Intraosseous Dermoid Presenting as an Expansile Lytic Lesion.

Cranial dermoids have the tendency to occur in the midline, especially near fontanelles and sutures early in the life of a patient. Here we present an unusual case of an intraosseous dermoid that presented initially as a lytic lesion, off of the midline and not associated with cranial sutures or fontanelles. The diameter of the lesion grew to approx 15 mm over time, thus the decision was made to take the child to surgery for removal of dermoid with the use of neuronavigation and cranioplasty. A dermoid cyst was confirmed on histopathologic analysis.

A Qualitative Study of the System-level Barriers to Bariatric Surgery Within the Veterans Health Administration.

OBJECTIVE: To characterize system-level barriers to bariatric surgery from the perspectives of Veterans with severe obesity and obesity care providers. SUMMARY OF BACKGROUND DATA: Bariatric surgery is the most effective weight loss option for Veterans with severe obesity, but fewer than 0.1% of Veterans with severe obesity undergo it. Addressing low utilization of bariatric surgery and weight management services is a priority for the veterans health administration. METHODS: We conducted semi-structured interviews with Veterans with severe obesity who were referred for or underwent bariatric surgery, and providers who delivered care to veterans with severe obesity, including bariatric surgeons, primary care providers, registered dietitians, and health psychologists. We asked study participants to describe their experiences with the bariatric surgery delivery process in the VA system. All interviews were audio-recorded and transcribed. Four coders iteratively developed a codebook and used conventional content analysis to identify relevant systems or "contextual" barriers within Andersen Behavioral Model of Health Services Use. RESULTS: Seventy-three semi-structured interviews with veterans (n = 33) and providers (n = 40) throughout the veterans health administration system were completed. More than three-fourths of Veterans were male, whereas nearly three-fourths of the providers were female. Eight themes were mapped onto Andersen model as barriers to bariatric surgery: poor care coordination, lack of bariatric surgery guidelines, limited primary care providers and referring provider knowledge about bariatric surgery, long travel distances, delayed referrals, limited access to healthy foods, difficulties meetings preoperative requirements, and lack of provider availability and/or time. CONCLUSIONS: Addressing system-level barriers by improving coordination of care and standardizing some aspects of bariatric surgery care may improve access to evidence-based severe obesity care within VA.

Systemic Immunosuppression for Prevention of Recurrent Tendon Adhesions.

BACKGROUND: The recovery for patients after tendon repair is frequently limited by development of tendon adhesions. This scar tissue formation is dependent on immune system activation. Tacrolimus has unique properties that may contribute to the prevention of overactive scarring by inhibition of inflammatory cytokines. METHODS: Herein, we present a case using systemic immunosuppression to prevent recurrent adhesion accumulation in a patient with a prior spaghetti wrist injury. Tacrolimus began 1 week before repeat-secondary tenolysis surgery, and it continued for 3 months postoperative. Dosing was tapered to a serum level between 5 and 8 µg/L. RESULTS: The 27-year-old male patient suffered a volar wrist laceration transecting all flexor tendons and volar wrist nerves. He underwent immediate repair but had a poor outcome despite early range of motion therapy. A primary tenolysis only improved his average arc of finger motion from 72 to 95 degrees. Secondary tenolysis augmented with systemic tacrolimus improved his arc of finger motion from 95 to 202 degrees. Mechanistically, tacrolimus prevents proper function of activated T and B cells. This results in decreased proliferation, angiogenesis, and cytoskeletal organization of fibroblasts on inflammation and integrin adhesions, and it potentially explains the reduced tendon molecule adhesions seen in this patient. CONCLUSIONS: Tacrolimus may be effective in reducing motion, limiting tendon adhesions. The novel use of this medication resulted in the return of near-normal hand function in a patient placed on low-dose tacrolimus after primary tenolysis had failed.

Long-term dysphagia resolution following POEM versus Heller myotomy for achalasia patients.

BACKGROUND: Heller myotomy (HM) has historically been considered the gold standard treatment for achalasia. Peroral endoscopic myotomy (POEM) is a less-invasive procedure and offers a quicker recovery. Although some studies have compared short-term outcomes of HM and POEM, predictors of long-term dysphagia resolution remain unclear. The objective of this study was to evaluate patient-reported outcomes for achalasia patients who underwent either POEM or HM over a 9-year period. METHODS: Data from our single academic institutional foregut database were used to identify achalasia patients who underwent HM or POEM from 2009 to 2018. Electronic health record data were reviewed to obtain patient characteristics and operative data. Achalasia severity stages were established for each patient using esophagram findings from an attending radiologist blinded to the procedure type. Postoperative outcomes were assessed via telephone for patients with at least 9 months of follow-up using Eckardt dysphagia scores. Patient age, sex, type of operation, and duration of follow-up were included in a multivariable linear regression model with Eckardt score as the outcome. RESULTS: Our cohort included 141 patients (97 HM and 44 POEM). Eighty-two patients completed a phone survey at the 9 months or greater time interval (response rate = 58%). Mean Eckardt scores were 2.98 and 2.53 at a median follow-up of 3 years and 1 year for HM and POEM patients, respectively (an Eckardt score ≤ 3 is considered a successful myotomy). Lower stages of achalasia on esophagram (e.g., Stage 0 vs. Stage 4) were associated with greater dysphagia improvement. On multivariable analysis, operative approach was not associated with a statistically significant difference in dysphagia outcomes. CONCLUSIONS: POEM and HM were associated with similar rates of dysphagia resolution for achalasia patients at a median of 2 years of follow-up. Both procedures appear to be durable options for achalasia treatment.

