Subtotal cholecystectomy with omental pedicle plug for the challenging gallbladder: A case report and review of the literature.

If patient anatomy or disease does not allow for a traditional or partial cholecystectomy, an omental pedicle plug may be a viable option to limit the risk of postoperative uncontrolled bile leak from the cystic duct and to control patient symptoms.

The effect of donor graft type on survival after liver transplantation for hepatoblastoma in children.

BACKGROUND: Liver transplantation (LT) is the only potentially curative option for children with unresectable hepatoblastoma (HBL). Although post-transplant outcomes have improved in the contemporary era, the impact of donor graft type on survival remains unclear. METHODS: Using the United Network for Organ Sharing database (02/2002-06/2021), demographics, clinical characteristics, and patient and graft survival were analyzed in children (<18 years) who underwent LT for HBL according to donor graft type. The Kaplan-Meier method, log-rank tests, and Cox regression modeling were used to evaluate the effect of whole, partial, and split deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT) on patient and graft survival. RESULTS: A total of 590 pediatric HBL LT recipients (344 whole graft DDLT; 62 partial graft DDLT; 139 split graft DDLT; 45 LDLT) were included. During 2012-2021 the proportion of LDLTs for HBL decreased to about 5% compared with about 11% during 2002-2011. No significant differences were identified by donor graft type in either patient survival (log-rank test, p = .45) or graft survival (log-rank test, p = .69). The results remained similar during the 2002-2011 era, while during the 2012-2021 era, split graft DDLT was associated with decreased graft loss risk versus whole graft DDLT (hazard ratio: 0.48, 95% confidence interval: 0.23-0.99, p = .046) without any other significant between-group differences. CONCLUSIONS: Utilizing non-whole liver grafts can increase access to LT in children with unresectable HBL while ensuring favorable outcomes. LDLT is underutilized in children with HBL in the United States, and efforts to explore LDLT options should be undertaken.

Artificial intelligence tool detection of intravenous contrast enhancement using spleen attenuation.

PURPOSE: To assess the ability of an automated AI tool to detect intravenous contrast material (IVCM) in abdominal CT examinations using spleen attenuation. METHODS: A previously validated automated AI tool measuring the attenuation of the spleen was deployed on a sample of 32,994 adult (age ≥ 18) patients (mean age, 61.9 ± 14.7 years; 13,869 men, 19,125 women) undergoing 65,449 supine position CT examinations (41,020 with and 24,429 without IVCM by DICOM header) from January 1, 2000 to December 31, 2021. After exclusions, receiver operating characteristic (ROC) curve analysis was performed to determine the optimal threshold for binary classification of IVCM status (non-contrast vs IVCM enhanced), which was then applied to the sample. Discordant examinations (i.e., IVCM status determined by AI tool did not match DICOM header) were manually reviewed to establish ground truth. Repeat ROC curve and contingency table analysis were performed to assess AI tool performance. RESULTS: ROC analysis of the initial study sample of 61,783 CT examinations yielded AUC of 0.970 with Youden index suggesting an optimal spleen attenuation threshold of 65 Hounsfield units (HU). Manual review of 2094 discordant CT examinations revealed discordance due to DICOM header error in 1278 (61.0%) and AI tool misclassification in 410 (19.6%), with 406 (9.4%) meeting exclusion criteria. Analysis of 61,377 CT examinations in the final study sample yielded AUC of 0.999 with accuracy of 99.3% at the 65 HU threshold. Error rate for DICOM header information was 2.1% (1278/61,377) versus 0.7% (410/61,377) for the AI tool. CONCLUSION: The automated spleen attenuation AI tool was highly accurate for detection of IVCM at a threshold of 65 HU.

Using research feedback loops to implement a disability case study with Aboriginal and Torres Strait Islander communities and service providers in regional and remote Australia.

While there is a well-developed body of literature in the health field that describes processes to implement research, there is a dearth of similar literature in the disability field of research involving complex conditions. Moreover, the development of meaningful and sustainable knowledge translation is now a standard component of the research process. Knowledge users, including community members, service providers, and policy makers now call for evidence-led meaningful activities to occur rapidly. In response, this article presents a case study that explores the needs and priorities of Aboriginal and Torres Strait Islander women in Australia who have experienced a traumatic brain injury due to family violence. Drawing on the work of Indigenous disability scholars such as Gilroy, Avery and others, this article describes the practical and conceptual methods used to transform research to respond to the realities of community concerns and priorities, cultural considerations and complex safety factors. This article offers a unique perspective on how to increase research relevance to knowledge users and enhance the quality of data collection while also overcoming prolonged delays of knowledge translation that can result from the research-production process.

