Theranostic Risk Stratification for Thyroid Cancer in the Genomic Paradigm.

Theranostics define diagnostic evaluations directing patient-specific therapeutic decisions. Molecular theranostics involves genomic, transcriptomic, proteomic, metabolomic and finally phenonic definitions thyroid cancer differentiation. It is the functional differentiation that determines the sensitivity and accuracy of RAI imaging as well as the effectiveness of RAI treatment. Total thyroidectomy is performed to empower an anticipated RAI treatment. A preoperative determination of the genomic and transcriptomic profile of the tumor is a strong predictor of response to therapeutic interventions. This article discusses the oncopathophysiologic basis of the theranostic risk stratification approach.

Postoperative opioid prescribing practices in US adult trauma patients: A systematic review.

BACKGROUND: Opioids have been proven effective in pain management, but overprescription can lead to addiction and abuse. Although current guidelines regarding opioid prescription for chronic and acute pain are available, they fail to address the use of opioids for pain management in traumatic injury patients who undergo operations. The primary objective of this study was to examine opioid prescribing practices for US adult trauma patients who require surgical management, based on prior history of opioid use, type of surgical practice, and age. METHODS: PubMed and Cochrane Journals were used to identify relevant articles between October 2010 and December 29, 2020. Our primary outcome was discrepancies of morphine milligram equivalents (MMEs) prescribed to trauma patients. Significance was defined as p < 0.05. RESULTS: Eleven studies on US trauma patients prescribed opioids were evaluated, creating a total of 30,249 patients stratified by prior opioid use, age, and race. Patterns seen among patients with prior opioid use include higher MMEs prescribed, lower likelihoods of opioid discontinuation, higher mortality rates, and higher complication rates. Orthopedic surgeons prescribed higher values of MMEs than nonorthopedic surgeons. CONCLUSION: Higher incidences of opioid prescriptions are seen with orthopedic trauma surgery and prior opioid use by the patient. We recommend further development of national protocol implementation for acute pain management for the US trauma population. LEVEL OF EVIDENCE: Systematic review, level III.

Surgical, metabolic, and prognostic outcomes for Roux-en-Y gastric bypass versus sleeve gastrectomy: a systematic review.

The purpose of this systematic review was to study 4 different aspects of Roux-en-Y gastric bypass (RYBG) and sleeve gastrectomy (SG). Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are two commonly performed bariatric procedures. This systematic review aims to compare RYGB with SG when it comes to weight changes, and cardiometabolic risk profile. Another aim was to evaluate laparoscopic and robotic techniques for both surgeries. PubMED, Cochrane Library, and JAMA Network were searched for articles evaluating RYGB and SG from 2005-2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. Four different categories were analyzed comparing RYGB with SG as well as robotic versus laparoscopic approach. The Critical Appraisal Skills Program (CASP) checklist was used to assess the quality of evidence in the studies included in this systematic review. A total of 29 studies were included looking at different aspects of RYGB and SG. RYGB is superior to SG for weight loss, improved or complete remission of cholesterol and hypertensive medications. Consensus is lacking regarding decrease in BMI, total cholesterol, and triglycerides. There is lack of evidence regarding decrease of incidence of MI or stroke. For RYGB and SG, the majority of studies found that the robotic technique was more expensive and took longer. RYGB when compared with SG was associated with larger weight loss, decreased or cessation of cholesterol and hypertensive medications, and lower cholesterol. Decrease in BMI had varying results, with RYGB being superior in more studies, while there was no difference in other studies. There was a lack of evidence to support if RYGB or SG was superior to decreasing triglyceride levels. For both RYGB and SG, the robotic approach was costlier and took more operating time versus the laparoscopic approach.

A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review.

INTRODUCTION: Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy. PRESENTATION OF CASE: A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent. DISCUSSION: BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks. CONCLUSION: Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.

Twitter Hashtag and Online Engagement During Surgical Society Meetings Over a 5-Year Period.

