Parastomal hernia repairs: A nationwide cohort study in the Republic of Ireland.

BACKGROUND: In the context of improving colorectal cancer outcomes, post-survivorship quality of life has become an important outcome measure. Parastomal hernias and their associated morbidity remain largely under-reported and under-appreciated. Despite their burden, conservative management is common. This study aims to provide a national overview on the current trends in parastomal hernia repairs (PHRs). METHODS: All PHRs performed in public hospitals across the country between 1/2017 to 7/2022 were identified retrospectively from the National Quality Assurance and Improvement System (NQAIS) database. Anonymised patient characteristics and quality indices were extracted for statistical analysis. RESULTS: A total of 565 PHRs, 64.1 % elective and the remainder emergent, were identified across 27 hospitals. The 8 national colorectal units performed 67.3 % of all repairs. While 42.3 % of PHRs were standalone procedures, reversal of Hartmann's procedure was the commonest simultaneous procedure in the remainder. The median age, ASA and Charlson Co-Morbidity Index were 64 years (19), 3(1) and 3(10) respectively. Mean length of stay (LOS) was 16.25 days (SD = 29.84). Linear regression analysis associated ASA (95 % CI 0.58-16.08, p < 0.035) and emergency admissions (95 % CI 5.86-25.55, P < 0.002) with a significantly longer LOS, with the latter also associated with more frequent emergency re-admissions (95 % CI 0.18-0.82, p < 0.002). CONCLUSION: Patients undergoing emergency PHR were older and significantly more comorbid. Consequently, these patients were subjected to longer hospital stays, more frequent readmissions and overall higher hospital costs. Multidisciplinary perioperative optimisation and standardised referral pathways should underpin the shift towards elective PHRs.

Pre-hospital emergency medicine: a spectrum of imaging findings.

The goal of emergency medical services (EMS) is to provide urgent medical care and stabilization prior to patient transport to a healthcare facility for definitive treatment. The number and variety of interventions performed in the field by EMS providers continues to grow as early management of severe injuries and critical illness in the pre-hospital setting has been shown to improve patient outcomes. The sequela of many field interventions, including those associated with airway management, emergent vascular access, cardiopulmonary resuscitation (CPR), patient immobilization, and hemorrhage control may be appreciated on emergency department admission imaging. Attention to these imaging findings is important for the emergency radiologist, who may be the first to identify a malpositioned device or an iatrogenic complication arising from pre-hospital treatment. Recognition of these findings may allow for earlier corrective action to be taken in the acute care setting. This review describes common EMS interventions and their imaging findings.

Minimally Invasive and Open Gastrectomy for Gastric Cancer: A Systematic Review and Network Meta-Analysis of Randomized Clinical Trials.

BACKGROUND AND OBJECTIVES: Optimal surgical management for gastric cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing outcomes after open gastrectomy (OG), laparoscopic-assisted gastrectomy (LAG), and robotic gastrectomy (RG) for gastric cancer. METHODS: A systematic search of electronic databases was undertaken. An NMA was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using R and Shiny. RESULTS: Twenty-two RCTs including 6890 patients were included. Overall, 49.6% of patients underwent LAG (3420/6890), 46.6% underwent OG (3212/6890), and 3.7% underwent RG (258/6890). At NMA, there was a no significant difference in recurrence rates following LAG (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.77-1.49) compared with OG. Similarly, overall survival (OS) outcomes were identical following OG and LAG (OS: OG, 87.0% [1652/1898] vs. LAG: OG, 87.0% [1650/1896]), with no differences in OS in meta-analysis (OR 1.02, 95% CI 0.77-1.52). Importantly, patients undergoing LAG experienced reduced intraoperative blood loss, surgical incisions, distance from proximal margins, postoperative hospital stays, and morbidity post-resection. CONCLUSIONS: LAG was associated with non-inferior oncological and surgical outcomes compared with OG. Surgical outcomes following LAG and RG superseded OG, with similar outcomes observed for both LAG and RG. Given these findings, minimally invasive approaches should be considered for the resection of local gastric cancer, once surgeon and institutional expertise allows.

Characterization of all-terrain vehicle-related thoracolumbar spine injury patterns in children using the AOSpine classification system.