Fibrinolysis resistance after liver transplant as a predictor of early infection.

BACKGROUND: Infection is a leading cause of morbidity in liver transplant (LT). Considering that the fibrinolytic system is altered in sepsis, we investigated the relationship between fibrinolysis resistance (FR) and post-transplant infection. METHODS: Fibrinolysis was quantified using thrombelastography (TEG) with the addition of tPA to quantify FR. FR was defined as LY30 = 0% and stratified as transient if present on POD1 or POD5 (tFR), persistent (pFR) if present on both, or no FR (nFR) if absent. RESULTS: 180 LT recipients were prospectively enrolled. 52 (29%) recipients developed infection. 72 had tFR; 37 had pFR; and 71 had nFR. Recipients with pFR had significantly greater incidence of infections (51% vs. 26% tFR vs. 20% nFR, p = 0.002). pFR was independently associated with increased odds of post-transplant infection (adjusted OR 3.39, p = 0.009). CONCLUSIONS: Persistent fibrinolysis resistance is associated with increased risk of post-transplant infection.

Radioactivity concentration measurements in fish and shellfish samples from the west coast of Canada after the Fukushima nuclear accident (2011-2018).

Radioactive contamination of the Pacific Ocean following the Fukushima nuclear accident has raised public concern about seafood safety, particularly in coastal Indigenous communities. To address this, Health Canada and partners have collected and analyzed a total of 621 samples of commonly consumed salmon, ground fish, and shellfish from the Canadian west coast from 2011 to 2018. While the vast majority of the 137Cs and 134Cs levels were below the Minimum Detectable Concentration (MDC, typically 0.7-1.0 Bq kg-1 fw for a 6 h counting), further examination of 19 fish samples revealed 137Cs concentrations of 0.17-0.53 Bq kg-1 fw with an average value and uncertainty (k = 1) of 0.29 ± 0.02 Bq kg-1 fw. Of these, only two samples were found to have trace levels of 134Cs likely derived from the Fukushima accident. The global fallout contribution from atmospheric nuclear weapons testing to the observed 137Cs in these two samples was determined to be 0.26 ± 0.08 Bq kg-1 fw (49 ± 14%) and 0.12 ± 0.02 Bq kg-1 fw (24 ± 4%) for collection years 2015 and 2016, respectively. The annual average level of 137Cs in fish and shellfish was also determined by spectral summation for collection years 2014-2018. In fish, 137Cs levels determined through spectral summation were relatively constant (0.18-0.25 Bq kg-1 fw) with an average value and uncertainty of 0.21 ± 0.02 Bq kg-1 fw. By contrast, 38 shellfish samples (bivalves) were measured and revealed no radiocesium or other anomalies in either tissue or shell. In all, measurements over eight years showed that the radioactivity in fish and shellfish was dominated by natural radionuclides and that the level of anthropogenic radionuclides, as indicated by the radioactive cesium content, remained small. An upper bound for ingested dose from 137Cs was determined to be approximately 0.26 µSv per year, far below the worldwide average annual effective dose of 2400 µSv from exposure to natural background radiation. We can therefore conclude that fish, such as salmon, ground fish, and shellfish from the Canadian west coast are of no radiological health concern despite the Fukushima Dai-ichi nuclear accident of 2011.

Relationship between surface dissolved iron inventories and net community production during a marine heatwave in the subarctic northeast Pacific.

From winter 2013-14 to the end of 2015-16, a high pressure atmospheric system induced elevated sea surface temperatures in the offshore subarctic northeast Pacific, resulting in a marine heatwave. Increased stratification due to the heatwave resulted in shoaling of the winter mixed layer and a decrease in nutrient re-supply to the euphotic zone. Here, we investigate relationships between dissolved iron (dFe) and macronutrients, net community production (NCP), (micro)nutrient uptake ratios, and phytoplankton community composition in the winter and summer from 2012 to 2015 to gain insight into coupled biogeochemical responses to the heatwave. Our investigation highlights the importance of external dFe supply during marine heatwave events, as a more shallow mixed layer reduces the transport of essential (micro)macronutrients to the surface layer. We conclude that recycled dFe did not contribute to NCP in 2014, but rather the vertical displacement of dFe rich water unrelated to mixed layer deepening played a major role. In 2015, such transport was not detected, resulting in abnormally low dFe and shift toward higher biomass of pico- and nano-phytoplankton size-classes.

Access to Left Ventricular Assist Device: Travel Time Does Not Tell The Whole Story.

