A Wolf in Sheep's Clothing: An Unusual Presentation of Diabetic Myonecrosis.

GENERAL PURPOSE: To provide information about the diagnosis and treatment of diabetic myonecrosis (DMN).This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Cite the incidence and symptomatology of diabetic myonecrosis.2. Identify the diagnostic tests associated with DMN.3. Summarize the evidence-based treatments for DMN.Diabetic myonecrosis is a rare complication of poorly controlled diabetes mellitus that presents similarly to many common conditions such as cellulitis, abscess, and fasciitis. Therefore, a high index of suspicion is required for diagnosis. Magnetic resonance imaging is the investigative test of choice. Treatment includes antiplatelet therapy, nonsteroidal anti-inflammatory agents, and glycemic control.

Wound Care Center of Excellence: A Process for Continuous Monitoring and Improvement of Wound Care Quality.

GENERAL PURPOSE: To provide information about a study using a new process for continuous monitoring to improve chronic wound care quality.This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.After completing this continuing education activity, you should be better able to:1. Recognize problems associated with chronic wound care.2. Identify methods used in this project to improve care.3. Illustrate the findings from this and similar projects and implications for providing improved wound care.Patients with chronic wounds require complex care because of comorbidities that can affect healing. Therefore, the goal of this project was to develop a system of reviewing all hospitalized patients seen by the study authors' wound care service on a weekly basis to decrease readmissions, morbidity, and mortality. Weekly multidisciplinary conferences were conducted to evaluate patient data and systematically assess for adherence to wound care protocols, as well as to create and modify patient care plans. This review of pathology and the performance of root-cause analyses often led to improved patient care.

A Framework to Assist Providers in the Management of Patients with Chronic, Nonhealing Wounds.

GENERAL PURPOSE: To describe the development of an evidence-based wound electronic medical record (WEMR) framework for providers to execute timely, protocol-based, best-practice care for patients with chronic, nonhealing wounds. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to: ABSTRACT: The care of patients with nonhealing wounds involves a host of treatment modalities. The authors developed a wound-specific framework to enhance provider management of these wounds and a summary sheet to involve patients and caregivers in their own healthcare to improve treatment adherence and outcomes. Implementing evidence-based practice for chronic wounds enables corrective actions to optimize care.

Bariatric and general surgical procedures in obese patients with a history of venous thromboembolism and concurrent anticoagulation therapy.

OBJECTIVE: The objective of this study was to examine the use and outcomes of perioperative anticoagulation (AC) in obese patients with a known history of venous thromboembolism event (VTE). METHOD: A retrospective review of a prospective database for patients with a VTE history undergoing bariatric and general surgery at a single center (1/2008-12/2017) was performed. Factors assessed included demographics, surgical details, and outcomes. RESULTS: Sixty-five patients underwent 76 procedures: 46 females (71%); mean age 51 years (range 26-73), mean weight 284 pounds (range 110-558), mean body mass index 45 (range 19-87). Comorbidities include hypertension (60%), gastroesophageal reflux disease (54%), osteoarthritis (49%), obstructive sleep apnea (45%), and diabetes (37%). Operations: 22 general surgeries (29%), 20 sleeve gastrectomies (26%), 12 revisions/conversions (16%), 12 Roux-en-Y gastric bypasses (16%), and 10 gastric bands (13%). Modalities: 67% laparoscopic, 28% robotic, and 5% open. Twenty-two patients (34%) had a pre-operative inferior vena cava filter placed with no complications. The mean length of stay was 4.4 days (range 1-31). Complications: seven 30-day readmissions (9%), one 30-day reoperation (1%), and two 90-day VTEs (3%). Thirty-day readmissions: four for inability to tolerate PO, two for small bowel obstruction, and one for symptomatic anastomotic ulcer. CONCLUSIONS: In our patients, post-operative AC could be started without an increased risk of bleeding in patients with a history of VTE undergoing bariatric surgery.