PURPOSE: To evaluate thoracolumbar spine injury patterns, demographics, and clinical characteristics in pediatric patients following all-terrain vehicle-related trauma. METHODS: A retrospective review of patients 0-17 years old admitted to a level I trauma center following an ATV-related incident from 2004 to 2013 was performed. Thoracolumbar spine injury patterns, accident mechanism, driver/passenger status, and demographic and clinical data were compared between patients with and without a spine injury. RESULTS: Of 456 pediatric patients involved in ATV-related trauma, 36 sustained one or more thoracolumbar spine injuries (7.9%). These patients tended to be older, taller, heavier, and had a higher BMI. ATV rollover was the major statistically significant mechanism of injury to cause spine fractures (61%). Patients with spine injuries had twice the hospital length of stay compared with those without (4 days vs. 2 days, P = 0.003). Nonstructural spine injuries (A0) were the most common type of injury (49.1%), followed by wedge-compression fractures (A1) (41.1%). In patients with a thoracolumbar spine injury, there was a mean of 3.11 spine injuries per child. Four (10%) patients with thoracolumbar spine fractures also sustained a cervical spine fracture. CONCLUSION: Once a thoracolumbar spine injury has been detected in a patient, the entire spinal column should be scrutinized because there is a high likelihood for additional injuries throughout the spine. Younger pediatric patients (≤ 8 years old) exhibit a spine fracture pattern distinct from that of older children who have a mature osseous-ligamentous complex.

Characterization of all-terrain vehicle-related chest injury patterns in children.

PURPOSE: To evaluate chest injury patterns in pediatric patients involved in all-terrain vehicle (ATV) accidents. METHODS: Retrospective review of patients 0-18 years old admitted to a level I trauma institute following an ATV-related incident from 2004 to 2013 was performed. Chest injury type, accident mechanism, driver/passenger status, and demographic and clinical data were compared between patients with and without chest injury. RESULTS: Chest injury was present in 102 (22%) of total 455 patients. The most common chest injuries were pulmonary contusion (61%), pneumothorax (45%), and rib fracture (34%). There were no cardiac, esophageal, or tracheobronchial injuries. Pulmonary lacerations, hemothoraces, and scapular fractures were predominantly not detected on radiography and recognized on CT only (86-92%). Patients with chest injury had longer median hospital stays (3 days vs 2 days, p = 0.0054). There was no significant difference in admission to intensive care after controlling for injury severity scores in patients with chest injury compared to those without (17 vs 9). Eight patients with chest injury died (8%) compared to 2 patients without chest injury (0.6%) (p = 0.0002). CONCLUSIONS: Chest injuries are common in children following ATV accidents and may be a marker of more severe trauma. Increased public awareness of these potentially devastating injuries and continuing safety efforts are needed.

Vaunting the independent amateur: Scientific American and the representation of lay scientists.

This paper traces how media representations encouraged enthusiasts, youth and skilled volunteers to participate actively in science and technology during the twentieth century. It assesses how distinctive discourses about scientific amateurs positioned them with respect to professionals in shifting political and cultural environments. In particular, the account assesses the seminal role of a periodical, Scientific American magazine, in shaping and championing an enduring vision of autonomous scientific enthusiasms. Between the 1920s and 1970s, editors Albert G. Ingalls and Clair L. Stong shepherded generations of adult 'amateur scientists'. Their columns and books popularized a vision of independent non-professional research that celebrated the frugal ingenuity and skills of inveterate tinkerers. Some of these attributes have found more recent expression in present-day 'maker culture'. The topic consequently is relevant to the historiography of scientific practice, science popularization and science education. Its focus on independent non-professionals highlights political dimensions of agency and autonomy that have often been implicit for such historical (and contemporary) actors. The paper argues that the Scientific American template of adult scientific amateurism contrasted with other representations: those promoted by earlier periodicals and by a science education organization, Science Service, and by the national demands for recruiting scientific labour during and after the Second World War. The evidence indicates that advocates of the alternative models had distinctive goals and adapted their narrative tactics to reach their intended audiences, which typically were conceived as young persons requiring instruction or mentoring. By contrast, the monthly Scientific American columns established a long-lived and stable image of the independent lay scientist.

