Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes.

Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.

Developing the Ready Military Medical Force: military-specific training in Graduate Medical Education.

Introduction: Graduate Medical Education plays a critical role in training the next generation of military physicians, ensuring they are ready to uphold the dual professional requirements inherent to being both a military officer and a military physician. This involves executing the operational duties as a commissioned leader while also providing exceptional medical care in austere environments and in harm's way. The purpose of this study is to review prior efforts at developing and implementing military unique curricula (MUC) in residency training programs. Methods: We performed a literature search in PubMed (MEDLINE), Embase, Web of Science, and the Defense Technical Information Center through August 8, 2023, including terms "graduate medical education" and "military." We included articles if they specifically addressed military curricula in residency with terms including "residency and operational" or "readiness training", "military program", or "military curriculum". Results: We identified 1455 articles based on title and abstract initially and fully reviewed 111. We determined that 64 articles met our inclusion criteria by describing the history or context of MUC, surveys supporting MUC, or military programs or curricula incorporated into residency training or military-specific residency programs. Conclusion: We found that although there have been multiple attempts at establishing MUC across training programs, it is difficult to create a uniform curriculum that can be implemented to train residents to a single standard across services and specialties.

Case Volume and Readiness to Deploy: Clinical Opportunities for Active-Duty Surgeons Outside of Military Hospitals.

BACKGROUND: The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach. STUDY DESIGN: Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training. RESULTS: Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold. CONCLUSIONS: Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.

Committee on Surgical Combat Casualty Care position statement on the use of single surgeon teams and invited commentaries.

BACKGROUND: Over the last 20 years of war, there has been an operational need for far forward surgical teams near the point of injury. Over time, the medical footprint of these teams has decreased and the utilization of mobile single surgeon teams (SSTs) by the Services has increased. The increased use of SSTs is because of a tactical mobility requirement and not because of proven noninferiority of clinical outcomes. Through an iterative process, the Committee on Surgical Combat Casualty Care (CoSCCC) reviewed the utilization of SSTs and developed an expert-opinion consensus statement addressing the risks of SST utilization and proposed mitigation strategies. METHODS: A small triservice working group of surgeons with deployment experience, to include SST deployments, developed a statement regarding the risks and benefits of SST utilization. The draft statement was reviewed by a working group at the CoSCCC meeting November 2021 and further refined. This was followed by an extensive iterative review process, which was conducted to ensure that the intended messaging was clear to senior medical leaders and operational commanders. The final draft was voted on by the entire CoSCCC membership. To inform the civilian trauma community, commentaries were solicited from civilian trauma leaders to help put this practice into context and to further the discussion in both military and civilian trauma communities. RESULTS: After multiple revisions, the SST statement was finalized in January 2022 and distributed to the CoSCCC membership for a vote. Of 42 voting members, there were three nonconcur votes. The SST statement underwent further revisions to address CoSCCC voting membership comments. Statement commentaries from the President of the American Association for the Surgery for Trauma, the chair of the Committee on Trauma, the Medical Director of the Military Health System Strategic Partnership with the American College of Surgeons and a recently retired military surgeon we included to put this military relevant statement into a civilian context and further delineate the risks and benefits of including the trauma care paradigm in the Department of Defense (DoD) deployed trauma system. CONCLUSION: The use of SSTs has a role in the operational environment; however, operational commanders must understand the tradeoff between tactical mobility and clinical capabilities. As SST tactical mobility increases, the ability of teams to care for multiple casualty incidents or provide sustained clinical operations decreases. The SST position statement is a communication tool to inform operational commanders and military medical leaders on the use of these teams on current and future battlefields.

Utilizing the Army Physical Fitness Test as a Primary Outcome in Surgical Clinical Research.

Functional data as part of clinical outcomes such as Activities of Daily Living and Quality of Life (QOL) frequently depend on surveys and are thus inherently limited by self-reporting and patient subjectivity. Specifically, the 12-Item Short Form Survey (SF-12), 36-Item Short Form Survey (SF-36), and Carolinas Comfort Scale are validated instruments for assessing medical and surgical QOL outcomes. However, performance-based measures of disability are lacking. We propose the Army Physical Fitness Test (APFT) as a novel clinical measure of function following surgical intervention. We believe that studies using the APFT as a surgical outcome can potentially provide novel, relevant insights that may guide the utilization of specific surgical interventions and that the use of APFT data in surgical research will meet contemporary ethical standards.

