A Nationwide Analysis of Gunshot Wounds of the Head and Neck: Morbidity, Mortality, and Cost.

BACKGROUND: Gun violence in the United States rose continuously from 2010 to 2022, spiking during the pandemic, and peaking in 2021 at 48,830 deaths (14.8 per 100,000). Previous reports investigated health and financial burden associated with gunshot wounds (GSWs) during 2004 to 2013; however estimates related specifically to head and neck (H&N) injuries have been lacking. This population-based study aims to examine incidence, morbidity, mortality, and health resource utilization of H&N injuries utilizing the Nationwide Inpatient Sample database. METHODS: A population-based study was undertaken using the National (Nationwide) Inpatient Sample (NIS) database (2015Q4-2017Q4). The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to create a composite variable (inclusive of brain, eye, facial nerve, and facial fractures) resulting from GSW to the H&N. Incidence per 100,000 hospitalizations and case fatality rates were calculated to determine the health burden of H&N injuries. Length of hospital stay, and inflation- adjusted hospital charges were compared among H&N and non-H&N injuries. Χ 2 (classical and bootstrapped) and Mann-Whitney tests were used to compare groups. RESULTS: Of 101,300 injuries caused by firearms, 16,140 injuries (15.9%) involved H&N region. The average incidence of H&N injuries was 20.1 cases per 100,000 hospitalizations, with intentional injuries having the highest case fatality rates of 32.4%. Patients with H&N injuries had extreme loss of function (33.4% versus 18.3%, P <0.001) and extreme likelihood of mortality (27.0% versus 11.3%, P <0.001) than non-H&N injuries. Statistically significant differences in the median length of stay (4.8 d versus 3.7 d; P <0.001) and median inflation-adjusted hospital charges ($80,743 versus $58,946, P <0.001) were found among H&N and non-H&N injuries. CONCLUSIONS: Injuries due to GSW remain an inordinate health care and financial burden, with trauma to the H&N carrying an especially high cost in dollars, morbidity, and mortality.

Radiation Exposure in Interventional Pain Management Physicians: A Systematic Review of the Current Literature.

BACKGROUND: Millions of interventional pain procedures are performed each year to address chronic pain. The increase in these procedures also raises the concern of health risks associated with ionizing radiation for interventional pain management physicians who perform fluoroscopy-guided operations. Some health concerns include cancers, cataracts, and even pregnancy abnormalities. Little is known regarding the long-term and cumulative effects of small radiation doses. OBJECTIVES: The objective of this systematic review was to identify common body parts that are exposed to ionizing radiation during interventional pain procedures and examine methods to help physicians reduce their radiation exposure. STUDY DESIGN: The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist was used to comprehensively identify articles from 2 medical databases. The radiation dose to interventional pain management physicians obtained from relevant peer-reviewed articles were aggregated and used for analysis. METHODS: PubMed was first used to collect the articles for two broad keyword searches of "radiation exposure pain management" and "radiation exposure interventionalist" with years ranging from 1956 - February 2023. EMBASE was also used to collect the articles for the two keyword searches of "radiation exposure pain management" and "radiation exposure interventionalist" with years ranging from 1969 - February 2023. This systematic approach yielded a total of 2,736 articles; 24 were included in our paper. The risk of bias for these articles was performed using the Cochrane Risk of Bias tool and the National Institutes of Health tool. RESULTS: Through our systematic literature search, more than 3,577 patients were treated by 30 interventional pain management physicians. Some areas of exposure to radiation include the physician's neck, chest, groin, hands, and eyes. One common body region that is exposed to radiation is the chest; our review found that wearing lead aprons can lower the radiation dose by more than 95%. Wearing protective equipment and managing the distance between the operator and fluoroscope can both independently lower the radiation dose by more than 90% as well. Our literature review also found that other body parts that are often overlooked in regard to radiation exposure are the eyes and hands. In our study, the radiation dose to the outside (unprotected) chest ranged from 0.008 ± 27 mrem to 1,345 mrem, the outside neck ranged from 572 mrem to 2,032 mrem, the outside groin ranged from 176 mrem to 1,292 mrem, the hands ranged from 0.006 ± 27.4 mrem to 0.114 ± 269 mrem, and the eyes ranged from 40 mrem to 369 mrem. When protective equipment was worn, the radiation exposure to the inside chest ranged from 0 mrem to 108 mrem, the inside neck ranged from 0 mrem to 68 mrem, and the inside groin ranged from 0 mrem to 15 mrem. LIMITATIONS: Limitations of this study include its small sample size; only the radiation exposure of 30 interventional pain management physicians were examined. Furthermore, this review mainly consisted of observational studies rather than randomized clinical trials. CONCLUSION:   Implementing safety precautions, such as wearing protective gear, providing educational programs, and keeping a safe distance, demonstrated a significant decrease in radiation exposure. The experience of interventional pain management physicians also factored into their radiation exposure during procedures. Radiation is a known carcinogen, and more research is needed to better understand its risk to interventional pain management physicians.