The Impact of Geniculate Artery Collateral Circulation on Lower Limb Salvage Rates in Injured Patients.

BACKGROUND: This study aimed to determine the association between geniculate artery flow on admission computed tomography (CT) angiography and limb salvage outcomes in patients with lower extremity arterial injury. METHODS: All injured patients at a level I trauma center with CT angiogram (CTA) confirmed limited or no flow to the tibial vessels were included. Demographics, injury severity score (ISS), mechanism of injury, physiological parameters, the presence of geniculate artery collateral circulation (superior medial, superior lateral, medial, inferior medial, inferior lateral), and 30-day limb salvage outcome were recorded. Statistical analysis was completed using descriptive statistics and the chi-squared tests. RESULTS: From 2009 to 2012, a total of 84 patients with lower extremity arterial injury underwent diagnostic evaluation with CTA on admission that confirmed limited or no flow to the tibial vessels. A total of 10 patients (12%) underwent amputation. Primary amputation was performed in 3 (4%) patients, and secondary amputation was performed in 7 (8%) patients. There was no difference in age, gender, ISS, extremity abbreviated injury score, mechanism of injury, admission systolic blood pressure, heart rate, respiratory rate, transfusion volume, or type of vascular interventions between patients who had successful limb salvage and those who received an amputation. The number of patent geniculate arterial vessels was inversely associated with amputation with 3.3 patent geniculate arteries in the limb salvage group compared to 2.1 in the amputation group (P < 0.05). The 2 geniculate artery vessels that were significantly associated with limb salvage were the superior lateral geniculate and the inferior medial geniculate arteries (P < 0.05). CONCLUSIONS: Geniculate collateral circulation may have an important role in limb salvage after lower extremity vascular injury. The geniculate arteries that are associated with the highest rates of limb salvage appear to be the superior lateral geniculate and the inferior medical geniculate artery.

Conformational stability and catalytic activity of PTEN variants linked to cancers and autism spectrum disorders.

Phosphoinositides are membrane components that play critical regulatory roles in mammalian cells. The enzyme PTEN, which catalyzes the dephosphorylation of the phosphoinositide PIP3, is damaged in most sporadic tumors. Mutations in the PTEN gene have also been linked to autism spectrum disorders and other forms of delayed development. Here, human PTEN is shown to be on the cusp of unfolding under physiological conditions. Variants of human PTEN linked to somatic cancers and disorders on the autism spectrum are shown to be impaired in their conformational stability, catalytic activity, or both. Those variants linked only to autism have activity higher than the activity of those linked to cancers. PTEN-L, which is a secreted trans-active isoform, has conformational stability greater than that of the wild-type enzyme. These data indicate that PTEN is a fragile enzyme cast in a crucial role in cellular metabolism and suggest that PTEN-L is a repository for a critical catalytic activity.

Observation may be an inadequate approach for injured extremities with single tibial vessel run-off.

INTRODUCTION: Trauma patients with sudden loss of distal perfusion due to tibial injuries are frequently not offered vascular interventions if a single vessel retains patency. We hypothesized that sudden loss of either all or some tibial vasculature would result in increased non-operative failure and higher amputation rates. METHODS: In this retrospective observational study, all traumatically injured patients from 2009 to 2012 with CT-angiogram-confirmed anterior tibial, posterior tibial, or peroneal artery injuries were included. RESULTS: From 2009 to 2012, 437 patients were admitted with arterial extremity injury of which 234 (53%) were lower extremity. From this group, 84 (36%) patients were identified with CT-angiogram-confirmed limited or no flow in the tibial arteries. A total of 44% (4/9) with 0 or 1 tibial vessel failed observation while only 8% (2/27) failed if they had 2 or 3 patent vessels (p < 0.05). Amputation rate was inversely related the number of open tibial vessels. There were 2.7 open tibial vessels in the limb salvage group compared to 1.1 in the amputation group (p < 0.05). CONCLUSION: Patients who failed an initial trial of observation were significantly more likely to have 0 or 1 tibial vessels patent. The number of open tibial vessels is significantly associated with limb salvage.

The use of multislice CT angiography preoperative study for supraclavicular artery island flap harvesting.

