Laparoscopic-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography With Placement of a Biliary Stent to Treat Traumatic Intrahepatic Bile Duct Disruption in a Patient With Roux-en-Y Gastric Bypass.

Hepatic injuries are common following blunt trauma and while frequently managed expectantly, biliary injury as a result of the trauma requires a high index of suspicion, a focused workup, and likely interventional treatment. A 44-year-old female with a history of Roux-en-Y gastric bypass presented after a ground level fall and was initially discharged home but represented with worsening abdominal pain and elevated liver enzymes. She was found to have a segment 5/6 biliary injury requiring laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography with common bile duct stent placement. This case represents the difficulty of diagnosing biliary injuries following blunt trauma, and the need for advanced endoscopic interventions for treatment in patients with atypical anatomy.

Acute Traumatic Spinal Cord Injury: Implementation of a Multidisciplinary Care Pathway.

BACKGROUND: Management of acute traumatic spinal cord injuries is complex, and patients are at risk for severe complications while inpatient. Performance review revealed opportunities for improvement in the care of patients with acute traumatic spinal cord injury at our institution. OBJECTIVE: To compare mortality, failure-to-rescue, and health care utilization of patients with acute traumatic spinal cord injury after implementation of a revised multidisciplinary care pathway. METHODS: Using a pre- and post-between-subjects study design, a retrospective cross-sectional analysis of consecutive patients admitted to our Level I trauma center with acute traumatic spinal cord injury was performed. An updated care pathway for all patients who presented with acute traumatic spinal cord injury was implemented in July 2020. This pathway includes a revised order set in the electronic medical record, distribution of a "best practice" guide to inpatient providers, a formal twice-daily respiratory evaluation, and weekly clinical nurse specialist-led patient rounds. RESULTS: One hundred and eight patients were included in analysis (prepathway: n = 52, postpathway: n = 56). Total mean hospital length of stay was 15.2 (14.0) and 21.5 (24.8) days for the pre- and postpathway groups. Eleven patients (21%) compared with six patients (11%) died, and failure-to-rescue occurred in six patients (60%) compared with zero patient in the pre- and postpathway groups, respectively. In addition, 10 (20%) postpathway patients were discharged to home compared with one (2%) in the prepathway group. DISCUSSION: Following implementation of the updated acute traumatic spinal cord injury pathway, overall inpatient mortality decreased, and fewer patients died after experiencing a complication. Results highlight the need for continued review of care practices and multidisciplinary review in quality improvement initiatives.

Operative Management Considerations in a Patient With Multiple Occult Penetrating Cardiac Injuries.

Penetrating cardiac injury remains one of the deadliest traumatic injuries. Early identification and definitive operative management are critical tenets for patient survival; however, variable clinical presentations can obscure the diagnosis. Here, we present the case of a 58-year-old obese man who presented to an urban level 1 trauma center with multiple stab wounds to the epigastrium and lateral left chest in the axillary line with an unknown weapon. The patient was taken emergently to the operating room for exploratory laparotomy, median sternotomy, and attempted repair of multiple full-thickness lacerations of the right ventricle and left and right atrium. This case demonstrates several instructive points. First, a high index of suspicion for penetrating cardiac injury is needed, especially during triage of multiple injuries. Second, careful release of cardiac tamponade is critical. Finally, there are several indications for cardiopulmonary bypass, which include multichambered injuries, uncontrollable hemorrhage, and concern for intracardiac injury.

"Sutton's Law in Surgery: 'That's Where the Money is'".

Many students, residents, and learners have heard of the infamous bank robber, who when arrested was asked "Why do you rob banks?" He supposedly replied "Because that's where the money is." Except it did not happen that way. He did rob close to a hundred banks and jewelry stores and stole an estimated $2,000,000.1 A well-known maxim in medicine and surgery, few know the details of the unrelated men behind "Sutton's Law."

Outcomes after ultramassive transfusion in the modern era: An Eastern Association for the Surgery of Trauma multicenter study.

