Operating under the influence: the effect of alcohol on operative performance using a virtual robotic training platform-an experimental comparative cohort study.

An elevated percentage of medical personnel reports using alcohol to relieve stress. Levels of alcohol addiction are almost double that of the general population. Robotic surgery is becoming more widespread. The purpose of this study is to evaluate the effects of alcohol ingestion on performance of a standardized curriculum using a robotic training platform. Surgeons and surgical trainees were recruited. Candidates performed 4 standardized exercises (Vitruvian Operation (VO), Stacking Challenge (SC), Ring Tower (RT), Suture Sponge (SS)) at 0.0 blood alcohol concentration (BAC), followed by testing in the elimination phase at a target BAC of 0.8‰. Learning effects were minimised through prior training. A total of 20 participants were recruited. Scores for RT and SS exercises were significantly worse under the influence of alcohol [instruments out of view (SS (z = 2.012; p = 0.044), RT (z score 1.940, p = 0.049)), drops (SS (z = 3.250; p = 0.001)), instrument collisions (SS (z = 2.460; p = 0.014)), missed targets (SS (z = 2.907; p = 0.004)]. None of the scores improved with alcohol consumption, and there were measurable deleterious effects on the compound indicators risk affinity and tissue handling. Despite the potential mitigating features of robotic surgery including tremor filtration, motion scaling, and improved three-dimensional visualization, alcohol consumption was associated with a significant increase in risk affinity and rough tissue handling, along with a deterioration of performance in select virtual robotic tasks. In the interest of patient safety, alcohol should not be consumed prior to performing robotic surgery and sufficiently long intervals between alcohol ingestion and surgical performance are mandatory.

Air Guns: A Contemporary Review of Injuries at Six Pediatric Level I Trauma Centers.

BACKGROUND: Studies spanning the last three decades demonstrated the injury causing capability of air gun (AG) projectiles. Recent studies have suggested the impact and incidence of these injuries may be declining because of edcational efforts. We hypothesize that injuries in the pediatric population resulting from AGs remain a significant health concern. METHODS: A retrospective review (1/1/2007 to 12/31/2016), of AG-injured children < 19 years old, was performed across six level I Pediatric Trauma Centers, part of the ATOMAC research consortium. AG injuries were defined as injuries sustained by ball-bearing or pellet air-powered guns. Paint ball and soft foam AGs were excluded. Following institutional review board approval, patients were identified by ICD code from the trauma registry. Included were demographic data, injury severity scores, length of stay (LOS), outcome at discharge, and overall cost of admission. Descriptive statistics and parametric tests were employed. RESULTS: A total of 499 patients sustained injuries. Mean age 9.5 (±4.0) y; 81% of victims were male; all survived to hospital discharge. 30% (n = 151) required operative intervention. Hospital LOS was 2.3 (±2.2) d; with mean cost of $23,756 (±$34,441). Injury severity score mean of 3.7 (±4.6) on admission. Over 40% of the injuries to the head/thorax that were severe (AIS ≥ 3) required operative intervention (P < 0.001). CONCLUSIONS: AG injuries to the head or thorax seen at trauma centers were likely to require operative management. While no fatalities occurred, the cost was substantial. This study demonstrates pediatric injuries resulting from AG projectiles remain a significant health concern.

Massive transfusion in pediatric trauma: An ATOMAC perspective.