Augmented Web-based applicant experiences for anesthesiology away audition rotations: A systematic review of the current literature.

Objective: The objective of this paper is to evaluate Augmented Web-based Applicant Experiences in the field of Anesthesiology. We hope to advocate for Augmented Web-based Applicant Experiences rotations and address their limitations in case in-person rotations become restricted again. Methods: A thorough search of articles from the years 1978 to 2023 was completed using the search phrases "Away Rotations Anesthesiology," "Away Rotations Anesthesia," "Audition Rotation Anesthesia" and "Audition Rotation Anesthesiology." These search phrases were used on both the PubMed (Medline) and Excerpta medica database (EMBASE) databases, and the number of total articles that appeared was 73. These articles were then filtered to gather relevant articles for our study. Results: After the articles were filtered, there was one remaining article that was used for our study. To supplement this article, 29 additional sources were added using the worldwide web. However, these did not address rotations in Anesthesiology. Although these other sources did not involve Anesthesiology residencies, they still provide significant perspectives that can be applied to online rotations. A total of 30 sources were used for our manuscript. Conclusion: Although in-person rotations are preferred, Augmented Web-based Applicant Experiences rotations are valuable as they give residency programs an opportunity to evaluate students. Augmented Web-based Applicant Experiences rotations also provide students with learning opportunities and also help familiarize them with the residency programs. There are limitations that come with Augmented Web-based Applicant Experiences rotations. However, addressing these shortcomings can help Augmented Web-based Applicant Experiences rotations become a proper substitution for in-person rotations if they become restricted again.

Spontaneous secondary pneumothorax due to cannabis-induced bullous lung disease: a case report.

Marijuana use has grown rapidly in the last decade with a prevalence greater than that of cocaine and opioids. With its increasing recreational and medical use, potential adverse outcomes from heavy use may be associated with bullous lung disease and spontaneous pneumothorax. This case report has been reported in line with the SCARE Criteria. Case presentation: The authors describe a case of an adult male with a past medical history of spontaneous pneumothorax and long-standing marijuana use presenting with dyspnoea who was found to have a secondary spontaneous pneumothorax requiring invasive treatment. Clinical discussion: The aetiology of lung injury due to heavy marijuana smoke may be from direct tissue injury from inhaled irritants and the method of which marijuana smoke is inhaled compared with tobacco smoke. Conclusion: Chronic marijuana use should be considered when evaluating structural lung disease and pneumothorax in the setting of minimal tobacco use.

Radiofrequency Ablation's Effectiveness for Treating Abdominal and Thoracic Chronic Pain Syndromes: A Systematic Review of the Current Literature.