Soft skills in a hard world: Why emergency management and business continuity leaders must update their professional toolbox.

In today's rapidly changing threat environment, especially amid the COVID-19 pandemic, the roles of emergency management (EM) and business continuity (BC) professionals are continuously evolving. Today's EM/BC professional has become more mission-critical than ever, with their position placed under a spotlight as companies of all sizes prepare themselves for the next unknown, but inevitable, crisis. A common problem, however, is that many professionals with the requisite hard skills lack a light touch when it comes to communicating the goals they are striving to achieve. This paper discusses the importance of soft skills for the crisis management guru. The paper lays out which of the multitude of soft skills are the most critical, outlining ways for EM/BC professionals to build, utilise and maintain their soft skills, with case studies that exemplify the use or misuse of such skills.

Concurrent granulomatous mastitis and invasive ductal cancer in contralateral breasts-a case report and review.

Idiopathic granulomatous mastitis (GM) is an uncommon chronic benign disease of the breast that is challenging to clinically distinguish from malignancy. However, it is unusual to diagnose GM concurrently with carcinoma in the same breast and rarer still to encounter GM and malignancy in contralateral breasts. We describe the case of a 39-year-old female who presented with right multifocal breast cancer and left granulomatous mastitis, discuss complexities in her management plan and review the literature on this unusual concurrent condition.

Successful Placement of REBOA in a Rotary Wing Platform Within a Combat Theater: Novel Indication for Partial Aortic Occlusion.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to augment resuscitation in patients with noncompressible torso hemorrhage, which is a leading cause of death on the battlefield. However, the implementation of REBOA has resulted in considerable debate within the military medical community. We present a case of the first successful placement of an REBOA by a small surgical team within a mobile rotary wing platform.

Conceptual design considerations for a wireless intraocular pressure sensor system for effective glaucoma management.

As a leading form of preventable visual impairment, it is imperative to assess glaucoma treatment as a function of intraocular pressure (IOP). IOP can spike throughout the day. This necessitates a device that can (1) monitor IOP outside of clinical visits by providing a memory when IOP exceeds a set threshold indicating the possibility for glaucomatous damage to occur; and (2) accurately assess IOP. Both requirements point ultimately towards the development of an implantable device. The Wireless Intraocular Pressure Sensor System (WIPSS) devised by our team uses optical technologies and may assist an overseeing clinician with assessing glaucoma treatment efficacy and avoiding irreversible glaucomatous visual field loss downstream.

Uranium isotope fractionation by abiotic reductive precipitation.

Significant uranium (U) isotope fractionation has been observed during abiotic reduction of aqueous U, counter to the expectation that uranium isotopes are only fractionated by bioassociated enzymatic reduction. In our experiments, aqueous U is removed from solution by reductive precipitation onto the surfaces of synthetic iron monosulfide. The magnitude of uranium isotopic fractionation increases with decreasing aqueous U removal rate and with increasing amounts of neutrally charged aqueous Ca-U-CO3 species. Our discovery means that abiotic U isotope fractionation likely occurs in any reducing environment with aqueous Ca ≥ 1 mM, and that the magnitude of isotopic fractionation changes in response to changes in aqueous major ion concentrations that affect U speciation. Our results have implications for the study of anoxia in the ancient oceans and other environments.

Using strontium isotopes to evaluate the spatial variation of groundwater recharge.