OBJETIVO: Examinar el uso y los resultados de la anticoagulación perioperatoria en pacientes bariátricos con antecedentes de tromboembolia venosa (TEV). MÉTODO: Revisión retrospectiva (base de datos prospectiva) de pacientes sometidos a cirugía general y bariátrica (1/2008-12/2017). Se evaluaron datos demográficos, detalles quirúrgicos y resultados. RESULTADOS: Sesenta y cinco pacientes se sometieron a 76 procedimientos: 46 mujeres (71%), edad media 51 años (rango: 26-73), peso medio 284 libras (rango: 110-558), índice de masa corporal medio 45 (rango: 19-87). Comorbilidad: hipertensión (60%), enfermedad por reflujo gastroesofágico (54%), osteoartritis (49%), apnea obstructiva del sueño (45%), diabetes (37%). Operaciones: 22 cirugía general (29%), 20 gastrectomías en manga (26%), 12 revisiones/conversiones (16%), 12 Y-de-Roux (16%), 10 bandas gástricas (13%). Modalidades: 67% laparoscópica, 28% robótica, 5% abierta. A 22 pacientes (34%) se les colocó un filtro de vena cava inferior preoperatorio sin complicaciones. La estancia media fue de 4.4 días (rango: 1-31). Complicaciones: 7 reingresos a los 30 días (9%), 1 reoperación a los 30 días (1%), 2 TEV a los 90 días (3%). Reingresos a los 30 días: 4 por incapacidad para tolerar la vía oral, 2 obstrucciones de intestino delgado y 1 úlcera anastomótica sintomática. CONCLUSIONES: En nuestros casos, la anticoagulación posoperatoria pudo iniciarse sin aumento del riesgo de sangrado en pacientes con antecedentes de TVE sometidos a cirugía bariátrica.

Kwashiorkor after gastric bypass.

Gastric bypass has grown in popularity in recent years due to its high efficacy in achieving long-term weight loss in patients with morbid obesity. Gastric bypass has been described to further exacerbate baseline nutritional deficiencies due to reduced gastric capacity and malabsorption. In rare cases, when protein deficiency is severe, Kwashiorkor disease may arise. The incidence of Kwashiorkor specifically following gastric bypass is rare, with an incidence of 4.7%. We report a case of a female patient who underwent a gastric bypass and subsequently developed Kwashiorkor. Physicians' suspicion of index for Kwashiorkor should be high for patients presenting with signs or symptoms of severe malnutrition following weight-loss procedures.

Outcomes in Obese vs Non-Obese Injured Patients at a Level 1 Trauma Center and Bariatric Surgery Center of Excellence.

BACKGROUND: We hypothesized that the outcomes of trauma patients with a body mass index (BMI) equal to or greater than 30 compared to patients with BMI less than 30 would not differ at a level 1 trauma center that is also a Metabolic and Bariatric Surgery Center of Excellence in the Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP). STUDY DESIGN: Patients equal to and greater than 18 years old treated between 1/1/2018 and 12/31/2020 were included. Demographics, BMI, comorbidities, and outcomes (hospital-LOS, ICU-LOS, blood products used, and mortality) were compared between 2 groups: obese (BMI ≥30) vs non-obese (BMI <30). RESULTS: Of the 4192 patients identified, 3821 met the inclusion criteria; 3019 patients had a BMI <30, and 802 had a BMI ≥30. There was a statistically significant difference between the 2 groups with respect to gender (females: 57% vs 47%, P < .0001) and age (median: 80 [IQR: 63-88] vs 69 [IQR: 55-81], P < .0001). When adjusted for age, sex, DM, dementia, ISS, and ICU admission, there was no statistically significant difference in hospital-LOS (4.30 [95% CI: 4.10, 4.52] vs 4.48 [95% CI: 4.18, 4.79]) or mortality. No statistical differences were seen between the 2 groups in blood product use. CONCLUSIONS: Obesity did not correlate with poorer outcomes at an ACS-verified level 1 Trauma Center and Bariatric Surgery Center of Excellence. Further studies are needed to determine whether outcomes vary at hospitals without both designations.