BACKGROUND: Despite the widespread institution of modern massive transfusion protocols with balanced blood product ratios, survival for patients with traumatic hemorrhage receiving ultramassive transfusion (UMT) (defined as ≥20 U of packed red blood cells [RBCs]) in 24 hours) remains low and resource consumption remains high. Therefore, we aimed to identify factors associated with mortality in trauma patients receiving UMT in the modern resuscitation era. METHODS: An Eastern Association for the Surgery of Trauma multicenter retrospective study of 461 trauma patients from 17 trauma centers who received ≥20 U of RBCs in 24 hours was performed (2014-2019). Multivariable logistic regression and Classification and Regression Tree analysis were used to identify clinical characteristics associated with mortality. RESULTS: The 461 patients were young (median age, 35 years), male (82%), severely injured (median Injury Severity Score, 33), in shock (median shock index, 1.2; base excess, -9), and transfused a median of 29 U of RBCs, 22 U of fresh frozen plasma (FFP), and 24 U of platelets (PLT). Mortality was 46% at 24 hours and 65% at discharge. Transfusion of RBC/FFP ≥1.5:1 or RBC/PLT ≥1.5:1 was significantly associated with mortality, most pronounced for the 18% of patients who received both RBC/PLT and RBC/FFP ≥1.5:1 (odds ratios, 3.11 and 2.81 for mortality at 24 hours and discharge; both p < 0.01). Classification and Regression Tree identified that age older than 50 years, low initial Glasgow Coma Scale, thrombocytopenia, and resuscitative thoracotomy were associated with low likelihood of survival (14-26%), while absence of these factors was associated with the highest survival (71%). CONCLUSION: Despite modern massive transfusion protocols, one half of trauma patients receiving UMT are transfused with either RBC/FFP or RBC/PLT in unbalanced ratios ≥1.5:1, with increased associated mortality. Maintaining focus on balanced ratios during UMT is critical, and consideration of advanced age, poor initial mental status, thrombocytopenia, and resuscitative thoracotomy can aid in prognostication. LEVEL OF EVIDENCE: Prognostic, level III.

An evaluation of emergency general surgery transfers and a call for standardization of practices.

BACKGROUND: There is an increasing trend toward regionalization of emergency general surgery, which burdens patients. The absence of a standardized, emergency general surgery transfer algorithm creates the potential for unnecessary transfers. The aim of this study was to evaluate clinical reasoning prompting emergency general surgery transfers and to initiate a discussion for optimal emergency general surgery use. METHODS: Consecutive emergency general surgery transfers (December 2018 to May 2019) to 2 tertiary centers were prospectively enrolled in an institutional review board-approved protocol. Clinical reasoning prompting transfer was obtained prospectively from the accepting/consulting surgeon. Patient outcomes were used to create an algorithm for emergency general surgery transfer. RESULTS: Two hundred emergency general surgery transfers (49% admissions, 51% consults) occurred with a median age of 59 (18 to 100) and body mass index of 30 (15 to 75). Insurance status was 25% private, 45% Medicare, 21% Medicaid, and 9% uninsured. Weekend transfers (Friday to Sunday) occurred in 45%, and 57% occurred overnight (6:00 pm to 6:00 am). Surgeon-to-surgeon communication occurred with 22% of admissions. Pretransfer notification occurred with 10% of consults. Common transfer reasons included no surgical coverage (20%), surgeon discomfort (24%), or hospital limitations (36%). A minority (36%) underwent surgery within 24 hours; 54% did not require surgery during the admission. Median length of stay was 6 (1 to 44) days. CONCLUSION: Conditions prompting emergency general surgery transfers are heterogeneous in this rural state review. There remains an unmet need to standardize emergency general surgery transfer criteria, incorporating patient and hospital factors and surgeon availability. Well-defined requirements for communication with the accepting surgeon may prevent unnecessary transfers and maximize resource allocation.

Sexual Harassment during Residency Training: A Cross-Sectional Analysis.

The reality of sexual harassment is unmasking in many fields, and medical trainees constitute a vulnerable and at-risk group. We report the prevalence of sexual harassment among GI, internal medicine, and pediatric residents, with a focus on identifying underlying reasons for lack of victim reporting. A modified previously validated Department of Defense survey on sexual harassment was e-mailed to 261 GI, 132 pediatric, and 271 internal medicine program directors. Three hundred eighty-one residents responded to the survey. Female trainees were more likely to be subject to sexual harassment (83% vs 44%, P <0 .0001). Offensive and/or suggestive jokes and comments were the most common type of harassment experienced. Most residents were unlikely to report the offender (87% females, 93% males). Although 77 per cent of residents believed they would be supported by their program if they reported a sexual harassment event, only 43 per cent were aware of institutional support in place for victims at their program. Although there is a persistently high incidence of harassment in training, the avenues in which to report it are largely unknown and underused. Further research should focus on evidence-based interventions to encourage reporting and to design institutional programs for victims of sexual harassment.

