Intestinal Ischemia - Etiology and Foundational Concepts.

Intestinal Ischemia: Etiology and Foundational ConceptsThe authors provide an overview of the intestinal anatomy and the pathophysiology and etiology of intestinal ischemia.

Social Determinants of Health Associated With the Need for Urgent Versus Elective Cholecystectomy at an Urban, Safety-Net Hospital.

Background: Benign gallstone disease is the most frequent indication for cholecystectomy in the United States. Many patients present with complicated disease requiring urgent interventions, which increases morbidity and mortality. We investigated the association between individual and population-level social determinants of health (SDoH) with urgent versus elective cholecystectomy. Patients and Methods: All patients undergoing cholecystectomy (2014-2021) for benign gallstone disease were included. Demographic and clinical data were linked to population-level SDoH characteristics using census tracts. Data were analyzed using descriptive and inferential statistics. Results: A total of 3,197 patients met inclusion criteria; 1,913 (59.84%) underwent urgent cholecystectomy, 1,204 (37.66%) underwent emergent cholecystectomy, and 80 (2.5%) underwent interval cholecystectomy. On multinomial logistic regression, patients who were older (relative risk [RR], 1.010; p < 0.001), black (RR, 1.634; p = 0.008), and living in census tracts with a higher percent of poverty (RR, 0.017; p = 0.021) had a higher relative risk of presenting for urgent cholecystectomy. Patients who were female (RR, 0.462; p < 0.001), had a primary care provider (PCP; RR, 0.821; p = 0.018), and lived in census tracts with low supermarket access (RR, 0.764; p = 0.038) had a lower relative risk of presenting for urgent cholecystectomy. Only age (RR, 1.066; p < 0.001), female gender (RR, 0.227; p < 0.001), and having a PCP (RR, 1.984; p = 0.034) were associated with presentation for interval cholecystectomy. Conclusions: Patients who were older, black, and living in census tracts with high poverty levels had a higher relative risk of presenting for urgent cholecystectomy at our institution, whereas females and patients with PCPs were more likely to undergo elective cholecystectomy. Improved access to primary care and surgical clinics for all patients at safety-net hospitals may result in improved outcomes in the management of benign gallstone disease by increasing diagnosis and treatment in the elective setting.

Non-operative Management of an Isolated Blunt Traumatic Retrohepatic Inferior Vena Cava Injury.

Traumatic inferior vena cava (IVC) injuries are often fatal. Blunt IVC injuries are encountered less often. Conservative management, albeit an option, is not often discussed in the literature. This report explores the non-operative management of a 52-year-old female unrestrained driver who presented with a blunt retrohepatic IVC injury identified on a computed tomography (CT) scan that revealed IVC disruption with extravasation of contrast. Here, we discuss the nonoperative management of the patient and review the literature concerning IVC anatomy, traumatic injuries, and management. We conclude that a hemodynamically stable patient with an isolated blunt traumatic IVC injury can be managed non-operatively.

Resuscitation of an exsanguinated obstetrics patient with HBOC-201: A case report.

BACKGROUND: Hemorrhagic shock is a clinically challenging disease process with high mortality. When conventional blood products are unable to be administered, oxygen-carrying blood alternatives are sometimes utilized. The international experience with this scenario is limited. We aim to add to this body of literature. STUDY DESIGN AND METHODS: This is a case report of the administration of bovine hemoglobin-based oxygen-carrying red blood cell (RBC) substitute HBOC-201 (HemoPure®) to a patient with post-partum bleeding and hemorrhagic shock because the patient declined RBC transfusion. HBOC-201 was administered with consent under a one-time Emergency Investigational New Drug (eIND) approval from the Food and Drug Administration with appropriate notification of the Institutional Review Board. RESULTS: The patient was successfully resuscitated with HBOC-201 from hemorrhagic shock. She was weaned off of vasopressor support and extubated with the recovery of her baseline mental status within 4 h. However, approximately 36 h after this, the patient developed multi-organ system dysfunction, volume overload, right heart failure and ultimately expired early on post-partum day 4. DISCUSSION: Resuscitation from hemorrhagic shock with HBOC-201 as an RBC alternative is feasible, but significant challenges remain with the management of sequelae resulting from prolonged low-flow, ischemic states as well as the significant colloid pressure and volume overload experienced after massive transfusion with an acellular colloid oxygen carrier.

Boot Camp in a Box: Initial Experience with Pretraining Skills Preparation for New Interns.

PURPOSE: In order to increase selected skills at onset of training, we provided newly matched PGY-1 trainees with materials and instructions to practice these skills, as well as the opportunity to share video-recorded performance and receive feedback based on these videos. METHODS: Knot tying and suturing kits, instruments and supplies, and video instructions for task performance were sent to newly matched trainees to our program (n = 10), with instructions to practice 4 tasks (1- and 2-handed knot tying, interrupted and running suturing) until self-assessed comfort with each task was achieved or the 8-week time point before start of training was reached. Each trainee returned a video of each task, which was graded by blinded reviewers for time and errors using an itemized evaluation instrument (12 items for suturing and five items for knot-tying). Feedback (annotations of submitted videos) was provided after grading was completed. Task performance was repeated and reassessed at the time of new intern "Boot Camp" and again 8 weeks after start of training. Performance scores were compared for the 3 time points and with scores of PGY 2-4 residents using ANOVA with posthoc tests. RESULTS: Compliance with instruction for practice and return of video recorded tasks in the months before start of PGY-1 training was high, with only 1 of 10 failing to return knot-tying videos. A significant pattern of performance change (p < 0.05) was observed for all tasks with an initial decrease between the pre-employment practice period and the Boot Camp test followed by an increase to the highest level of performance 2 months after start of training. At that point, scores were not significantly different than those of more senior residents. CONCLUSIONS: A high level of compliance was achieved with requested skills practice and video documentation of performance. We attribute the consistently lower scores on the tasks during Boot Camp tests to higher stress test environment which was apt to be less favorable than having the trainee choose to submit their best possible preresidency video recording of performance in a low-stress situation. Subsequent achievement of significantly higher performance even compared to more senior residents may have been helped by incentivized pretraining practice.