The First COVID-19 Pandemic Wave and the Effect on Health Care Trainees: A National Survey Study.

BACKGROUND: This study observes the trends and patterns among trainees during the coronavirus disease 2019 (COVID-19) pandemic and their response to resident education and hospital/program support. METHODS: An anonymous online 31-question survey was distributed to medical students and postgraduate year residents. Topics included were demographics, clinical responsibilities, educational/curricula changes, and trainee wellness. Descriptive analysis was performed for each set of demographic groupings as well as 2 and 3 group comparisons. RESULTS: Total 1051 surveys collected, 930 used for analysis: 373 (40.1%) male, 434 (46.6%) aged 30-34 years, 588 (63.2%) white, 417 (44.8%) married, 168 (18%) with children, and 323 (34.7%) from the Northeast region. The Northeast experienced difficulty sleeping, feelings of guilt, hopelessness, and changes in appetite (P = .0077). The pandemic interfered significantly with relationships and living situations (P < .0001). Trainees 18-34 years believed the pandemic affected residency training (P < .0001). Surgical residents were concerned about reaching numbers of operative procedures to graduate (P < .0001). Residency programs adhered to ACGME work restrictions (P < .0001). CONCLUSION: We aim to provide continued educational support for our trainees' clinical development and well-being during the COVID-19 pandemic.

Safety of Bariatric Surgery in Patients With Congestive Heart Failure: Results of an 11-Year Retrospective Study.

INTRODUCTION: Congestive heart failure (CHF) is a known risk factor for increased postoperative morbidity. However, the safety in patients with CHF has not been well established. The objective of this study was to assess the safety of surgery in patients with a history of CHF undergoing bariatric surgical procedures. METHODS: Retrospective review of a prospectively maintained Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence database. Patients with known CHF undergoing bariatric procedures over an 11-year period were reviewed. RESULTS: Over the 11-year period, 4470 total bariatric surgeries were performed, of which 41 (.92%) patients had known CHF. Twenty-one patients were men (51.2%) with a mean age of 55.8 years and mean body mass index (BMI) of 51.9. Comorbidities included hypertension (87.8%), obstructive sleep apnea (80.5%), osteoarthritis (63.4%), gastroesophageal reflux disease (56%), and diabetes (53.7%). Surgical procedures included 16 sleeve gastrectomies (SGs) (39%), 11 Roux-en-Y gastric bypasses (RYGBs) (26.8%), 10 laparoscopic adjustable gastric bands (LAGBs) (24.4%), 1 removal of a gastric band and conversion to SG (2.4%), 1 removal of a gastric band to RYGB (2.4%), 1 gastric band over RYGB pouch (2.4%), and 1 gastric band replacement (2.4%). All cases were performed minimally invasively (73.2% laparoscopic and 26.8% robotic). Mean LOS was 2.53 days. Thirty-day complications included 2 readmissions (4.9% [1 small bowel obstruction and 1 pulmonary edema]), 1 reoperation (2.4% [small bowel obstruction]), and 1 mortality (2.4%) on postoperative day 30 unrelated to the surgery. CONCLUSIONS: Bariatric surgery can be performed safely in patients with CHF.

Giant mediastinal teratoma in a young infant: a case report.