BACKGROUND: Many patients suffer from abdominal and thoracic pain syndromes secondary to numerous underlying etiologies. Chronic abdominal and thoracic pain can be difficult to treat and often refractory to conservative management. In this systematic literature review, we evaluate the current literature to assess radiofrequency ablation's (RFA) efficacy for treating these debilitating chronic pain conditions in the thoracic and abdominal regions. OBJECTIVES: The objective of this study is to determine the pain relief efficacy of RFA on chronic thoracic and chronic abdominal disease states. STUDY DESIGN: This study is a systematic literature review that uses the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) method to gather academic literature articles through a methodical approach. The numbers obtained from each academic manuscript were then used to calculate the percent efficacy of radiofrequency ablation on thoracic and abdominal pain relief. METHODS: Articles from 1992 through 2022 were gathered using PRISMA guidelines. The search terms "Radiofrequency Ablation Thoracic Pain" and "Radiofrequency Ablation Abdominal Pain" were used to identify articles to include in our study. Our search yielded a total of 575 studies, 32 of which were included in our study. The articles were then categorized into pain causes. The efficacy of RFA for each qualitative study was then quantified. Risk of bias was also assessed for articles using the Cochran Risk of Bias tool, as well as a tool made by the National Institutes of Health. RESULTS: The PRISMA search yielded a total of 32 articles used for our study, including 16 observational studies, one cohort study, 6 case reports, 6 case series, and 3 clinical trials. Twenty-five articles were labeled good quality and one article was labeled fair quality according to the risk of bias assessment tools. The studies examined RFA efficacy on chronic abdominal and chronic pain syndromes such as spinal lesions, postsurgical thoracic pain, abdominal cancers, and pancreatitis. Among these etiologies, RFA demonstrated notable efficacy in alleviating pain among patients with spinal osteoid osteomas or osteoblastomas, lung cancer, and pancreatic cancer. The modes of RFA used varied among the studies; they included monopolar RFA, bipolar RFA, pulsed RFA, and RFA at different temperatures. The average efficacy rate was 84% ranging from 55.8% - 100%. A total of 329 males and 291 females were included with ages ranging 4 to 90 years old. LIMITATIONS: Limitations of this review include the RFA not being performed at the same nerve level to address the same pathology and the RFA not being performed for the same duration of time. Furthermore, the efficacy of RFA was evaluated via large case series and single cohort observational studies rather than control group observational studies and clinical trial studies. CONCLUSION: A systematic review of the literature supports RFA as a viable option for managing abdominal and thoracic pain. Future randomized controlled trials are needed to investigate the efficacy of the various RFA modalities to ensure RFA is the source of pain relief as a large body of the current literature focuses only on observational studies.

Cardiac Anesthesia Intraoperative Interpretation Accuracy of Transesophageal Echocardiograms: A Review of the Current Literature and Meta-Analysis.

Background: In the United States, echocardiography is an essential component of the care of many cardiac patients. Recently, increased attention has been given to the accuracy of interpretation of cardiac-based procedures in different specialties, amongst them the field of cardiac anesthesiology and primary echocardiographers for transesophageal echocardiogram (TEE). The purpose of this study was to assess the TEE skills of cardiac anesthesiologists in comparison to primary echocardiographers, either radiologists or cardiologists. In this systematic review, we evaluated available current literature to identify if cardiac anesthesiologists interpret TEE procedures at an identical level to that of primary echocardiographers. Methods: A PRISMA systematic review was utilized from PubMed from the years 1952-2022. A broad keyword search of "Cardiology Anesthesiology Echocardiogram" and "Echocardiography Anesthesiology" to identify the literature was used. From reviewing 1798 articles, there were a total of 9 studies included in our systematic review, 3 of which yielded quantitative data and 6 of which yielded qualitative data. The mean accuracy from each of these three qualitative studies was calculated and used to represent the overall accuracy of cardiac anesthesiologists. Results: Through identified studies, a total of 8197 TEEs were interpreted by cardiac anesthesiologists with a concordance rate of 84% to the interpretations of primary echocardiographers. Cardiac anesthesiologists had a concordance rate of 83% when compared to radiologists. On the other hand, cardiac anesthesiologists and cardiologists had a concordance rate of 87% in one study and 79% in another study. Conclusion: Based on these studies, cardiac anesthesiologists are shown to interpret TEEs similarly to that of primary echocardiographers. At this time, there is no gold standard to evaluate the accuracy of TEE readings. One way to address this is to individually assess the TEE interpretation of anesthesiologists and primary echocardiographers with a double-blind study.