BACKGROUND: Utilizing social media platforms can augment medical conferences by sharing new knowledge and information through hashtags. We aim to investigate the use of Twitter, enhanced conference experience, and education at the Eastern Association for the Surgery of Trauma (EAST) Annual Scientific Assembly 2016-2020. METHODS: EAST hashtags were analyzed for the Annual Scientific Assembly 2016-2020: #EAST2016, #EAST2017, #EAST2018, #EAST2019, and #EAST2020. Using #EAST2016 as a baseline, active interaction through engagement, measured by tweets and retweets, passive interaction through impressions, measured by views, as well as users, and influencers were analyzed. RESULTS: 2016-2018 saw a significant increase in engagement (7400 to 9200 to 11 000, respectively, P < .05). 2018-2020 then showed a significant decrease in engagement (11 000 to 9000 to 6700, respectively, P < .05). Impressions, increased significantly from 2016 to 2020 (6.6 million to 13.3 million to 12.6 million to 19.9 million to 20.3 million, respectively, P < .05). Users significantly increased to 2700 in 2018 compared with 1000 in 2016 (P < .05), and significantly decreased to 814 in 2020 compared with 2700 in 2018 (P < .05). The top online influencer was the EAST organization Twitter account. CONCLUSION: #EAST2016-2018 showed a significant increase in engagement between users, measured by tweets/retweets. However, #EAST2019-2020 suffered declines in users' engagement, maybe a result of social media fatigue. Although, #EAST2016-2020 showed a significant increase in impressions. Both passive and to a more extent active forms of online social media engagement can potentially disseminate new knowledge and medical information. Scientific societies should focus on more effective ways to maintain and enhance users' online experience and engagement toward better utilization of social media platforms.

Post-Traumatic Stress Disorder in Adult and Pediatric Trauma Populations: A Literature Review.

Each year, traumatic injuries affect 2.6 million adults in the United States leading to significant health problems. Although many sequelae stem directly from physical manifestations of one's sustained injuries, mental health may also be affected in the form of post-traumatic stress disorder (PTSD). PTSD can lead to decreased physical recovery, social functioning, and quality of life. Several screening tools such as the Injured Trauma Survivor Screen, PTSD CheckList, Primary Care PTSD, and Clinician-Administered PTSD Scale for DSM-5 have been used for initial PTSD screening of the trauma patient. Early screening is important as it serves as the first step in delivering the appropriate mental health care to those in need. Factors that increase the likelihood of developing PTSD include younger age, nonwhite ethnicity, and lower socioeconomic status. Current data on male or female predominance of PTSD in trauma populations is inconsistent. Cognitive behavioral therapy, hypnosis, and psychoeducation have been used to treat symptoms of PTSD. This review discusses the impact PTSD has on the trauma patient and the need for universal screening in this susceptible population. Ultimately, trauma centers should implement such universal screening protocols as to avoid absence, or undertreatment of PTSD, both of which having longstanding consequences.

Current grading of gall bladder cholecystitis and management guidelines: Is it sufficient?

•These two cases highlight the limitations in current grading systems, particularly in the context of gallbladder size.•We propose modifications to the PGS to include not only abnormal anatomy but instances of distorted gallbladder anatomy due to inflammation and/or the large to giant size in order to account for the increased risk of complications.•Both distorted gallbladder anatomy and giant gallbladder size can make laparoscopic cholecystectomy a challenge, and thus warrant contribution to overall clinical grade.•While the PGS, Tokyo Guidelines, and AAST grading scales are validated grading scales for acute cholecystitis, additional modifications can further characterize different types of acute cholecystitis to better guide patient management.

Huge gangrenous gallbladder presenting as gastro-esophageal reflux disease successfully treated by laparoscopic cholecystectomy: Case report and literature review.