Background: Giant mediastinal tumors in the pediatric population can pose unique challenges for resection such as cardiovascular collapse on induction of anesthesia and injury to surrounding structures that may be compressed, displaced, or invaded by the mass. Principles that must be borne in mind during removal of giant mediastinal masses include: appropriate cross-sectional imaging to define extent of mass; airway control during induction of anesthesia; a multidisciplinary collaborative approach including cardiothoracic surgery; preparation for urgent sternotomy; plan for peripheral cannulation to institute cardiopulmonary bypass if needed; preservation of neurovasculature structures during dissection; complete resection whenever possible. While complete resection is desirable and results in an excellent prognosis, it may not be achievable especially if the tumor encases coronary arteries, and it is acceptable to leave small amounts of tumor behind. Case Description: Here we present a case describing surgical management of a giant mediastinal teratoma in a two-month-old female. The patient was found to have a large mediastinal mass during workup for cough and noisy breathing. She underwent preoperative echocardiogram demonstrating normal cardiac function followed by uncomplicated, open resection of the mass. Conclusions: Giant mediastinal tumors give rise to unique challenges for resection in small infants. The principles of airway control, preparation for urgent sternotomy, preparation for peripheral cardiopulmonary bypass cannulation, and preservation of neurovasculature during dissection must be borne in mind.

Gastric Banding with Previous Roux-en-Y Gastric Bypass (Band over Pouch): Not Worth the Weight.

Background and Objectives: Revisional bariatric surgery continues to increase. Laparoscopic adjustable gastric banding (LAGB) after previous Roux-en-Y gastric bypass (RYGB), known colloquially as "band-overpouch" has become an option despite a dearth of critically analyzed long-term data. Methods: Our prospectively maintained database was retrospectively reviewed for patients who underwent band-overpouch at our Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in a 18-year period ending October 31, 2021. We evaluated: demographics, comorbidities, operative procedures, and outcomes (30-day and > 30-day). Results: During the study period, of 4,614 bariatric procedures performed, 42 were band-overpouch with 39 (93%) being women. Overall, mean age was 49.8 years (range 26-75), a mean weight 251 pounds (range 141-447), and mean body mass index 42.4 (range 26-62). Comorbidities included: hypertension (n = 31; 74%), diabetes (n = 27; 64%), obstructive sleep apnea (n = 26; 62%), gastroesophageal reflux disease (n = 26; 62%), and osteoarthritis (n = 25; 60%). All procedures were performed laparoscopically with no conversions to open. Mean length of stay was 1.2 days (range 1-3). Mean follow-up time was 4.2 years (range 0.5-11). Mean excess weight loss was 14.9%, 24.3%, and 28.2% at 6 months, 1 year and ≥ 3 years, respectively. There was one 30-day trocar-site hematoma requiring transfusion. Long-term events included: 1-year (1 endoscopy for retained food; 1 internal hernia), 3-year (1 LAGB erosion; 1 LAGB explant), 4-year (1 anastomotic ulcer), 6-year (1 LAGB explant and Roux-en-Y revision), and 8-year (1 LAGB erosion). One 5-year mortality occurred (2.4%), in association with hospitalization for chronic illness and malnutrition. Band erosions were successfully treated surgically without replacement. Conclusion: Band-overpouch is associated with moderate excess weight loss and has good short-term safety outcomes.

Outcomes of Bariatric Surgery: Patients with Body Mass Index 60 or Greater.