Recharge of alluvial aquifers is a key component in understanding the interaction between floodplain vadose zone biogeochemistry and groundwater quality. The Rifle Site (a former U-mill tailings site) adjacent to the Colorado River is a well-established field laboratory that has been used for over a decade for the study of biogeochemical processes in the vadose zone and aquifer. This site is considered an exemplar of both a riparian floodplain in a semiarid region and a post-remediation U-tailings site. In this paper we present Sr isotopic data for groundwater and vadose zone porewater samples collected in May and July 2013 to build a mixing model for the fractional contribution of vadose zone porewater (i.e. recharge) to the aquifer and its variation across the site. The vadose zone porewater contribution to the aquifer ranged systematically from 0% to 38% and appears to be controlled largely by the microtopography of the site. The area-weighted average contribution across the site was 8% corresponding to a net recharge of 7.5 cm. Given a groundwater transport time across the site of ~1.5 to 3 years, this translates to a recharge rate between 5 and 2.5 cm/yr, and with the average precipitation to the site implies a loss from the vadose zone due to evapotranspiration of 83% to 92%, both ranges are in good agreement with previously published results by independent methods. A uranium isotopic (234U/238U activity ratios) mixing model for groundwater and surface water samples indicates that a ditch across the site is hydraulically connected to the aquifer and locally significantly affects groundwater. Groundwater samples with high U concentrations attributed to natural bio-reduced zones have 234U/238U activity ratios near 1, suggesting that the U currently being released to the aquifer originated from the former U-mill tailings.

Morbidity Following Coloanal Anastomosis: A Comparison of Colonic J-Pouch vs Straight Anastomosis.

BACKGROUND: Low rectal tumors are often treated with sphincter-preserving resection followed by coloanal anastomosis. OBJECTIVE: The purpose of this study was to compare the short-term complications following straight coloanal anastomosis vs colonic J-pouch anal anastomosis. DESIGN: Patients were identified who underwent proctectomy for rectal neoplasia followed by coloanal anastomosis in the 2008 to 2013 American College of Surgeons National Surgical Quality Improvement Program database. Demographic characteristics and 30-day postoperative complications were compared between groups. SETTINGS: A national sample was extracted from the American College of Surgeons National Surgical Quality Improvement Project database. PATIENTS: Inpatients following proctectomy and coloanal anastomosis for rectal cancer were selected. MAIN OUTCOME MEASURES: Demographic characteristics and 30-day postoperative complications were compared between the 2 groups. RESULTS: One thousand three hundred seventy patients were included, 624 in the straight anastomosis group and 746 in the colonic J-pouch group. Preoperative characteristics were similar between groups, with the exception of preoperative radiation therapy (straight anastomosis 35% vs colonic J-pouch 48%, p = 0.0004). Univariate analysis demonstrated that deep surgical site infection (3.7% vs 1.4%, p = 0.01), septic shock (2.25% vs 0.8%, p = 0.04), and return to the operating room (8.8% vs 5.0%, p = 0.0006) were more frequent in the straight anastomosis group vs the colonic J-pouch group. Major complications were also higher (23% vs 14%, p = 0.0001) and length of stay was longer in the straight anastomosis group vs the colonic J-pouch group (8.9 days vs 8.1 days, p = 0.02). After adjusting for covariates, major complications were less following colonic J-pouch vs straight anastomosis (OR, 0.57; CI, 0.38-0.84; p = 0.005). Subgroup analysis of patients who received preoperative radiation therapy demonstrated no difference in major complications between groups. LIMITATIONS: This study had those limitations inherent to a retrospective study using an inpatient database. CONCLUSION: Postoperative complications were less following colonic J-pouch anastomosis vs straight anastomosis. Patients who received preoperative radiation had similar rates of complications, regardless of the reconstructive technique used following low anterior resection. See Video Abstract at http://links.lww.com/DCR/A468.

Overall Survival Associated With Ileostomy Closure in Patients With Rectal Cancer Before and After Adjuvant Therapy.

BACKGROUND: A diverting loop ileostomy is commonly constructed to protect a distal anastomosis after proctectomy for rectal cancer. Little data are available on whether closing the ileostomy before or after adjuvant chemotherapy affects survival. METHODS: We conducted a retrospective review of patients with rectal cancer who underwent a low anterior resection with diverting loop ileostomy followed by adjuvant chemotherapy at Ochsner Medical Center. The primary outcome was the long-term survival in patients who had their loop ileostomies closed before chemotherapy (BC) vs after chemotherapy (AC). RESULTS: Seventy-two patients were identified (22 in the BC group vs 50 in the AC group). No difference in mean age (BC 59.5 ± 9.8 vs AC 59.2 ± 12.6, P=0.9) or preoperative clinical stage was seen between study groups. The mean interval from ileostomy creation to closure was significantly shorter in the BC group vs AC group (16.9 ± 14.5 weeks vs 33.6 ± 18.1 weeks, P=0.0001). Follow-up data revealed a similar mean duration from surgery to last contact (BC 50.6 ± 23.6 months vs AC 43.5 ± 22.1 months, P=0.23) and similar overall survival (BC 86% vs AC 70%, P=0.23) between groups. CONCLUSION: Long-term survival was similar in patients who underwent ileostomy closure before and after adjuvant therapy following low anterior resection for rectal cancer. While this study was underpowered, it adds additional insight to an area of surgery lacking significant data. The timing of ileostomy closure should be individualized for each patient.