Recognition and repair of an incidental umbilical hernia repair during abdominoplasty.

Introduction: Umbilical hernias are found in 2% of the American adult population with increasing prevalence in overweight and multiparous women. A mesh repair is considered to be a suitable option for those desiring non-cosmetic surgical repair. Despite the mesh plug's reported value in reduction of the recurrence of umbilical hernia from 11% to 1%, there is an increased risk in de-vascularizing the umbilicus with its use. Presentation of Case: We present a case which avoids fascial incisions near the umbilicus, thus preserving the blood supply employing sutures to reduce the small abdominal wall defect which is then further reinforced by overlying rectus muscle plication. Discussion of Case: Hernia repair can be associated with a host of issues, minor and major, including regional tissue ischemia and the distortion of natural anatomy, likely due to ischemia of the epigastric vessels. Abdominoplasty is a suitable option for patients with redundancy of the abdominal skin and laxity abdominal wall musculature. Abdominoplasty has excellent exposure and correction of abdominal wall hernias. This "anatomic repair" employing sutures to reduce the small abdominal wall defect which is then further reinforced by overlying rectus muscle plication can be used in place of a mesh overlay for the purposes of umbilical hernia repair especially when the hernia may be asymptomatic. Conclusion: Abdominoplasty uniquely allows for an open hernia repair when anticipated or discovered at the time of surgery and is considered a true anatomical repair of an umbilical hernia which does not necessitates the use of foreign materials.

Regional and Acute Pain Anesthesiology Post COVID-19 Assessment and Recommendations for Fellowship Web Based Platforms.

In today's applicant landscape, the SARS-COV-2 pandemic has drastically altered the traditional model of in-person interviews shifting it to an online format often conducted by web-based applications. Fellowship programs and naturally fellowship program directors face a new challenge of standardizing information to be distributed to prospective fellowship applicants through American Society of Regional Anesthesia and Pain Medicine (ASRA) common application. Here we describe a set of 11 criteria recommended by other similar studies selected for evaluation of online program training platforms, where only 13.3% of the acute and regional pain fellowship program online platforms met 75% of the criteria with limited presence in areas of research, rotation schedules, list of fellows, alumni, and life in the area. Additional considerations pertaining to the types of procedures performed, evaluation, mentorship, academic involvement, and teaching should be undertaken by the programs.

COVID-19 association with purpura fulminans: report of a life threatening complication in a fully vaccinated patient.

SARS-CoV-2 manifestations have been an ongoing evolving topic that has spread beyond its initial respiratory associations. Recently, there have been reports of COVID-19 infections found to be associated with vascular pathologies. Here, we describe a case of a fully vaccinated COVID-19 adult male with past medical history of purpura fulminans that presented with diffuse necrotic cutaneous tissue sequelae resulting in intensive care unit management and dry gangrene of upper extremity. On admission, it was found that the patient had decreased activity rather than quantity of coagulation pathway protein S. Early recognition and work up are essential in patients with known history of vascular disease and confirmed cases of SARS-CoV-2 positive polymerase chain reaction.

Ipsilateral Posterior Hip Dislocation and Femur Shaft Fracture - A Rare Presentation.

INTRODUCTION: Posterior hip dislocation with an ipsilateral femur fracture is a rare injury - unfortunately, due to high-speed crashes, these complex injuries are increasing in nature. CASE PRESENTATION: This case report examines a 24-year-old male who was involved in a high-speed motorcycle accident. X-ray imaging after clinical suspicion exhibited a posterior hip. dislocation and ipsilateral femoral shaft fractures. Following unsuccessful reduction, the patient was treated under general anesthesia with a temporary external fixator followed by intramedullary nailing of the shaft. CONCLUSION: Hip dislocation is a traumatic injury and an emergency. Although the treatment of a posterior hip dislocation can prove difficult in the context of an ipsilateral fracture, a closed reduction with intermedullary nailing can prove difficult and might require a Schanz screw of external fixation for the purposes of leverage and reduction.