INTRODUCTION: Gallbladder disease is a common surgical pathology. Gallstones can remain asymptomatic or develop into an acute cholecystitis and need for surgical intervention. Significant enlargement of the gallbladder well beyond the normal volume is rare. Such "giant" gallbladders can affect feasibility of subsequent management options. PRESENTATION OF CASE: An 80-year-old female presented to the emergency department with a two-day history of acute on chronic gastric reflux with nausea and vomiting. On examination, she had right upper quadrant abdominal pain. CT imaging identified an enormous gallbladder creating mass effect and compression on the distal stomach. She underwent successful laparoscopic cholecystectomy and was discharged from the hospital the next day, doing well. On two-week follow up, her reflux symptoms had completely resolved and she had no complaints. DISCUSSION: Giant gallbladders are a rare entity. Our patient's case is unique in both its occurrence as well as presentation with predominant reflux symptoms secondary to mass effect by the enlarged gallbladder. Current cholecystitis grading systems do not utilize size as a means of predicting severity and risk of operative complications or difficulty of procedure. Laparoscopic cholecystectomy was a successful approach in managing this extreme pathology. CONCLUSION: Updated classifications systems that include size and mass effect as a predictive measure are needed to better assess surgical outcomes, especially in "giant" gallbladder disease. Despite the large size and potential mass effect on surrounding structures, laparoscopic cholecystectomy can still be attempted if no other contraindications exist.

Massive transfusion protocol in adult trauma population.

BACKGROUND: Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions. METHODS: PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes. RESULTS: Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient. CONCLUSION: Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.

Successful management of gunshot wound to the chest resulting in multiple intra-abdominal and thoracic injuries in a pediatric trauma patient: A case report and literature review.

INTRODUCTION: Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance. CASE PRESENTATION: A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition. DISCUSSION: Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible. CONCLUSION: Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes.

A rare case of pre-hospital globe enucleation after a penetrating injury to the orbit during an assault: A case report and literature review.

INTRODUCTION: Ocular trauma is a common occurrence in trauma settings but often occurs with little to no effect on the vision of the patient. Traumatic enucleation is a rare but devastating injury. CASE PRESENTATION: A 40-year-old male presented to our trauma center after an assault resulting in right globe enucleation. CT confirmed absence of the globe with disruption of the ipsilateral orbital contents and distal optic nerve disruption. The patient was started on intravenous antibiotics and the right orbit was packed. He was taken to the operating room for exploration of the right orbit and placement of an implant. His remaining hospital course was unremarkable. DISCUSSION: Documented mechanisms of injury for traumatic enucleation are diverse, but often involve significant retro-ocular force to completely dislodge the globe from the orbit. Optic nerve avulsion may cause associated optic nerve chiasm damage leading to temporal hemianopia in the uninjured contralateral eye. Treatment involves stabilization and preparation for future implant placement. CONCLUSION: Traumatic enucleation is extremely rare. Development of a grading system applicable to traumatic enucleation may be helpful in guiding management in this complex patient population.

Surgeons and social media: The use of twitter hashtags at the Academic Surgical Congress 2015-2019: A cross sectional study.

BACKGROUND: The use of Twitter hashtags at medical conferences has revolutionized the way healthcare professionals interact and advance their education. We aim to investigate the scope of the Academic Surgical Congress's online reach and engagement through the use of Twitter hashtags #ASC from 2015 to 2019, by analyzing the number of impressions and tweets and retweets. METHODS: A cross sectional study of Twitter data through Symplur with the following conference hashtags for the Academic Surgical Congress annual meetings for years 2015-2019: #ASC2015, #ASC2016, #ASC2017, #ASC2018, and #ASC2019. Data on tweets, retweets, users, and impressions was reviewed along with information on the top 10 influencers and the most frequently tweeted links. Symplur Signals software was utilized to extract and assimilate data. Statistical Significance was defined as p < 0.05. RESULTS: Twitter engagement metrics significantly increased from 11,400 to 32,100 from 2015 to 2017 (p < 0.05). However, from 2017 to 2019, there was a significant decline in engagement metrics from 32,100 to 26,100 (p < 0.05). Impressions increased significantly from 13,100 in 2015 to 71,800 impressions in 2019 (p < 0.05). Users grew significantly from 1500 in 2015 to peak at 4600 in 2017 before dropping back to 3300 in 2019 (p < 0.05). The most influential organizations during these years were the organizers of the conference: Association for Academic Surgery and the Society of University Surgeons. Conference attendance progressively increased from approximately 1700 in 2016 to about 2100 in 2019 (p < 0.05). CONCLUSIONS: Twitter engagement metrics at the Academic Surgical Congress 2015-2019 has fluctuated, while impressions significantly increased through the years indicating the consistent dissemination of conference content.