Effect of paleoseawater composition on hydrothermal exchange in midocean ridges.

Variations in the Mg, Ca, Sr, and SO4 concentrations of paleoseawater can affect the chemical exchange between seawater and oceanic basalt in hydrothermal systems at midocean ridges (MOR). We present a model for evaluating the nature and magnitude of these previously unappreciated effects, using available estimates of paleoseawater composition over Phanerozoic time as inputs and 87Sr/86Sr of ophiolite epidosites and epidote-quartz veins as constraints. The results suggest that modern hydrothermal fluids are not typical due to low Ca and Sr relative to Mg and SO4 in modern seawater. At other times during the last 500 million years, particularly during the Cretaceous and Ordovician, hydrothermal fluids had more seawater-derived Sr and Ca, a prediction that is supported by Sr isotope data. The predicted 87Sr/86Sr of vent fluids varies cyclically in concert with ocean chemistry, with some values much higher than the modern value of ∼0.7037. The seawater chemistry effects can be expressed in terms of the transfer efficiency of basaltic Ca and Sr to seawater in hydrothermal systems, which varies by a factor of ∼1.6 over the Phanerozoic, with minima when seawater Mg and SO4 are low. This effect provides a modest negative feedback on seawater composition and 87Sr/86Sr changes. For the mid-Cretaceous, the low 87Sr/86Sr of seawater requires either exceptionally large amounts of low-temperature exchange with oceanic crust or that the weathering flux of continentally derived Sr was especially small. The model also has implications for MOR hydrothermal systems in the Precambrian, when low-seawater SO4 could help explain low seawater 87Sr/86Sr.

Portal vein thrombosis after laparoscopic total colectomy for colonic inertia.

Portal vein thrombosis (PVT) has been recently documented after a variety of laparoscopic surgeries. Although it is well established in splenectomies, its prevalence in other laparoscopic procedures is rare. PVT in colectomies has been associated with inflammatory processes, such as ulcerative colitis and diverticulitis. We report a case of postoperative PVT following a total abdominal colectomy for colonic inertia. A 27-year-old female underwent an uneventful elective laparoscopic total colectomy with ileorectal anastomosis for colonic inertia, and presented on postoperative day (POD) 3 with obstipation, abdominal distention and emesis. Her abdominal pain increased on POD 4 and computed tomography revealed PVT. PVT following laparoscopic surgery is rare in cases not involving the spleen. Although previously seen in colectomies for inflammatory conditions, it can present after colonic inertia. A high index of suspicion should be maintained to diagnosis this rare complication.

Type I/type III collagen ratio associated with diverticulitis of the colon in young patients.

BACKGROUND: The incidence of diverticulitis in young patients is rising, whereas the type I:III collagen ratio of the colon decreases with age. Perhaps a lower type I:III collagen ratio in younger patients may predispose these patients to the development of the disease. METHOD: The purpose of this study was to evaluate the collagen content and type I:III collagen ratio in patients with diverticulitis versus a control group. Patients who underwent a colon resection were identified. Three groups of patients were created for analysis: those with diverticulitis aged <50 y, >50 y, and a control group. Tissue samples were stained with Sirius red/fast green and photographed. Photos analysis was performed to quantify the amount of type I collagen and type III collagen. The type I:III collagen ratio was calculated for each patient and compared. RESULTS: The quantity of type I collagen and type III collagen was higher in patients with diverticulitis aged >50 y (P = 0.04 and P < 0.0001, respectively); however, the collagen ratio was greatest in those patients with diverticulitis aged <50 y (P = 0.01). Further analysis demonstrated a significant higher type I:III ratio in all patients aged less than 50 y compared with all patients aged over 50 y (P = 0.04). CONCLUSIONS: Our study demonstrated that diverticulitis in the younger patient was not associated with a lower type I:III collagen ratio. It appears that the decrease in collagen ratio of the colon with age is associated with an increase in type III collagen deposition.