30-Day Outcomes After Intraoperative Leak Testing for Bariatric Surgery Patients.

BACKGROUND: Intraoperative testing of anastomoses and staples lines is commonly performed to minimize the risk of postoperative leaks in bariatric surgery, but its impact is unclear. The aim of this study was to determine the association between leak testing and 30-d postoperative leak, bleed, reoperation, and readmission rates for patients undergoing laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB). METHODS: This is a retrospective observational study utilizing 2015-2016 data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Postoperative outcomes were compared using χ2 test. Multivariable logistic regression was used to identify factors associated with 30-d outcomes. RESULTS: We included 237,081 patients. Leak testing was performed on 73.0% and 92.1% of LSG and RYGB patients, respectively. LSG was associated with lower rates of leak, bleed, reoperation, and readmission than RYGB. On multivariable analysis, intraoperative leak testing was associated with increased rates of postoperative leak for LSG and RYGB (OR 1.48 and 1.90, respectively) and lower rates of bleed for LSG (OR 0.76). There were no significant associations between leak testing and rates of reoperation or readmission. CONCLUSIONS: Use of intraoperative leak testing was not associated with improved outcomes for either LSG or RYGB. A prospective trial investigating leak testing is warranted to better elucidate its impact.

Motivations of Males with Severe Obesity, Who Pursue Medical Weight Management or Bariatric Surgery.

Background: Both medical weight management (MWM) and bariatric surgery are significantly underutilized by patients with severe obesity, particularly males. Less than 30% of participants in MWM programs are male, and only 20% of patients undergoing bariatric surgery are men. Objectives: To identify motivations of males who pursue either MWM or bariatric surgery. Setting: Interviews with males with severe obesity (body mass index ≥35 kg/m2), who participated in a Veteran Affairs weight loss program in the Midwest. Materials and Methods: Participants were asked to describe their experiences with MWM and bariatric surgery. Interviews were audio-recorded, transcribed, and uploaded to NVivo for data management and analysis. Five coders iteratively developed a codebook using inductive content analysis to identify relevant themes. We utilized theme matrices organized by type of motivation and treatment pathway to generate higher-level analysis and generate themes. Results: Twenty-five males participated. Participants were 58.7 (standard deviation 8.6) years old on average, and 24% were non-white. Motivations for pursuing MWM or surgery included a desire to improve physical or psychological health and to enhance quality of life. Patients seeking bariatric surgery were motivated by the fear of death and felt that they had exhausted all other weight loss options. MWM patients believed they had more time to pursue other weight loss options. Conclusion: The opportunity to improve health, optimize quality of life, and lengthen lifespan motivates males with severe obesity to pursue weight loss treatments. These factors should be considered when providers educate patients about obesity treatment options and outcomes.

Kamishibai cards to sustain evidence-based practices to reduce healthcare-associated infections.

BACKGROUND: Sustaining healthcare-associated infection (HAI) prevention practices is complex. We examined the use of Kamishibai Cards (K Cards) as a tool to encourage compliance interactions between leaders and staff. METHODS: We explored one unit of a children's hospital to assess acceptability of K Cards. Interactions were recorded (n = 14), and interviews were conducted (n = 22). We used the Health Belief Model (HBM) for analyses. Central line utilization, bundle compliance and rates of HAIs were also examined. RESULTS: Staff members consider K Card interactions reminders of bundle elements and acceptable for creating positive interactions. Although no causal inference can be made, during K Card implementation, CLABSI rates dropped from 1.83 in 2015 to 0.0 through June 2018. Central line utilization decreased by 3%. DISCUSSION: Moving beyond theory to providing practical sustainability tools is an important implementation step. Although our findings are not generalizable, capturing what occurred on one unit provides opportunity to discover how key leadership factors (communication and leadership style) influence the uptake, acceptability and sustained adoption of evidence-based practices. CONCLUSIONS: K Cards are a practical tool to sustain evidence-based practices and promote communication between leadership and staff - keeping compliance on the minds of frontline workers.