Enteral Access Outcomes in Patients Hospitalized With Cardiac Disease: A Retrospective Cohort Study.

INTRODUCTION: Patients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures. METHODS: Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access. RESULTS: 912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from -2.45 × 10-8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to -0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035). CONCLUSIONS: Despite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.

Collaborative Development and Implementation of a Hybrid Virtual Surgery Clerkship Curriculum in a Vietnamese Medical School.

OBJECTIVE: To collaboratively develop a hybrid virtual curriculum for a medical school surgery clerkship within an emerging medical university in Vietnam. DESIGN: A hybrid virtual surgery clerkship curriculum was collaboratively developed by Vietnamese and American surgeons as part of an international partnership between their respective universities. A set of 25 virtual lectures with associated materials were created and deployed in tandem with live, in-person review and skills sessions. Student quantitative and qualitative evaluation methods were developed and deployed to allow continuous iteration. A 6-month course was deployed to develop surgical faculty into effective teachers. SETTING: The curriculum was deployed at VinUniversity College of Health Sciences, the youngest medical university in Vietnam. It was developed in collaboration with the University of Pennsylvania Perelman School of Medicine. Each cohort of 12 students in the surgical clerkship will participate in the curriculum. CONCLUSIONS: The development of this hybrid surgical clerkship in Vietnam leveraged local resources and expertise with those available remotely. Lessons learned are directly applicable to future collaborative curriculum development efforts at other emerging medical schools.

Outcomes in Enteral Access Based on Specialty and Approach: A Single-Center Three-Year Experience.

INTRODUCTION: Interventional radiologic, endoscopic, and surgical approaches are commonly utilized to establish durable enteral access in adult patients. The purpose of this study is to examine differences in nutritional outcomes in a large cohort of patients undergoing enteral access creation. METHODS: Adult patients who underwent enteral access procedures by interventional radiologists, gastroenterologists, and surgeons between 2018 and 2020 at a single institution were reviewed. Included access types were percutaneous endoscopic gastrostomy (PEG), open or laparoscopic gastrostomy, laparoscopic jejunostomy, and percutaneous gastrostomy (perc-G), percutaneous jejunostomy , or primary gastrojejunostomy. RESULTS: 912 patients undergoing enteral access cases met the criteria for inclusion. PEGs and perc-Gs were the most common procedures. PEGs had higher Charlson scores (4.5 [3.0-6.0] versus 2.0 [1.0-2.0], P = 0.007) and lower starting albumin (3.0 [2.6-3.4] versus 3.6 [3.5-3.8] g/dL, P < 0.0001). Time to goal feeds (4 [2-6] vs 4 [3-5] d, P = 0.970), delta prealbumin (3.6 [0-6.5] versus 6.2 [2.3-10] mg/L, P = 0.145), time to access removal (160 [60-220] versus 180 [90-300] d, P = 0.998), and enteral access-related complications (19% versus 16%, P = 0.21) between PEG and perc-G were similar and differences were not statistically significant. A greater percent change in prealbumin was noted for perc-G (10 [-3-20] versus 41.7% [11-65], P = 0.002). CONCLUSIONS: Despite having higher Charlson scores and worse preoperative nutrition, there is a similar incidence of enteral access-related complications, time to goal feeds, delta prealbumin, or time to access removal between PEG and perc-G patients. Our data suggest that access approach should be made on an individual basis, accounting for anatomy and technical feasibility.

Eosinophilic Myenteric Ganglionitis Presenting as Sigmoid Volvulus: A Brief Report.

Eosinophilic myenteric ganglionitis (EMG) is a rare pathologic finding within the Auerbach myenteric plexus characterized by eosinophilic infiltration on light microscopy. The plexus's ultimate obliteration results in chronic intestinal pseudo-obstruction (CIPO). EMG is almost exclusively seen in the pediatric population. The diagnosis of EMG is made through full-thickness rectal biopsy and EMG is not detectable through routine screening measures such as imaging or colonoscopy. The current treatment modality for this disorder is not standardized, and has often been treated with systemic steroids given its eosinophilic involvement. This case presents a 73-year-old male with chronic constipation presenting with new obstipation in the setting of recent orthopedic intervention requiring outpatient opioids. Admission radiographs were consistent with sigmoid volvulus. Following endoscopic detorsion, exploratory laparotomy revealed diffuse colonic dilation and distal ischemia requiring a Hartmann's procedure. Surgical pathology revealed EMG, increasing the complexity of subsequent surgical decision-making after his urgent operation.