Se Isotopes as Groundwater Redox Indicators: Detecting Natural Attenuation of Se at an in Situ Recovery U Mine.

One of the major ecological concerns associated with the in situ recovery (ISR) of uranium (U) is the environmental release of soluble, toxic selenium (Se) oxyanions generated by mining. Post-mining natural attenuation by the residual reductants in the ore body and reduced down-gradient sediments should mitigate the risk of Se contamination in groundwater. In this work, we investigate the Se concentrations and Se isotope systematics of groundwater and of U ore bearing sediments from an ISR site at Rosita, TX, USA. Our results show that selenate (Se(VI)) is the dominant Se species in Rosita groundwater, and while several up-gradient wells have elevated Se(VI), the majority of the ore zone and down-gradient wells have little or no Se oxyanions. In addition, the δ82SeVI of Rosita groundwater is generally elevated relative to the U ore up to +6.14‰, with the most enriched values observed in the ore-zone wells. Increasing δ82Se with decreasing Se(VI) conforms to a Rayleigh type distillation model with an ε of -2.25‰ ± 0.61‰, suggesting natural Se(VI) reduction occurring along the hydraulic gradient at the Rosita ISR site. Furthermore, our results show that Se isotopes are excellent sensors for detecting and monitoring post-mining natural attenuation of Se oxyanions at ISR sites.

A short-duration restrictive diet reduces visceral adiposity in the morbidly obese surgical patient.

BACKGROUND: This study aims to determine if visceral obesity can be reduced after a brief preoperative diet in obese patients. METHODS: Forty morbidly obese patients were placed on a 1,000 kCal per day diet for 14 days before bariatric surgery. Patients had weight measurements and an abdominal ultrasound performed on days 1 and 14. The ultrasound measured visceral obesity using the distance between the abdominal muscle and the aorta, the fat thickness of the perinephric space, and the distance between the abdominal muscle and splenic vein. Mesenteric fat burden was calculated and compared. RESULTS: Thirty-eight patients (95%) lost weight on the diet, with a mean loss of 5.2 lbs. Twenty-five patients (63%) had a reduction in mesenteric fat. The average visceral obesity lost was 7.76 cm3 or 3% of the visceral adiposity of the average obese patient (250 cm3). CONCLUSIONS: A short preoperative calorie restricting diet is well tolerated and results in a reduction in visceral obesity.

Isotopic Evidence for Reductive Immobilization of Uranium Across a Roll-Front Mineral Deposit.

We use uranium (U) isotope ratios to detect and quantify the extent of natural U reduction in groundwater across a roll front redox gradient. Our study was conducted at the Smith Ranch-Highland in situ recovery (ISR) U mine in eastern Wyoming, USA, where economic U deposits occur in the Paleocene Fort Union formation. To evaluate the fate of aqueous U in and adjacent to the ore body, we investigated the chemical composition and isotope ratios of groundwater samples from the roll-front type ore body and surrounding monitoring wells of a previously mined area. The (238)U/(235)U of groundwater varies by approximately 3‰ and is correlated with U concentrations. Fluid samples down-gradient of the ore zone are the most depleted in (238)U and have the lowest U concentrations. Activity ratios of (234)U/(238)U are ∼5.5 up-gradient of the ore zone, ∼1.0 in the ore zone, and between 2.3 and 3.7 in the down-gradient monitoring wells. High-precision measurements of (234)U/(238)U and (238)U/(235)U allow for development of a conceptual model that evaluates both the migration of U from the ore body and the extent of natural attenuation due to reduction. We find that the premining migration of U down-gradient of the delineated ore body is minimal along eight transects due to reduction in or adjacent to the ore body, whereas two other transects show little or no sign of reduction in the down-gradient region. These results suggest that characterization of U isotopic ratios at the mine planning stage, in conjunction with routine geochemical analyses, can be used to identify where more or less postmining remediation will be necessary.