INTRODUCTION: Perioperative outcomes of bariatric surgery in patients with super super obesity (SSO) (BMI ≥ 60 kg/m2) merit further investigation. METHODS: A retrospective review was conducted of patients with SSO who underwent surgery from Jun 2005 through Jun 2018 at a Metabolic and Bariatric Surgery Center of Excellence. Quantitative demographic data was summarized using descriptive statistics; categorical variables were compared using Fisher's exact test. RESULTS: Two hundred fourteen procedures were performed, of which 208 were eligible for inclusion. Majority were female (65.4%). The mean age and BMI was 43 (17-68 years) and 65.9 kg/m2 (60 95 kg/m2), respectively. Comorbidities included: obstructive sleep apnea (74%), hypertension (59%), gastro-esophageal reflux disease (43%), osteoarthritis (41%), and diabetes mellitus (30%). Surgical approach: 97 Roux-en-Y gastric bypasses (46%), 88 laparoscopic sleeve gastrectomies (42%), and 23 adjustable gastric bands (11%). Additional subset included: primary (87%), conversion (7.7%), and revision (5.3%); majority being laparoscopic (75%) and robotic (24%). Complications via Clavien-Dindo classification: one Grade I, one Grade II, three Grade IIIa, three Grade IIIb, and three Grade IVa. Thirty-day events: 11 complications (5.3%; one leak [0.5%], one deep vein thrombosis [0.5%]), six re-admissions (3%), four re-operations (2%): repair of staple-line leak, repair of incisional hernia, uterine dilation and curettage, and cholecystectomy. No mortalities occurred. Complications occurred in 14.8% of conversion/revision cases, 3.9% in primary cases (p = 0.0395) with no difference observed between laparoscopic (4.5%) and robotic (6.1%) modalities (p = 0.7051). CONCLUSION: Bariatric surgery is feasible in patients with SSO. Revision procedures may increase risk of operative complications.

Development of a Method for Clinical Evaluation of Artificial Intelligence-Based Digital Wound Assessment Tools.

Importance: Accurate assessment of wound area and percentage of granulation tissue (PGT) are important for optimizing wound care and healing outcomes. Artificial intelligence (AI)-based wound assessment tools have the potential to improve the accuracy and consistency of wound area and PGT measurement, while improving efficiency of wound care workflows. Objective: To develop a quantitative and qualitative method to evaluate AI-based wound assessment tools compared with expert human assessments. Design, Setting, and Participants: This diagnostic study was performed across 2 independent wound centers using deidentified wound photographs collected for routine care (site 1, 110 photographs taken between May 1 and 31, 2018; site 2, 89 photographs taken between January 1 and December 31, 2019). Digital wound photographs of patients were selected chronologically from the electronic medical records from the general population of patients visiting the wound centers. For inclusion in the study, the complete wound edge and a ruler were required to be visible; circumferential ulcers were specifically excluded. Four wound specialists (2 per site) and an AI-based wound assessment service independently traced wound area and granulation tissue. Main Outcomes and Measures: The quantitative performance of AI tracings was evaluated by statistically comparing error measure distributions between test AI traces and reference human traces (AI vs human) with error distributions between independent traces by 2 humans (human vs human). Quantitative outcomes included statistically significant differences in error measures of false-negative area (FNA), false-positive area (FPA), and absolute relative error (ARE) between AI vs human and human vs human comparisons of wound area and granulation tissue tracings. Six masked attending physician reviewers (3 per site) viewed randomized area tracings for AI and human annotators and qualitatively assessed them. Qualitative outcomes included statistically significant difference in the absolute difference between AI-based PGT measurements and mean reviewer visual PGT estimates compared with PGT estimate variability measures (ie, range, standard deviation) across reviewers. Results: A total of 199 photographs were selected for the study across both sites; mean (SD) patient age was 64 (18) years (range, 17-95 years) and 127 (63.8%) were women. The comparisons of AI vs human with human vs human for FPA and ARE were not statistically significant. AI vs human FNA was slightly elevated compared with human vs human FNA (median [IQR], 7.7% [2.7%-21.2%] vs 5.7% [1.6%-14.9%]; P < .001), indicating that AI traces tended to slightly underestimate the human reference wound boundaries compared with human test traces. Two of 6 reviewers had a statistically higher frequency in agreement that human tracings met the standard area definition, but overall agreement was moderate (352 yes responses of 583 total responses [60.4%] for AI and 793 yes responses of 1166 total responses [68.0%] for human tracings). AI PGT measurements fell in the typical range of variation in interreviewer visual PGT estimates; however, visual PGT estimates varied considerably (mean range, 34.8%; mean SD, 19.6%). Conclusions and Relevance: This study provides a framework for evaluating AI-based digital wound assessment tools that can be extended to automated measurements of other wound features or adapted to evaluate other AI-based digital image diagnostic tools. As AI-based wound assessment tools become more common across wound care settings, it will be important to rigorously validate their performance in helping clinicians obtain accurate wound assessments to guide clinical care.