Surgical consent during the COVID19 pandemic: Saving lives while in crisis editorial.

•Compares obtaining informed consent from a non-COVID-19 patient versus a COVID-19 person under investigation or confirmed positive in order to maintain healthcare workers safety and minimize PPE use.•Explains the use of technology in the form of video chat to aid in informed consent from healthcare surrogates of patients who are unable to provide their own informed consent.•Discusses alternative solutions to obtaining informed consent from a COVID-19 person under investigation or confirmed positive.

Perforated proximal jejunal gastrointestinal stromal tumor pT4N0M0 presenting with severe sepsis: A case report and literature review.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that occur along the alimentary tract, and are most commonly found in the stomach. Rarely, these tumors can occur in the small bowel, and when located in the duodenum or proximal jejunum, they may require challenging reconstruction of the alimentary tract. Patients with GISTs often present with non-specific abdominal pain or symptoms of obstruction, hemorrhage, and less commonly perforation. PRESENTATION OF CASE: A 46-year-old male presented to the hospital with a one-day history of left upper quadrant pain with fevers and chills. Physical examination was significant for signs of peritonitis, and laboratory results revealed leukocytosis and lactic acidosis. CT abdomen showed a large soft tissue mass in the proximal jejunum. In the operating theater he was found to have a perforated jejunal tumor. Pathology report revealed a 13cm GIST, pT4N0M0, Stage IIIa. He had an uneventful recovery and was discharged nine days after surgery. DISCUSSION: Proximal jejunal GISTs are a rare entity and when present, perforation is unlikely. Pathological diagnosis of GISTs are relies on immunohistochemistry demonstrating c-KIT or CD34 positivity. The prognosis of GISTs are dependent on the size and the mitotic index. Definitive treatment of non-metastatic GISTs is R0 resection. When located in the duodenum or proximal jejunum, resection can be very challenging and may require clinical expertise in order to safely perform complex alimentary tract reconstruction. CONCLUSION: Further investigation is required in order to determine best practice management for patients who present with proximal GISTs.

Traumatic diaphragmatic rupture successfully managed in 4-year-old patient: Case report and literature review.

INTRODUCTION: Traumatic diaphragmatic ruptures are rare injuries in the pediatric population that can present with dyspnea, abdominal pain, or even be asymptomatic. CASE PRESENTATION: A 4-year-old boy presents to our Level 1 Pediatric Trauma Center after being hit by a car. He presented awake and alert but with low oxygen saturations and chief complaint of left sided abdominal and chest pain. The initial chest radiograph showed an elevated left diaphragm and bilateral opacities. A laparoscopic approach confirmed the diagnosis of a diaphragm rupture and an open approach allowed for the diaphragm repair, after returning the stomach, colon and spleen back to the abdominal cavity. He had an uneventful recovery and was discharged home on postoperative day seven. DISCUSSION: Traumatic diaphragmatic hernia continues to be a difficult diagnosis to make without a high index of suspicion with variable time to diagnosis. This has been attributed to nonspecific clinical presentation and low incidence of the condition. Chest radiograph has been suggested to be an appropriate initial imaging modality with computed tomography as an accurate adjunct. Right sided diaphragm hernias, although less common, still occur and are often misdiagnosed. Recovery without significant morbidity after definitive surgical treatment with laparotomy is common. CONCLUSION: Consider a traumatic diaphragmatic hernia in a blunt pediatric trauma patient with abdominal pain and dyspnea once other life-threatening injuries have been ruled out. This is an easily missed injury that can lead to significant morbidity and mortality if not identified early in the patient's hospital course.