BACKGROUND: The vascular anatomy of the supraclavicular artery island (SAI) flap has been investigated using both cadaveric anatomic dissections and angiographic studies. Accurate preoperative evaluation and localization of its vascular pedicle confirms its location, course, anatomic variation, and improves flap success. The objective of this report is to demonstrate the utility of multislice computed tomography (CT) angiography for confirming the presence of the vascular pedicle of the SAI flap when planning head and neck reconstruction. METHODS: Patients were studied using 64-multislice CT angiography (CTA) to localize the supraclavicular artery, including its origin and destination. Axial images, multiplanar reconstructions, and 3D volume-rendered images were analyzed on a Philips workstation. Radiologic image findings and clinical experience will be described. RESULTS: SAI CT angiography was successfully performed in 15 patients (30 shoulders) ranging from ages 22 to 81 years. Accurate identification of the main vascular pedicle was achieved in 14/15 patients. Location, course, pedicle length, and anatomic variations were reported for 23 of 30 arteries. Mean vessel diameter was found to be 1.49 mm (range, 0.8-2.0 mm) on the right and 1.51 mm (range, 1.0-2.1 mm) on the left. The mean length of the artery was 38.3 mm on the right (range, 26.6-59.6 mm) and 38.4 mm on the left (range, 24.3-67.0 mm). In all patients, the supraclavicular artery originated off the transverse cervical artery-a branch of the thyrocervical trunk. Positioning of the patient's upper extremities at the side was helpful in the identification of the supraclavicular artery and its distribution. Contrast injection site should be contralateral to the side needed for the flap if sidedness is of importance, secondary to contrast bolus artifact. CONCLUSIONS: Preoperative evaluation of the SAI flap with multislice computed tomography angiography is feasible in patients. A radiologic study protocol has been developed which improves the ability to detect this vessel. This technique provides a noninvasive approach to the identification of the vascular anatomy and is easily standardized/reproducible. The identification of the vascular pedicle and its anatomy can be a benefit to the surgical team during preoperative design of the SAI flap; however, clinical experience confirming these radiologic findings will be needed to optimize surgical outcome.

Small Bowel Obstruction Secondary to Migration of a Fractured Esophageal Stent.

Esophageal stent placement is commonly indicated for the management of inoperable esophageal malignancies, benign strictures, and esophageal perforations including Boerhaave's syndrome. We present a case of a 74-year-old female, who presented with small bowel obstruction secondary to a migrated esophageal stent, which was placed 20 weeks previously for Boerhaave's syndrome. She was surgically managed with laparotomy and retrieval of the fractured stent with local resection of the small bowel, followed by primary anastomosis.

In vivo performance of a rare earth free Mg-Zn-Ca alloy manufactured using twin roll casting for potential applications in the cranial and maxillofacial fixation devices.

A magnesium alloy containing essential, non-toxic, biodegradable elements such as Ca and Zn has been fabricated using a novel twin-roll casting process (TRC). Microstructure, mechanical properties, in vivo corrosion and biocompatibility have been assessed and compared to the properties of the rare earth (RE) element containing WE43 alloy. TRC Mg-0.5 wt% Zn- 0.5 wt% Ca exhibited fine grains with an average grain size ranging from 70 to 150 µm. Mechanical properties of a TRC Mg-0.5Zn-0.5Ca alloy showed an ultimate tensile strength of 220 MPa and ductility of 9.3%. The TRC Mg-0.5Zn-0.5Ca alloy showed a degradation rate of 0.51 ± 0.07 mm/y similar to that of the WE43 alloy (0.47 ± 0.09 mm/y) in the rat model after 1 week of implantation. By week 4 the biodegradation rates of both alloys studied were lowered and stabilized with fewer gas pockets around the implant. The histological analysis shows that both WE43 and TRC Mg-0.5Zn-0.5Ca alloy triggered comparable tissue healing responses at respective times of implantation. The presence of more organized scarring tissue around the TRC Mg-0.5Zn-0.5Ca alloys suggests that the biodegradation of the RE-free alloy may be more conducive to the tissue proliferation and remodelling process.

Quality and reliability evaluation of current Internet information regarding mesh use in inguinal hernia surgery using HONcode and the DISCERN instrument.