BACKGROUND/PURPOSE: Massive transfusion protocols (MTPs) are considered valuable in pediatric trauma. Important questions regarding the survival benefit and optimal blood component ratio remain unknown. METHODS: The study time frame was January 2007 through December 2013 five Level I Pediatric Trauma Centers reviewed all trauma activations involving children ≤18 years of age. Included were patients who either had the institutional MTP or received >20 mL/kg or > 2 units packed red blood cells (PRBCs). RESULTS: 110/202 qualified for inclusion. Median age was 5.9 years (3.0-11.4). 73% survived to discharge; median hospitalization was 10 (3.1-22.8) days. Survival did not vary by arrival hemoglobin (Hgb), gender or age. Partial prothrombin time (PTT), INR, GCS and injury severity score (ISS) significantly differed for nonsurvivors (all p < 0.05). Logistic regression found increased mortality (OR 3.08 (1.10-8.57), 95% CI; p = 0.031) per unit increase over a 1:1 ratio of pRBC:FFP. CONCLUSION: In pediatric trauma pRBC:FFP ratio of 1:1 was associated with the highest survival of severely injured children receiving massive transfusion. Ratios 2:1 or ≥3:1 were associated with significantly increased risk of death. These data support a higher proportion of plasma products for pediatric trauma patients requiring massive transfusion. LEVEL OF EVIDENCE: Level IV.

In trauma, expect the unexpected: a rare case of post-traumatic pancreatitis associated with salmonellosis and enterocolitis.

A 16-year-old Hispanic man was transferred to our level I paediatric trauma centre with pancreatitis. Ten days prior, he had sustained a gunshot wound to the abdomen requiring an exploratory laparotomy for repair of a traumatic left diaphragmatic injury. Additional injuries included gastric, renal, liver and pancreatic lacerations as well as a T12 burst fracture that resulted in paraplegia. Conservative management of pancreatitis was unsuccessful over the next 10 days, resulting in progressive symptoms of severe unresolved pain, nausea, emesis and rising lipase. Workup for post-traumatic, biliary and drug-associated causes of pancreatitis was negative, and no anatomical abnormalities were found on imaging. A fever workup on hospital day 10 revealed a urinary tract infection with non-typhoid Salmonella sp, and subsequent stool and imaging studies revealed salmonellosis associated with right-sided colitis and Clostridium difficile infection. Pancreatitis resolved within 48 hours following treatment of salmonellosis and Clostridium.

Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis.

BACKGROUND: Pectus excavatum repair (PEX) is among the most painful thoracic procedures performed. Continuous peripheral nerve blockade (CPNB) is known to be efficacious in optimizing pain control while limiting narcotic use in adult thoracic procedures. It was introduced in May 2015 as a bridge to oral pain control in children undergoing PEX. Consequently, the surgical site infection (SSI) rate increased from 2.7% to 27.7%. METHODS: SSI surveillance followed national guidelines. The abrupt increase prompted root cause analysis and cessation of CPNB use. A dynamic systems model of SSI in PEX was developed. Statistical analysis compared SSI outcomes with and without CPNB. RESULTS: From May 2015 to June 2015, 21 PEX were performed; 11 with CPNB. 6 SSIs were observed. Use of CPNB significantly (p=0.008) increased SSI incidence. Haller index, number of bars, usage of Fiberwire®, methicillin resistant S. aureus colonization and length of stay did not differ. Root cause analysis revealed the proximity of CPNB catheters to the wound, the use of CPNB with implanted hardware and a delayed utilization of CPNB catheters to be of concern. CONCLUSION: Introduction of CPNB coincided with a significant increase in SSI. Further study is needed to assess the safety of CPNB in pediatric PEX. LEVEL OF EVIDENCE: Level III treatment study.

Association of FOXM1 expression with tumor histology and prognosis in Wilms tumor: Potential for a new prognostic marker.

Wilms tumor (WT) is the most common pediatric renal malignancy. A recent ontogenic model suggests that undifferentiated tumor state, and hence poor prognosis, in WT is determined by stabilization of ß-catenin in the nucleus. Forkhead box M1 (FOXM1) is a downstream component of the Wnt pathway and promotes nuclear localization of ß-catenin. As elevation of FOXM1 gene expression is prognostic in various types of malignancy, we hypothesized that high FOXM1 expression in WT is associated with undifferentiated histology and thus poor prognosis. In the current study, the expression of FOXM1 mRNA was determined in 46 WT specimens and 11 renal tissue controls from patients undergoing tumor nephrectomy, and these data were assessed with regard to clinicopathological parameters. The results demonstrated an upregulation of FOXM1 in WT by 10-fold compared to normal tissue. Expression differed significantly between controls and tumors of intermediate- and high-risk histopathology (P<0.001, Kruskal-Wallis), and distinguished normal tissue from tumors of good and adverse clinical outcome (P<0.001, Kruskal-Wallis). Notably, FOXM1 expression was significantly lower (P=0.009) in patients that received preoperative doxorubicin. These results suggest that FOXM1 may serve as a companion diagnostic factor for doxorubicin-based therapies in WT.

Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012: Retrospective Cohort Study.

OBJECTIVE: To compare trends in pediatric emergency appendectomy and adverse surgical outcomes between district general hospitals (DGHs) and specialist pediatric centers (SPCs). BACKGROUND: In the past decades in England, a significant reduction in the number of children operated by adult general surgeons has raised concerns about their surgical outcomes compared with specialist pediatric surgeons. METHODS: Using Hospital Episode Statistics, we analyzed patient-level data between April 2001 and March 2012. Main inclusion criteria were children younger than 16 years admitted to NHS-England hospitals for an emergency appendectomy. Main outcomes were annual age-sex adjusted appendectomy rates and postoperative risk of readmission, complication, and reintervention. RESULTS: A total of 83,679 emergency pediatric appendectomies were performed in 21 SPCs and 183 DGHs in England. SPCs performed only 18% of these operations (15,002). Annual age-sex standardized appendectomy rates fell from 87 to 68 per 100,000 population at an estimated 2% (rate ratio, 0.98) fall per annum. This was accompanied by a national annual increased risk of negative appendectomy, complication, reintervention, and readmission (adjusted odds ratio: 1.02, 1.03, 1.04, and 1.06, respectively). Children who had appendectomies in DGHs had 28% more negative appendectomies, 11% more complications, and 11% more readmissions than those in SPCs. Postoperative length of stay was double in SPCs compared with DGHs (median, 4 vs 2 days). CONCLUSIONS: Major reductions in the number of pediatric emergency appendectomies in England over the past decade were associated with an overall increase in adverse surgical outcomes. Children operated in DGHs have more reinterventions, complications, and negative appendectomy rates than those operated in SPCs.

The cooling tube: A novel small animal model of systemic hypothermia in awake Syrian Golden Hamsters (mesocricetus auratus).

Hypothermia is increasingly used as a therapeutic strategy in a diversity of clinical scenarios. Its impact on mammalian physiology, particularly on the microcirculatory changes of critical organ systems, are, however, incompletely understood. Close examination of the literature reveals a marked paucity of small animal models of rapid systemic hypothermia. All published models introduce important microvascular confounders by investigating either local cooling processes or using anaesthetised animals. Here we present the first rapid systemic hypothermia model in an awake hamster. We developed a waterstream cooled copper tube system for standardized systemic temperature control. With this novel system core body temperature (Tc) in 14 awake animals could be precisely stabilised at temperatures of 30°C and 18°C (7 animals, respectively) within 10-20 min. Rewarming was achieved over 10-15 min. Tolerance of the procedure was excellent. Hamsters did not show any behavioural changes in the mild hypothermia group. In the deep hypothermia group 6 of 7 animals regained normal behaviour within 2-11 hs. As hypothermia was induced in dorsal skinfold chamber bearing animals this model seems suitable for investigation of microcirculatory purposes.Advantages over previously established experimental hypothermia models are significant. Amongst these, the possibility of visualization of microcirculation, the lack of microcirculation confounding factors such as anaesthetic drugs, the ability for precise Tc control and rapid induction of hypothermia are prominent.

Laparoscopic treatment of intussusception in children: a systematic review.