Time to Transfer as a Quality Improvement Imperative: Implications of a Hub-and-Spoke Health System Model on the Timing of Emergency Procedures.

BACKGROUND: In the increasingly prevalent hub-and-spoke health system model, specialized services are centralized at a hub hospital, while spoke hospitals offer more limited services and transfer patients to the hub as needed. In one urban, academic health system, a community hospital without procedural capabilities was recently incorporated as a spoke. The goal of this study was to assess the timeliness of emergent procedures for patients presenting to the spoke hospital under this model. METHODS: The authors performed a retrospective cohort study of patients transferred from the spoke hospital to the hub hospital for emergency procedures after the health system restructuring (April 2021-October 2022). The primary outcome was the proportion of patients who arrived within their goal transfer time. Secondary outcomes were time from transfer request to procedure start and whether procedure start occurred within guideline-recommended treatment time frames for ST-elevation myocardial infarction (STEMI), necrotizing soft tissue infection (NSTI), and acute limb ischemia (ALI). RESULTS: A total of 335 patients were transferred for emergency procedural intervention during the study period, most commonly for interventional cardiology (23.9%), endoscopy or colonoscopy (11.0%), or bone or soft tissue debridement (10.7%). Overall, 65.7% of patients were transferred within the goal time. 23.5% of patients with STEMI met goal door-to-balloon time, and more patients with NSTI (55.6%) and ALI (100%) underwent intervention within the guideline-recommended time frame. CONCLUSION: A hub-and-spoke health system model can provide access to specialized procedures in a high-volume, resource-rich setting. However, ongoing performance improvement is required to ensure that patients with emergency conditions receive timely intervention.

Evaluation of the educational quality of publicly available online videos on laparoscopic jejunostomy by utilizing the LAP-VEGaS guidelines.

BACKGROUND: Despite its common nature, there is no data on the educational quality of publicly available laparoscopic jejunostomy training videos. The LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool, released in 2020, has been developed to ensure that teaching videos are of appropriate quality. This study applies the LAP-VEGaS tool to currently available laparoscopic jejunostomy videos. METHODS: A retrospective review of YouTube® videos was conducted for "laparoscopic jejunostomy." Included videos were rated by three independent investigators using LAP-VEGaS video assessment tool (0-18). Wilcoxon rank-sum test was used to evaluate differences in LAP-VEGaS scores between video categories and date of publication relative to 2020. Spearman's correlation test was performed to measure association between scores and length, number of views and likes. RESULTS: 27 unique videos met selection criteria. Academic and physician video walkthroughs did not demonstrate a significant difference in median scores (9.33 IQR 6.33, 14.33 vs. 7.67 IQR 4, 12.67, p = 0.3951). Videos published after 2020 demonstrated higher median scores than those published before 2020 (13 IQR 7.5, 14.67 vs. 5 IQR 3, 9.67, p = 0.0081). A majority of videos failed to provide patient position (52%), intraoperative findings (56%), operative time (63%), graphic aids (74%), and audio/written commentary (52%). A positive association was demonstrated between scores and number of likes (rs = 0.59, p = 0.0011) and video length (rs = 0.39, p = 0.0421), but not number of views (rs = 0.17, p = 0.3991). CONCLUSION: The majority of available YouTube® videos on laparoscopic jejunostomy fail to meet the basic educational needs of surgical trainees, and there is no difference between those produced by academic centers or independent physicians. However, there has been improvement in video quality following the release of the scoring tool. Standardization of laparoscopic jejunostomy training videos with the LAP-VEGaS score can ensure that videos are of appropriate educational value with logical structure.

What are trainees watching? Assessing the educational quality of online laparoscopic cholecystectomy training videos using the LAP-VEGaS guidelines.