INTRODUCTION: Mesh-related complications following pelvic prolapse surgery has potentiated societal fear and led to increased investigation into mesh use in inguinal hernia repair (IHR) surgery online. However concern exists regarding the quality of Internet health informatics. The DISCERN Instrument and HONcode  tool can be used to assess the quality and reliability of online health information. The aim of this study is to investigate the reliability and quality of online information pertaining to mesh use in IHR surgery using the DISCERN instrument and HONcode tool. METHODS: An Internet search using the keywords: 'mesh', 'inguinal hernia' and 'surgery' was carried out via Google, Yahoo, Bing, Facebook and Twitter. The HONcode and DISCERN scores were generated for each of the first ten search engine result pages (SERPs). RESULTS: Google provided the most reliable [Median HONcode score 77% (IQR 25.5%)] and highest quality information [Median DISCERN score; 61.5 (IQR 18.25)]. Social media yielded both the most unreliable and lowest quality information. Facebook was the most unreliable [Median HONcode score 21% (IQR 14.25%)], while Twitter imparted the lowest quality information [Median DISCERN score of 18.5 (IQR 25.25)]. DISCUSSION: A 2018 Cochrane review concluded the use of mesh in IHR to be safe and associated with superior outcomes. However, numerous SERPs present results contradicting this, based solely upon Level 5 evidence. Commercialisation of the Internet has resulted in search engine optimisation, which can permit lesser quality sites to obtain higher SERP ranking. Alarmingly  if only a limited search is carried out by patients [4], lower quality, sensationalist evidence may be the only information they are exposed to. As such this may negatively influence the patient decision-making process detrimentally. However utilisation of social media by healthcare professionals may offer a solution to bridge the gap between the public and high quality medical information. CONCLUSIONS: Online information regarding mesh repair of inguinal herniae is of variable quality and reliability. Enhanced quality assurance of online health information is necessary. However, increased presence by hernia societies on social media may help to disseminate high quality information to patients, thus enabling pre-hospital education to set the scene prior to formal hospital consultation.

In Vivo Evaluation of Bioabsorbable Fe-35Mn-1Ag: First Reports on In Vivo Hydrogen Gas Evolution in Fe-Based Implants.

This work investigates the influence of Ag (1 wt%) on the mechanical properties, in vitro and in vivo corrosion, and biocompatibility of Fe-35Mn. The microstructure of Fe-35Mn-1Ag possesses a uniform dispersion of discrete silver particles. Slight improvements in compressive properties are attributed to enhanced density and low porosity volume. Fe-35Mn-1Ag exhibits good in vitro and in vivo corrosion rate of Fe-35Mn due to an increase in microgalvanic corrosion. Gas pockets, which originate from an inflammatory response to the implants, are observed in the rats after 4 weeks implantation but are undetectable after 12 weeks. No chronic toxicity is observed with the Fe-35Mn-1Ag, suggesting acceptable in vivo biocompatibility. The high corrosion rate of the alloy triggers an increased level of nonadverse tissue inflammatory responses 4 weeks after implantation, which subsequently subsides at 12 weeks. The Fe-35Mn-1Ag displays properties that are suitable for orthopedic applications.

Imaging Findings of SARS-CoV-2 Infection in Pediatrics: A Systematic Review of Coronavirus Disease 2019 (COVID-19) in 850 Patients.

RATIONALE AND OBJECTIVES: Children with COVID-19 seem to have a relatively milder disease and better prognosis; however, severe disease or death could still occur in this age group. Although the knowledge on the clinical and epidemiology of COVID-19 in pediatric patients is being accumulated rapidly, relevant comprehensive review on its radiological manifestations is still lacking. The present article reviews the radiological characteristics of COVID-19 in pediatrics, based on the previous studies. MATERIALS AND METHODS: We conducted a systematic literature search for published articles by using Medline, Scopus, Google Scholar and Embase online databases. All studies describing CT findings of COVID-19 in pediatrics (<18years) were included. RESULTS: A total of 39 studies with 850 pediatric patients were reviewed. 225 (26.5%) of patients had normal CT findings. Ground-glass opacities and consolidations were the most common CT abnormalities (384/625, 61.5%). Other findings were halo sign, interstitial opacities, bronchial wall thickening, and crazy-paving sign. Approximately 55% of patients had unilateral pulmonary findings. Most studies found peripheral and lower-lobe distribution to be a prominent imaging finding. CONCLUSION: Our study showed that imaging findings in children were often milder and more focal than adults, typically as ground-glass opacities and consolidations with unilateral lower-lobe predominance, which have been regressed during the recovery time. A balance must be struck between the risk of radiation and the need for chest CT. If still necessary, low-dose CT is more appropriate in this age group. Albeit, due to the limited number of reported pediatrics with COVID-19, and the lack of consistency in CT descriptors, further work is still needed in this regard.