Stop the Bleed: Is Mass Education the Best Approach?

The Stop the Bleed (STB) course teaches trainees prehospital hemorrhage control with a focus on mass education. Identifying populations most likely to benefit can help save on the significant cost and limited resources. In this study, we attempted to identify those populations and performed a cost analysis. Trainees underwent STB education and completed a survey on completion to assess demographics and prior experiences where STB skills could have been useful. Five hundred seventy-one trainees categorized as first responders (14%), students (56%), and the working public (30%) completed the survey. Most trainees found the lecture and simulation helpful, 96 per cent and 98 per cent, respectively. There were significant differences among groups who had previously been in situations where the STB course would have been helpful (88% first responders versus 40% students versus 43% public workers) (P < 0.001). Teaching a class of 10 students costs approximately $455; the cost can be as high as $1246 for a class of 50 students. Most STB trainees found the course helpful. First responders are most likely to be exposed to situations where course information could be helpful. Focusing on specific high-yield groups rather than mass education might be a more efficient approach to STB education.

Gunshot Injuries to the Extremity: Is Immediate General Surgery Presence Needed?

Gunshot wounds (GSW) are becoming increasingly prevalent in urban settings. GSW to the trunk mandate full trauma activation and immediate surgeon response because of the high likelihood of operative intervention. Extremity GSW proximal to the knee/elbow also require full trauma activation based on American College of Surgeons Committee on trauma standards. However, whether isolated extremity GSW require frequent operative intervention is unclear. We evaluated GSW at our Level I trauma center from January 2012 to December 2016. Demographic data and injury patterns were abstracted from the trauma registry and charts. The number of GSW increased yearly but the age, gender, Injury Severity Score and injury pattern did not change (P = ns, not shown). There were 504 GSW that included an extremity and 194 (38%) involved multiple body regions. There were 310 GSW (62%) isolated to an extremity and 176 were proximal to the elbow/knee. If proximal GSW had an Emergency Department systolic blood pressure <90 mm Hg, 53 per cent underwent vascular repair, 12 per cent had soft tissue repair, and 29 per cent required no operation. If proximal GSW had an Emergency Department blood pressure >90 mm Hg, 57 per cent underwent orthopedic repair, 22 per cent required no surgery, and only 13 per cent required vascular repair (P < 0.01). In the absence of other criteria for full trauma activation such as shock, the need for the immediate presence of a general surgeon to perform emergency surgery for a GSW isolated to the extremity is low.

The use of ABC score in activation of massive transfusion: The yin and the yang.

BACKGROUND: Hemorrhage is the most common cause of early death in trauma patients. Massive transfusion protocols (MTPs) have been designed to accelerate the release of blood products but can result in waste if activated inappropriately. The Assessment of Blood Consumption (ABC) score has become a widely accepted score for MTP activation. In this study, we compared the use of ABC criteria to physician judgment in MTP activation. METHODS: Adult trauma patients treated at University of Louisville Trauma Center from January 2016 to December 2016 were studied. Activation via ABC score was assessed retrospectively from emergency department (ED) data. Location, timing of activation, percent of patients using more than 5 units of packed red blood cells, amount of product waste, factors associated with early activation by physicians, and mortality were analyzed. RESULTS: Three thousand four hundred twenty-one patients were included in this study. Only 33% of the patients who would have had MTP activation based on the ABC criteria used more than 5 units of blood products within 24 hours of admission compared with 65% of the patients in whom clinical judgment was used. Seventy-six percent of all MTP activations from clinical judgment would have been activated by the ABC criteria in the ED. Fifty-five percent of all MTP activations via clinical judgment were activated in the operating room and 41% in the ED. Eighty-one percent of activations that occurred in the operating room by physician judgment could have been activated earlier in the ED if the ABC criteria had been used. However, ABC score can lead to higher potential fresh frozen plasma waste (588 vs. 84 units) compared with physician judgment. CONCLUSIONS: The ABC criteria overestimate need for massive transfusion and can lead to increased product waste compared with physician judgment, but its use leads to earlier MTP activation. Criteria to trigger MT activation should rely on both clinical acumen and validated prediction tools. LEVEL OF EVIDENCE: Prognostic, level III.