BACKGROUND: Laparoscopic cholecystectomy is the most common laparoscopic procedure performed in the US and a key component of general surgery training. Surgical trainees frequently access YouTube for educational walkthroughs of surgical procedures. This study aims to evaluate the educational quality of YouTube video walkthroughs on laparoscopic cholecystectomy by using the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool. METHODS: A YouTube search was conducted using "laparoscopic cholecystectomy." Results were sorted by relevance, and the top 100 videos were gathered. Videos with patient education or concomitant procedures were excluded. Included videos were categorized as Physician (produced by an individual physician), Academic (produced by a university or medical school), Commercial (produced by a surgical company), and Society (produced by a professional surgical society) and were rated by 3 investigators using the LAP-VEGaS video assessment tool (0-18). RESULTS: In all, 33 videos met the selection criteria. The average LAP-VEGaS score was 7.96 ± 3.95, and inter-rater reliability was .86. Academic videos demonstrated a significantly higher mean LAP-VEGaS score than Commercial (10.69 ± 3.54 vs 5.25 ± 2.38, P = .033). Most academic videos failed to provide formal case presentations (63%), patient positioning (50%), intraoperative findings (50%), graphic aids (63%), and operative time (75%). CONCLUSION: This is the first study to evaluate the quality of YouTube video walkthroughs on LC using the LAP-VEGaS tool. Despite demonstrating higher LAP-VEGaS scores than other categories, video walkthroughs provided by academic institutions still lack several essential educational criteria for this procedure, highlighting areas of improvement for educators.

Does Alteration of the Microbiome Cause Diverticular Disease?

The role of the microbiome in influencing the development and course of human disease is increasingly understood and appreciated. In diverticular disease, the microbiome presents an intriguing potential link between the disease and its long-established risk factors, dietary fiber and industrialization. However, current data have yet to demonstrate a clear link between specific alterations in the microbiome and diverticular disease. The largest study of diverticulosis is negative and studies of diverticulitis are small and heterogeneous. Although multiple disease-specific hurdles exist, the early state of the current research and the many un- or underexplored clinical phenotypes present a significant opportunity for investigators to improve our knowledge of this common and incompletely understood disease.

An Intensive Multidisciplinary Approach in Management of Extensive Nonuremic Calciphylaxis of the Bilateral Lower Extremities with Angioinvasive Fungus and Mold.

Management of infected wounds related to calciphylaxis poses a significant clinical challenge with high morbidity and mortality. Given no definitive management guidelines exist specific to nonuremic calciphylaxis, multiple modalities including sodium thiosulfate, antibiotics, hyperbaric oxygen therapy, and surgical debridement with wound care must be considered. When occurring over a large surface area, standard daily dressing changes are especially labor intensive, inefficient, and ineffective. Negative pressure wound therapy with instillation and dwell time offers broad wound coverage with ongoing therapeutic benefit. We present the case of a previously healthy 19-year-old woman who was transferred for tertiary level care of extensive nonuremic calciphylaxis wounds of the bilateral lower extremities complicated by angioinvasive coinfection with fungus and mold that was managed with a multidisciplinary approach of intensive medical management, aggressive surgical debridement, and negative pressure wound therapy with instillation of hypochlorous acid solution. Ultimately, she achieved full granulation and wound coverage with skin grafting. Large area, infected wounds related to nonuremic calciphylaxis can be successfully managed with multidisciplinary medical management, aggressive surgical debridement, and negative pressure wound therapy that can instill and dwell hypochlorous acid solution.

Fibroid expulsion: a unique presentation of mechanical small bowel obstruction 11 years after uterine artery embolization: a case report.

BACKGROUND: Uterine artery embolization in the treatment of uterine leiomyoma has been rarely associated with dislodgement and expulsion of infarcted uterine fibroids through the vagina, peritoneum, or bowel wall, predominantly occurring within 6 months of uterine artery embolization. CASE PRESENTATION: We present the case of a 54-year-old African American woman who underwent uterine artery embolization 11 years prior and developed mechanical small bowel obstruction from the migration of fibroid through a uteroenteric fistula with ultimate impaction within the distal small bowel lumen. Small bowel resection and hysterectomy were curative. CONCLUSIONS: Uteroenteric fistula with small bowel obstruction due to fibroid expulsion may present as a delayed finding after uterine artery embolization and requires heightened awareness.

What is the patient experience of surgical care during the coronavirus disease 2019 (COVID-19) pandemic? A mixed-methods study at a single institution.