Neural Monitoring for Robotic Abdominal Wall Reconstruction.

INTRODUCTION: Positioning-related neural injuries are an inherent risk in surgery, particularly in robotic-assisted abdominal wall reconstruction because of unique patient positioning and increased operative times. The implementation of intraoperative neurophysiological monitoring should be considered in such cases. METHODS: This was a two-armed study with one prospective intervention group and one retrospective control group. All patients underwent robotic abdominal wall reconstruction at an academic center. The prospective arm underwent robotic reconstruction from January through July 2019. The retrospective database reviewed patients who underwent the same procedure from August 2015 through July 2018. Factors assessed included: demographics (age, gender, body mass index, comorbidities), surgical details (American Society of Anesthesiologists class, procedure, operative time, positioning), outcomes (length of stay, 30-d readmission, reoperation), and any new-onset intraoperative or postoperative neuropathy. Patients were seen in the clinic postoperatively at weeks 1 and 6. RESULTS: Ten patients were included in the prospective arm. All received intraoperative neurophysiological monitoring using somatosensory evoked potentials. They were compared with 47 patients in the retrospective arm who underwent surgery without intraoperative neurophysiological monitoring. One position-related neural response from baseline was detected intraoperatively in the prospective arm; however, there were no peripheral neurological symptoms present postoperatively. Two patients in the control group developed transient peripheral neuropathies that resolved within 6 weeks. Demographics, surgical procedures, and length of surgery were similar in both groups. The prospective group had a higher rate of preoperative neuropathy and intraoperative use of vasopressors. CONCLUSION: Incorporation of neurophysiological monitoring in robotic surgery is feasible and may lead to the prevention and reduction in positioning-related injuries.

Short-Term Outcomes in Patients Undergoing Paraesophageal Hiatal Hernia Repair.

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. The ideal technique and timing of repair remains controversial. This report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20-91 years) and a mean BMI of 29.2 kg/m2 (17-42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0-3.0) and 2.0 days (1.0-2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. There were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

Factors associated with severity of accidental hypothermia: A cohort retrospective multi-institutional study.

BACKGROUND: Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients. METHODS: Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30-2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference. RESULTS: There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%-34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma. CONCLUSIONS: For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions.

Ascending the Learning Curve of Robotic Abdominal Wall Reconstruction.

BACKGROUND: Robotic complex abdominal wall reconstruction (r-AWR) using transversus abdominis release (TAR) is associated with decreased wound complications, morbidity, and length of stay compared with open repair. This report describes a single-institution experience of r-AWR. METHODS: A retrospective chart review was performed on patients who underwent r-AWR by a single surgeon (D.H.) from August 2015 through October 2018. RESULTS: Fifty-five patients underwent r-AWR (16 males [29%] and 39 females [71%]) with a mean age of 60.2 (range 33 to 87) years and a mean body mass index of 34.6 (range 23 to 54) kg/m2. Forty-one patients presented with an initial ventral hernia (74.5%) and 14 with a recurrent hernia (25.5%). Five patients had a grade 1 hernia (9.1%), 46 had a grade 2 hernia (83.6%), and 4 had a grade 3 hernia (7.3%) according to the Ventral Hernia Working Group system. Thirty-four (62%) patients underwent TAR, 21 (38%) patients underwent bilateral retrorectus release, and 10 (18.2%) patients underwent concomitant inguinal hernia repair. Mean operative time with TAR was 294 (range 106 to 472) minutes and 183 (range 126 to 254) minutes without TAR. Mean length of stay was 1.5 (range 0 to 10) days. Mean follow-up was 10.7 (range 1 to 52) weeks with no hernia recurrences. Seromas occurred in 6 (10.9%) patients, with 2 (3.6%) requiring drainage. Two (3.6%) 30-day readmissions occurred with no conversions to open or 30-day mortalities. CONCLUSIONS: r-AWR with and without TAR is a safe and feasible procedure associated with a short LOS, low complication rate, and low recurrence even within the surgeon's learning curve experience.