BACKGROUND: Idiopathic intussusception is one of the most common causes of small bowel obstruction in children. In the event of failed radiological reduction, laparotomy remains the treatment of choice. There is still no agreement in pediatric surgery about safety and effectiveness of the use of minimally invasive surgery in this common pediatric condition. By reviewing available data we aimed to establish whether laparoscopy should be the primary technique in the surgical reduction of intussusception. METHODS: A systematic review of all publications on the laparoscopic treatment of pediatric intussusception from January 1990 to April 2012 was performed. The following variables were analyzed: age, laparoscopic success rate, reason for conversion, enterotomy rate, operative time, complications, and length of stay (LOS). RESULTS: Ten retrospective studies treating 276 cases of laparoscopically reduced intussusception were identified. A total of 80 conversions corresponded to a 71.0% laparoscopic success rate. Only one case of intraoperative iatrogenic intestinal perforation was reported (0.4%). Postoperative complications occurred in 8 patients (2.9%), and adhesive small bowel obstruction was reported in 1 case (0.4%). Recurrence rate after laparoscopy was 3.6%. Three of 10 papers compared results between laparoscopic and open reduction of intussusception showing a shorter mean LOS in the former group (4.0 vs. 7.1 days, p<0.01). CONCLUSION: Laparoscopy is safe and effective in the treatment of pediatric intussusception. Tertiary centers with adequate minimally invasive skills should establish laparoscopy as the primary surgical technique in the treatment of this condition.

The Prevalence of Norovirus in returning international travelers with diarrhea.

BACKGROUND: There is a high incidence of diarrhea in traveling populations. Norovirus (NV) infection is a common cause of diarrhea and is associated with 7% of all diarrhea related deaths in the US. However, data on the overall prevalence of NV infection in traveling populations is limited. Furthermore, the prevalence of NV amongst travelers returning to Europe has not been reported. This study determined the prevalence of NV among international travelers returning to Germany from over 50 destinations in and outside Europe. METHODS: Stool samples of a total of 104 patients with a recent (< 14 days) history of international travel (55 male, mean age 37 yrs.) were tested for the presence of NV genogroup (GG) I and II infection using a sensitive and well established quantitative RT PCR method. 57 patients experienced diarrhea at the time of presentation at the Department of Infectious Diseases & Tropical Medicine. The remaining 47 patients had no experience of diarrhea or other gastrointestinal symptoms for at least 14 days prior to their date of presentation at our institute. RESULTS: In our cohort, NV infection was detected in 15.7% of returning travelers with diarrhea. The closer to the date of return symptoms appeared, the higher the incidence of NV, ranging as high as 21.2% within the first four days after return. CONCLUSIONS: In our cohort, NV infection was shown to be frequent among returning travelers especially in those with diarrhea, with over 1/5 of diarrhea patients tested positive for NV within the first four days after their return to Germany. Due to this prevalence, routine testing for NV infection and hygienic precautions may be warranted in this group. This is especially applicable to patients at an increased risk of spreading the disease, such as healthcare workers, teachers or food-handlers.

ACP1 genotype, glutathione reductase activity, and riboflavin uptake affect cardiovascular risk in the obese.

Erythrocyte acid phosphatase (ACP locus 1), also known as low-molecular-weight protein tyrosine phosphatase, has previously been associated to glycemia, dyslipidemia, and obesity. In this study, ACP1 genotype and activity were tested in 318 women aged 19 to 83 (mean, 51.74 +/- 13.44) years. ACP1 genotype was found to directly correlate to glutathione reductase activity (P < .001) and levels of low-density lipoprotein cholesterol (P = .038). Glutathione reductase activity was in turn found to correlate to a series of cardiovascular risk factors such as systolic arterial pressure (P < .001), total cholesterol levels (P = .018), and low-density lipoprotein cholesterol levels (P = .039). A possible protective effect of ACP1 genotype AA against these cardiovascular risk factors was observed in this study. Furthermore, this work hypothesizes that nutritional riboflavin uptake becomes more crucial as body mass index increases, to counteract oxidative stress and minimize cardiovascular risk. This might be especially true in ACP1 genotypes AC, BC, and CC, which might possibly show the least endogenous protection against oxidative stress.