MicroRNA-203 suppresses proliferation in liver cancer associated with PIK3CA, p38 MAPK, c-Jun, and GSK3 signaling.

Primary liver cancer (hepatocellular carcinoma, HCC) is a leading cause of cancer-related deaths, and alternative ways to treat this disease are urgently needed. In recent years, novel approaches to cancer treatment have been based on microRNAs, small non-coding RNA molecules that play a crucial role in cancer progression by regulating gene expression. Overexpression of some microRNAs has shown therapeutic potential, but whether or not this was the case for microRNA-203 (miR-203) in liver cancer was unknown. Therefore, the aim of this study was to investigate the effect of miR-203 overexpression in liver cancer and explore the related mechanisms. Liver cancer cells from the HepG2 and Hep3B cell lines were transfected with either miR-203 mimics or negative control RNA, and then the cells were subjected to cell viability, cell proliferation, and Western blotting assays. As a result of microRNA-203 overexpression, HepG2 and Hep3B cell viability and cell proliferation significantly declined. Furthermore, microRNA-203 overexpression led to inhibited expression of phosphatidylinositol-4,5-bisphosphate 3-kinase (PIK3)/protein kinase B (Akt), c-Jun, and p38 mitogen-activated protein kinases (p38 MAPK), and restored glycogen synthase kinase 3 (GSK 3) activity in HepG2 cells. Our results suggest that c-Jun, p38 MAPK, PIK3CA/Akt, and GSK3 signaling involved in the effect of miR-203 on the proliferation of HCC cells.

c-Jun N-terminal kinase 1 is required for Toll-like receptor 1 gene expression in macrophages.

The regulation of innate immune responses to pathogens occurs through the interaction of Toll-like receptors (TLRs) with pathogen-associated molecular patterns and the activation of several signaling pathways whose contribution to the overall innate immune response to pathogens is poorly understood. We demonstrate a mechanism of control of murine macrophage responses mediated by TLR1/2 heterodimers through c-Jun N-terminal kinase 1 (JNK1) activity. JNK controls tumor necrosis factor alpha production and TLR-mediated macrophage responses to Borrelia burgdorferi, the causative agent of Lyme disease, and the TLR1/TLR2-specific agonist PAM(3)CSK(4). JNK1, but not JNK2, activity regulates the expression of the tlr1 gene in the macrophage cell line RAW264.7, as well as in primary CD11b(+) cells. We also show that the proximal promoter region of the human tlr1 gene contains an AP-1 binding site that is subjected to regulation by the kinase and binds two complexes that involve the JNK substrates c-Jun, JunD, and ATF-2. These results demonstrate that JNK1 regulates the response to TLR1/2 ligands and suggest a positive feedback loop that may serve to increase the innate immune response to the spirochete.

Distinct bacterial dissemination and disease outcome in mice subcutaneously infected with Borrelia burgdorferi in the midline of the back and the footpad.

Subcutaneous inoculation of mice with Borrelia burgdorferi, the causative agent of Lyme disease, results in established infection and the development of acute arthritis and carditis, hallmarks of human disease. Because conflicting results may originate from the site of subcutaneous inoculation, we addressed the dissemination capacity of spirochetes injected in the shoulder region versus the footpad. Spirochetes inoculated in the footpad disseminated to a lesser extent to distant organs, such as the ear and the heart. This resulted in distinct degrees of joint and cardiac inflammation at the peak of the disease. The differences eventually leveled out. These results suggest that caution must be exercised in the interpretation of results obtained with routes of inoculation that do not closely represent the natural site of infection.

Delivery of the immunosuppressive antigen Salp15 to antigen-presenting cells by Salmonella enterica serovar Typhimurium aroA mutants.

A Salmonella enterica serovar Typhimurium aroA-deficient delivery system was used to target the immunosuppressive protein Salp15 to antigen-presenting cells. In vitro and in vivo infections with Salp15-containing Salmonella resulted in an impaired CD4(+)-T-cell activation, suggesting that the protein was produced by antigen-presenting cells in a physiologically active form.