Large extended abdominoplasty-dispelling the myths of prohibitively high BMI's: a case report.

Abdominoplasty is one of the most highly requested cosmetic procedures in the USA. Although it is famed for its cosmetic value, there are few reports that discuss its therapeutic potential. Furthermore, few abdominoplasties are completed in patients over the body mass index (BMI) of 30 due to fears of increased complications. A 63-year-old male presented due to development of a large pannus following weight loss postgastric bypass. Unfortunately, because of this pannus, the patient began experiencing significant physical and emotional distress. The patient had difficult urinating, ambulating and could no longer engage in sexual activity. The patient underwent abdominoplasty for removal of the pannus. At the 5-month follow-up, patient exhibited resolution of his symptoms. Abdominoplasty should not be limited to cosmetic procedures. It holds therapeutic value, and the BMI should not be listed as a firm contraindication to the procedure.

Abdominoplasty for treatment of abdominal gun-shot wound sequalae - A case report.

BACKGROUND: Gun violence is a public health epidemic in the United States with 15,315 non-suicide related deaths reported in 2019 by the Gun Violence Archive. To date, abdominoplasty is primarily a cosmetic procedure, which involves low-lying incision, removal of excess skin, fat, and tissue, and strengthening of the abdominal wall musculature. There currently are limited reports in regard to abdominoplasty as a procedure for scar revision and abdominal deformity repair associated with gunshot related injuries. METHODS: An African American female patient, 38 years of age, presented for correction of a wide healed surgical incision and incisional hernia in the midline abdomen. This resulted from a trauma laparotomy in treatment of multiple gunshot wounds. RESULTS: Patient presented post-operatively with no complications. She had successful reduction of her incisional hernia using an anatomic repair. Her wide hypertrophic abdominal scar was excised and primarily closed. CONCLUSION: In the cases of abdominal hernia and scarring secondary to trauma laparotomies performed for gunshot wounds, abdominoplasty is an option for revision and repair.

Anatomic reconstruction for major tissue loss following abdominoplasty: A case report.

INTRODUCTION: Abdominoplasty is currently one of the most widely requested cosmetic procedures in the United States. There is limited literature describing the corrective measures following skin loss from a flap necrosis due to an abdominoplasty complication. METHODS: A 53-year-old female presented with a large split thickness skin graft due to skin loss as a necrotic complication from an abdominoplasty performed at our center. The patient suffered from emotional stress related to the abdominal deformity, which included a lack of an umbilicus. RESULTS: Patient recovered well post-operatively. She required two procedures - the initial procedure involved excision of the skin graft and closure with the patient's own full-thickness skin and tissue. The second procedure, which occurred six months later, involved the creation of an umbilical stalk from a small cuff of skin. CONCLUSION: Abdominoplasty, although sought for cosmetic purposes, is indeed a major procedure and can result in complications especially from aggressive liposculpture. When complications do occur, revisions are indeed possible with aesthetically pleasing results.

Abdominal Flap Necrosis and Wound Dehiscence following a Medical Tourist Tummy Tuck.

Abdominoplasty is a major surgical procedure met with high rates of patient satisfaction and improved self-image. While many patients are lured abroad due to discounted prices for such highly requested procedures, unfortunately, there are also associated complications. A 47-year-old woman presented due to abdominal scar dehiscence due to skin necrosis secondary to a discounted abdominoplasty in Mexico. The patient had been turned away by several local surgical centers for treatment of the necrosis. The patient underwent incision, drainage, and two debridements before her abdominal wound was eventually closed. Patient recovered well postoperatively with improved aesthetic result. With the rise of social media advertisements, more patients elect to receive plastic surgery abroad. Unfortunately, many of these practices are not accurately vetted and this can complicate the postoperative care especially upon return to the United States.