BACKGROUND: The coronavirus disease 2019 outbreak has spread worldwide and has resulted in hospital restrictions. The perceived impact of these practices on patients undergoing essential surgeries is less understood. METHODS: Adult (≥18 years) patients who underwent medically necessary surgical procedures spanning multiple surgical specialties from March 23, 2020, to April 24, 2020, during the coronavirus disease 2019 pandemic were identified as eligible for a phone survey. Survey responses were analyzed using a mixed-methods approach involving descriptive statistics and thematic analysis of coded and annotated survey results. RESULTS: Of the 212 patients who underwent medically necessary surgical procedures during the coronavirus disease 2019 pandemic, the majority of these patients were male (61.3%), White (83.5%), married or with a domestic partner (68.9%), and underwent oncologic procedures (69.3%). Of the 46 patients (21.7%) who completed the survey, the majority of these patients indicated that coronavirus disease 2019 pandemic restrictions had no impact on their inpatient hospital stay and were satisfied with their decision to proceed with surgery. Severity of patient condition (44.4%), the risk/benefit discussion with the surgeon (24.4%), and coronavirus disease 2019 education and testing (19.5%) were the most important factors in proceeding with surgery during the pandemic; 34.4% of patients said their inpatient postoperative course was negatively affected by the lack of visitors. CONCLUSION: Medically necessary, time-sensitive surgical procedures, as determined by the surgeon, can be performed during a pandemic with good patient satisfaction provided there is an appropriate discussion between the surgeon and patient about the risks and benefits.

Impact of COVID-19 Restrictions on Demographics and Outcomes of Patients Undergoing Medically Necessary Non-Emergent Surgeries During the Pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in large-scale healthcare restrictions to control viral spread, reducing operating room censuses to include only medically necessary surgeries. The impact of restrictions on which patients undergo surgical procedures and their perioperative outcomes is less understood. METHODS: Adult patients who underwent medically necessary surgical procedures at our institution during a restricted operative period due to the COVID-19 pandemic (March 23-April 24, 2020) were compared to patients undergoing procedures during a similar time period in the pre-COVID-19 era (March 25-April 26, 2019). Cardinal matching and differences in means were utilized to analyze perioperative outcomes. RESULTS: 857 patients had surgery in 2019 (pre-COVID-19) and 212 patients had surgery in 2020 (COVID-19). The COVID-19 era cohort had a higher proportion of patients who were male (61.3% vs. 44.5%, P < 0.0001), were White (83.5% vs. 68.7%, P < 0.001), had private insurance (62.7% vs. 54.3%, p 0.05), were ASA classification 4 (10.9% vs. 3%, P < 0.0001), and underwent oncologic procedures (69.3% vs. 42.7%, P < 0.0001). Following 1:1 cardinal matching, COVID-19 era patients (N = 157) had a decreased likelihood of discharge to a nursing facility (risk difference-8.3, P < 0.0001) and shorter median length of stay (risk difference-0.6, p 0.04) compared to pre-COVID-19 era patients. There was no difference between the two patient cohorts in overall morbidity and 30-day readmission. CONCLUSIONS: COVID-19 restrictions on surgical operations were associated with a change in the racial and insurance demographics in patients undergoing medically necessary surgical procedures but were not associated with worse postoperative morbidity. Further study is necessary to better identify the causes for patient demographic differences.

Lessons Learned From Implementation and Management of Skin Allograft Banking Programs in Low- and Middle-Income Countries: A Systematic Review.

Wound excision and temporary coverage with a biologic dressing can improve survival for patients with large burns. Healthcare systems in low- and middle-income countries (LMICs) rarely have access to allografts, which may contribute to the limited survival of patients with large burns in these settings. Therefore, we aimed to describe the lessons learned from the implementation and maintenance of tissue banks in LMICs to guide system planning and organization. PubMed, MEDLINE, CINAHL, and World Health Organization Catalog were systematically searched with database-specific language to represent a priori terms (eg, skin, allograft, and tissue bank) and all LMICs as defined by the World Bank. Data regarding tissue banking programs were extracted and described in a narrative synthesis. The search returned 3346 records, and 33 reports from 17 countries were analyzed. Commonly reported barriers to ideal or planned implementation included high capital costs and operational costs per graft, insufficient training opportunities, opt-in donation schemes, and sociocultural stigma around donation and transplantation. Many lessons were learned from the implementation and management of tissue banks around the world. The availability of skin allografts can be improved through strategic investments in governance and regulatory structures, international cooperation initiatives, training programs, standardized protocols, and inclusive public awareness campaigns. Furthermore, capacity-building efforts that involve key stakeholders may increase rates of pledges, donations, and transplantations. Some issues were ubiquitously reported and could be addressed by current and future tissue banking programs to ensure allograft availability for patients living in countries of all income levels.