BACKGROUND: Negative health effects of traveling longer distances for surgical services have been reported. Given the high complexity of multidisciplinary care required for management of Left Ventricular Assist Device (LVAD) implantation, only 4 of 18 centers in our state perform these operations. Given the limited access we hypothesized increased travel time would adversely affect postoperative outcomes and 30-d mortality. METHODS: A statewide Society of Thoracic Surgeons database was queried to identify patients undergoing Heartmate II/III and HVAD implantation, and 725 patients were identified. Travel time was calculated by zip code. Patients were stratified into regional and distant groups by the upper quartile of travel time (1-h). Preoperative variables and outcomes were compared between the groups. Multivariate analysis was performed to evaluate the impact of travel time in risk-adjusted models of 30-d mortality. RESULTS: Median patient travel time to their LVAD center in our state is 32 min (mean 53 ± 65 min, 46 ± 71 miles). Patients in the distant group (n = 191) had lower median incomes, higher self-pay status, higher rates of medical comorbid disease. Despite these differences there was no difference between the groups in ICU and/or hospital length of stay, readmission, postoperative complications, or 30-d mortality. Multivariate regression demonstrated insurance status, age, and prior surgery predicted 30-d mortality, but not travel time. CONCLUSIONS: Despite only four centers in the state performing LVAD implantation, travel time was strongly associated with preoperative risk, and socioeconomic status but not postoperative outcomes or 30-d mortality. Therefore, increasing access should focus on insurance, and patient characteristics not travel time.

Liver Transplantation With Grafts From Super Obese Donors.

There are limited data on liver transplant (LT) outcomes with grafts from super obese donors. The present study aims to evaluate a unique cohort of recipients following LT using grafts from donors with body mass index (BMI) ≥50. METHODS: Patients receiving grafts from donors with BMI ≥50 and BMI <50 from 2010 to 2019 were identified. A 1:2 case-control match was conducted to compare outcomes between the groups. Survival was analyzed using the Kaplan-Meier curves. RESULTS: Six hundred sixty-five adult LTs were performed in the study period. Eighteen patients receiving a graft from a donor with BMI ≥50 were identified and matched to 36 patients receiving a graft from a donor with BMI <50. Grafts from male donors were significantly lower in the donor BMI ≥50 group when compared with the donor BMI <50 group (16.7% versus 66.7%, P = 0.001). Liver biopsy was performed in 77.8% of grafts in the donor BMI ≥50 group, whereas only in 38.8% of the grafts in the donor BMI <50 group (P = 0.007). Recipients in the donor BMI ≥50 group had a significantly higher diagnosis rate of hepatocellular carcinoma pretransplant versus the donor BMI <50 group (38.9% versus 8.3%, respectively; P = 0.006). Major complications within 30 d did not differ statistically between groups. Biliary complications within the first 30 d were equal among groups (16.7%). Subanalysis comparing the super obese donor group versus the nonobese donor group showed no differences in terms of postoperative complications, readmission rate, graft rejection, or major complications including the need for reoperation, retransplantation, or mortality. Graft and patient survival at 1-, 3-, and 5-y graft were similar between the donor BMI ≥50 group versus donor BMI <50 group (94%/89%/89% versus 88%/88%/88%, P = 0.89, and 94%/94%/94% versus 88%/88%/88%, P = 0.48, respectively). CONCLUSIONS: LT with carefully selected grafts from super obese donors can be safely performed with outcomes comparable with non-super obese donor livers. Therefore, these types of grafts could represent a safe means to expand the donor pool.

Impact of the Timing of Foot Tissue Resection on Outcomes in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia.

The objective of this study is to describe utilization of revascularization and tissue resection in patients with chronic limb-threatening ischemia (CLTI) and determine whether the timing of resection impacts outcomes. Revascularizations for CLTI were queried (ACS-NSQIP 2011-2015). Outcomes included 30-day major adverse limb events (MALE), major adverse cardiac events (MACE), length of stay (LOS), operative time, 30-day readmissions, and wound infections. Groups included revascularization alone, revascularization/tissue resection during the same procedure (concurrent), or revascularization/delayed tissue resection (delayed). Resections were debridement or transmetatarsal amputations. Multivariate logistic regression determined risk-adjusted effects of tissue resection on outcomes. There was no difference in overall 30-day MACE or MALE between groups (P = .70 and P = .35, respectively). Length of stay (6.1 days revascularization alone vs 7.8 days concurrent vs 8.7 days delayed, P < .0001) was longer in patients who underwent any tissue resection. Highest 30-day readmission and operative time was the concurrent group (P = .02 and P < .0001, respectively). Wound infection was highest in the delayed group (1.4% revascularization alone vs 1.3% concurrent vs 6.2% delayed, P < .0001). After risk adjustment, timing of resection did not impact LOS for concurrent and delayed groups compared to revascularization alone (both P < .0001). Debridement and minor amputations can be done concurrently in patients undergoing revascularization for CLTI.