Late biliary endoclip migration after laparoscopic cholecystectomy: Case report and literature review.

INTRODUCTION: Although formerly considered a rarity, biliary endoclip-related complications are being diagnosed with increasing frequencies. Among these, migration of endoclip into the common bile duct (CBD) is a rare encounter that usually presents in the first two years after surgery. PRESENTATION OF CASE: This case demonstrates a late biliary endoclip migration after laparoscopic cholecystectomy. DISCUSSION: An 82-year-old male patient, with a history of laparoscopic cholecystectomy 22 years ago, presented with two-day history of severe upper abdominal pain. Routine hemogram and serum chemistry were remarkable for slightly raised alanine aminotransferase and C-reactive protein. A computed tomographic (CT) scan demonstrated a new metallic density within the CBD when compared to a previous CT scan 14 months earlier. An endoscopic retrograde cholangiography confirmed a metal endoclip within the mid-CBD contained within a choledochal stone. Balloon extraction of the endoclip and stone was successfully performed. The patient was discharged 2 days later, and remained symptom free for 1 year. CONCLUSION: To our knowledge, a latency of 22 years between cholecystectomy and clip migration has never been reported before. In cases of post-cholecystectomy abdominal pain the awareness of the surgeon should always be drawn to a clinical suspicion of endoclip migration into the CBD that can be easily remedied. Endoscopic biliary sphincterotomy with endoclip/stone removal is the therapeutic procedure of choice which usually circumvents the need for surgical extraction.

Strangulated obturator hernia - an unusual presentation of intestinal obstruction.

An 81-year-old Caucasian emaciated female presented with 3 days history of colicky abdominal pain nausea, projectile vomiting and abdominal distension. A pre-operative diagnosis of mechanical bowel obstruction was made. The absence of characteristic clinical signs in this thin elderly woman with a small bowel obstruction failed to provide a pre-operative diagnosis. She underwent a midline laparotomy and resection and anastomosis of small bowel and repair of the strangulated right obturator hernia. The high mortality rate associated with this type of abdominal hernias requires a high index of suspicion to facilitate rapid diagnosis and prompt surgical intervention if the survival rate is to be improved.

The Prospects for Biodegradable Zinc in Wound Closure Applications.

Zinc is identified as a promising biodegradable metal along with magnesium and iron. In the last 5 years, considerable progress is made on understanding the mechanical properties, biodegradability, and biocompatibility of zinc and its alloys. A majority of these studies have focused on using zinc for absorbable cardiovascular and orthopedic device applications. However, it is likely that zinc is also suitable for other biomedical applications. In this work, the prospects for zinc in the fabrication of wound closure devices such as absorbable sutures, staples, and surgical tacks are critically assessed, with the aim of inspiring future research on biodegradable Zn for this medical application.

Absorbable Mg surgical tack: Proof of concept &in situ fixation strength.

A prototype magnesium (Mg) surgical tack is tested comparatively against commercially available tacks made of titanium (ProTacktm, Medtronic) and PLGA (AbsorbaTacktm, Medtronic). The pull-out force is measured in situ in a lap-shear pull-out test, using porcine abdominal muscle tissue as a model. The Mg tack had a pull-out force comparable to those of the commercially available tacks. The majority of the Mg tacks also had a more ductile failure mode (i.e. the tacks deformed prior to failure), compared to the commercial tacks which pulled directly from the tissue with no deformation. The Mg tacks deformed as they were removed from the tissue, causing less damage to the tissue in the process. This is the first reported use of a Mg alloy in this application, and the proof of concept indicates that this is an area that deserves further interest and study.