PROMs.

Long-term bowel dysfunction and decision regret in diverticulitis: A mixed methods study.

BACKGROUND: This study had aimed to describe long-term decision regret, bowel dysfunction, and the overall quality of life in patients with diverticulitis, and to determine if elective colectomy was associated with these patient-reported outcome measures. METHODS: This mixed-methods, survey-based study was administered to a national cohort of patients in the United States with diverticulitis. We measured decision regret (Brehaut Decision Regret), bowel dysfunction (Low Anterior Resection Syndrome score), and the overall quality of life (EuroQol 5 Dimension) in this population. We asked open-ended questions to elucidate factors that influenced patients' choices between elective colectomy and observation. RESULTS: Among the 614 respondents, 294 (48%) chose between colectomy and observational management, 94 (15%) had surgery, and 157 (26%) had major Low Anterior Resection Syndrome. Of the 294 that chose between colectomy and observational management, 51 (17%) experienced decision regret. Colectomy was associated with an average decrease in the Brehaut Decision Regret score by 6 points but was not associated with a categorical measure of decision regret (Brehaut Score ≥50). Bowel dysfunction and overall quality of life were not significantly associated with colectomy. Disease-related factors, psychosocial factors, and interactions with physicians were commonly cited as reasons for pursuing colectomy or observational management. CONCLUSION: Patients with self-reported diverticulitis describe high levels of decision regret and bowel dysfunction regardless of chosen management strategy. Physicians should be aware that psychosocial factors can strongly influence a patient's choice between colectomy and observational management. We advocated for future prospective studies using patient reported outcome metrics to improve outcomes in diverticulitis.

Efficacy and Safety of Recurrent Paraesophageal Hernia Repair with Roux-en-Y Gastric Bypass.

Roux-en-Y gastric bypass (RYGB) has been explored as a revisional option to failed paraesophageal hernia (PEH) repair with fundoplication, particularly in patients suffering from obesity. However, few studies have assessed long-term outcomes of RYGB with revisional PEH repair in regard to acid-suppressing medication use. We retrospectively identified 19 patients who underwent revisional PEH repair with RYGB between 2011 and 2018. The median operative time was 232 minutes with a median hospital length of stay of two days. The median length of follow-up was 24 months. Two patients (10.5%) had complications in the first 30 days, and five patients (26.3%) had complications within one year. Of the 12 patients on preoperative acid suppression, 6 (50%) were either off medication or on reduced dose at 12 months. The median BMI decrease was 14.4 kg/m² at 12 months and did not change significantly afterward. Although rates of acid-suppression medication use did not change overall after revisional PEH repair with RYGB, patients experienced successful long-term management of morbid obesity and sustained weight loss. Revisional PEH repair with RYGB is a safe and effective option, with a complication rate comparable with the reported rates after revisional foregut procedures such as revisional Nissen fundoplication.