Necrotizing Myositis: A Rare Necrotizing Soft Tissue Infection Involving Muscle.

INTRODUCTION: Necrotizing myositis (NM) is an extremely rare necrotizing soft tissue infection involving muscle. Unlike similar infections (eg, necrotizing fasciitis, clostridial myonecrosis) that can be more readily diagnosed, NM can have a benign presentation then rapidly progress into a life-threatening condition with a mortality rate of 100% without surgical intervention. CASE REPORT: A 74-year-old man with a history of prostate cancer with radiation therapy, seed implants, and 2 transurethral resection procedures presented to the emergency department after a fall. He was initially diagnosed and treated for urosepsis. Sixteen hours after presentation, he complained of pain and swelling of his right groin. Computed tomography of the abdomen and pelvis showed gas findings suspicious for necrotizing infection of the bilateral thighs. Surgical exploration revealed NM. Separate cultures from the left thigh and bladder grew Streptococcus intermedius, Clostridium clostridioforme, and Peptostreptococcus, suggesting a possible common source of infection from the prostate gland or the osteomyelitic pubic symphysis, which subsequently spread to the bilateral thighs. CONCLUSIONS: To the best of the authors' knowledge, this is the first reported case of S intermedius and C clostridioforme causing NM. A high index of suspicion is required for extremely rare conditions like NM, because early diagnosis and surgical intervention significantly reduce mortality.

An unusual presentation of Merkel cell carcinoma: a case report.

Merkel cell carcinoma (MCC) is a rare, aggressive carcinoma that usually arises in sun-exposed regions. MCC is a primary neuroendocrine tumor that arises in the skin. This report describes an unusual case of MCC on the buttocks that was treated with excision, radiation and chemotherapy. Physicians should consider MCC as a differential diagnosis when encountering a rapidly growing, painless lesion. Early diagnosis and treatment may improve patient survival rates.

A Perioperative Approach to Increase Limb Salvage When Treating Foot Ulcers in Patients With Diabetes.

Foot ulceration in patients with diabetes increases the risk of lower extremity amputation. Major amputations produce substantial adverse consequences, increase length of hospital stay, diminish quality of life, and increase mortality. In this article, we describe approaches that decrease amputations and improve the quality of life for patients with diabetes and foot ulcers. We highlight the role of the perioperative nurse, who is essential to providing optimal patient care in the perioperative period. Perioperative care of patients with diabetes involves providing optimal surveillance for a break in the skin of the foot, screening for neuropathy, following guidelines for foot ulcer infections, preparing for pathophysiology-based debridement, using adjuvant therapies, and offloading the patient's affected foot. Nurses should understand the disease process and pathophysiology and how to use these approaches in the perioperative setting to assist in curtailing the morbidity and mortality associated with foot ulcers in patients with diabetes.

The Future of Data-Driven Wound Care.

Care for patients with chronic wounds can be complex, and the chances of poor outcomes are high if wound care is not optimized through evidence-based protocols. Tracking and managing every variable and comorbidity in patients with wounds is difficult despite the increasing use of wound-specific electronic medical records. Harnessing the power of big data analytics to help nurses and physicians provide optimized care based on the care provided to millions of patients can result in better outcomes. Numerous applications of machine learning toward workflow improvements, inpatient monitoring, outpatient communication, and hospital operations can improve overall efficiency and efficacy of care delivery in and out of the hospital, while reducing adverse events and complications. This article provides an overview of the application of big data analytics and machine learning in health care, highlights important recent advances, and discusses how these technologies may revolutionize advanced wound care.