Further Histological and Cellular Characterization of Hidradenitis Suppurativa in 11 Patients.

Background: Hidradenitis suppurativa is a chronic inflammatory skin disease, with significant morbidity secondary to its recurrent painful and exudative lesions. Given limited research on the cytoarchitecture of hidradenitis suppurativa, this study describes the microscopic structure and cell surface markers present in hidradenitis suppurativa tissue to better understand the disease and identify potential therapeutic targets. Methods: Skin biopsies of hidradenitis suppurativa lesions from patients who underwent surgical excision (n = 11) were compared with grossly normal-appearing perilesional skin (n = 5) and normal skin biopsies from unaffected individuals (n = 4). Histopathology and epidermal thickness were assessed using hematoxylin and eosin and picrosirius red staining, and CD3, a T-cell marker, and CD31 (PECAM), a vascular endothelial cell marker, were assayed using immunofluorescence. Data were analyzed and compared using analysis of variance and Student's t test. Results: Histological examination showed that hidradenitis suppurativa samples had a significantly thicker epidermal layer than normal skin (335.23 ± 165.01 µm vs 57.24 ± 18.43 µm, P = .005), extending into and engulfing the dermis. The hidradenitis suppurativa dermis had extensive cellular infiltration and aggregation as well as disorganized collagen. Immunofluorescence analysis revealed that, at the dermal level, hidradenitis suppurativa lesions had a significantly greater quantity of CD3+ (324.29 ± 139.28 vs 14.93 ±16.32, P < .0001) and CD31+ (322.15 ± 155.46 vs 2.84 ± 5.56, P < .0001) cells/mm2 compared with normal skin samples. Conclusions: Hidradenitis suppurativa lesions have thicker epidermal layers, more dermal cellular infiltrate, and disorganized collagen fibers compared with normal skin. Furthermore, hidradenitis suppurativa dermis has a greater quantity of CD3+ and CD31+ cells than normal skin.

Extensive hidradenitis suppurativa with dorsal foot involvement: a case report.

Hidradenitis suppurativa (HS) is a highly morbid chronic inflammatory skin disease resulting in painful and purulent lesions classically occurring in areas with a high density of apocrine glands such as the groin and axillae. This is the case of a 53-year-old male with medically refractory Hurley stage III HS affecting multiple anatomical sites including the dorsum of the right foot, an atypical location. Throughout his hospital course, he underwent a series of surgical excision and graft procedures to treat extensive HS lesions on various anatomical locations. In patients with a history of HS, mechanical stress may result in atypical lesion locations. In addition to the standard medical and surgical treatment, management should include optimizing nutritional parameters, smoking cessation, wound care and reducing friction and pressure at the affected area.

Comparison of the Hepatitis C Continua of Care Between Hepatitis C Virus/HIV Coinfected and Hepatitis C Virus Mono-Infected Patients in Two Treatment Eras During 2008-2015.

Treatment of chronic hepatitis C virus (HCV) infection included use of pegylated interferon-based regimens before 2014 and direct-acting agents (DAA) since 2014 at the VA Medical Center in Washington, DC. We compared the continua of care between our HCV/HIV coinfected and HCV mono-infected patients during 2008-2015. A review of summary data from our local HCV Clinical Case Registry was conducted for the interferon treatment era (2008-2013) and the DAA era (2014-2015). Data were analyzed on a modified HCV Continuum of Care based on these stages: HCV diagnosis, engagement in medical care, HCV treatment, and HCV sustained virologic response (SVR) for differences between HCV/HIV coinfected and HCV mono-infected patients. All patients had 88% engagement in primary care during 2008-2013. HCV mono-infected and HCV/HIV coinfected patients had similar treatment (6% vs. 5%, p = .6622) and HCV SVR (1% vs. 0.5%, p = .1737) rates in the interferon era. However, more HCV/HIV coinfected patients were engaged in care (93% vs. 87%, p = .0044), accessed HCV treatment (36% vs. 23%, p < .0001), and achieved HCV SVR (31% vs. 21% p = .0002) compared to mono-infected patients in the DAA era. Both HCV/HIV coinfected and HCV mono-infected patients achieved higher SVR of ≥86% after DAA treatment. Although improvements were seen for treatment and SVR among HCV mono-infected patients, better rates for care engagement, HCV treatment, and SVR were realized for HCV/HIV coinfected patients in the DAA era.