Sex-Based Differences Among Experimental Swine Abdominal Aortic aneurysms.

BACKGROUND: Female sex protects against abdominal aortic aneurysms (AAAs); however, the mechanisms behind these sex-based differences remain unknown. The purpose of this study was to explore the role of sex and sex hormones in AAA formation among swine. MATERIALS AND METHODS: Using a previous validated model, infrarenal AAA were surgically created in uncastrated male (n = 8), female (n = 5), and castrated male (n = 4) swine. Aortic dilation was measured on postoperative day 28 during the terminal procedure and compared to initial aortic diameter measured during the index procedure. Tissue was analyzed for immunohistochemistry, cytokine array, gelatin zymography, serum 17ß-estradiol, and testosterone assay. RESULTS: Uncastrated males had significantly larger maximal aortic dilation compared to castrated males (113.5% ± 11.4% versus 38.1% ± 4.5%, P = 0.0012). Females had significantly higher mean aortic dilation compared to castrated males (96.2% ± 7.5% versus 38.1% ± 4.5%, P = 0.0004). Aortic diameters between females and uncastrated males were not significantly different on day 28. Female swine had significantly higher concentrations of 17ß-estradiol compared with uncastrated males (1590 ± 873.3 ng/mL versus 95.2 ± 2.3 ng/mL, P = 0.047), with no significant difference between females and castrated males. Uncastrated male AAA demonstrated significantly more elastin degradation compared with female and castrated males (P = 0.01 and <0 .01, respectively). No differences existed for T-cells or smooth muscle cells between groups. Multiple proinflammatory cytokines were elevated within uncastrated male aortic walls compared to females and castrated males. CONCLUSIONS: Sex hormones, specifically 17ß-estradiol and testosterone, influence experimental swine AAA formation as demonstrated by increased aneurysm size, collagen turnover, and elastolysis in uncastrated males in processes reflective of human disease.

Expanding the donor pool for liver transplantation with marginal donors.

The current supply of acceptable donor livers is not sufficient to meet the demands of listed patients awaiting transplantation resulting in thousands of deaths each year. Increased utilization of marginal livers may help alleviate this supply/demand mismatch by expanding the donor liver pool. The current status of liver transplantation using marginal donor grafts and efforts to optimize usage are discussed with attention to elderly donors, steatotic livers, donors after circulatory death, and split liver grafts.

Exploring the barriers and facilitators for the use of digital health technologies for the management of COPD: a qualitative study of clinician perceptions.

BACKGROUND: Digital health technology (DHT) promises to support patients and healthcare professionals (HCPs) to optimize the management of chronic obstructive pulmonary disease (COPD). However, there is a lack of evidence demonstrating the effectiveness of DHT for the management of COPD. One reason for this is the lack of user-involvement in the development of DHT interventions in COPD meaning their needs and preferences are rarely accounted for in the design phase. Although HCP adoption issues have been identified in relation to DHT, little is known about the challenges perceived by HCPs providing care to COPD patients. Therefore, this study aims to qualitatively explore the barriers and facilitators HCPs perceive for the use of DHT in the management of COPD. METHODS: Participants (n = 32) were recruited using snowball sampling from two university hospitals and several general practitioner clinics. A semi-structured interview was conducted with each participant. NVivo 12 software was used to complete thematic analysis on the data. RESULTS: Themes identified include: data quality; evidence-based care; resource constraints; and digital literacy presented as barriers; and facilitators include the following themes: digital health training and education; improving HCP digital literacy; and Personalized prescribing. Patient-centered approaches, such as pulmonary rehabilitation and shared decision-making were suggested as implementation strategies to ease the adoption of digital health for the management of COPD. CONCLUSION: These findings contribute new insights about the needs and preferences of HCPs working in COPD regarding DHT. The findings can be used to help mitigate user-experience issues by informing the design of person-centered implementation and adoption strategies for future digital health interventions in COPD.

Female Mice Exhibit Abdominal Aortic Aneurysm Protection in an Established Rupture Model.

BACKGROUND: Male gender is a well-established risk factor for abdominal aortic aneurysm (AAA), whereas estrogen is hypothesized to play a protective role. Although rupture rates are higher in women, these reasons remain unknown. In the present study, we sought to determine if female mice are protected from AAA rupture. MATERIALS AND METHODS: Apolipoprotein E-deficient male and female mice (aged 7 wk; n = 25 per group) were infused with angiotensin II (AngII; 2000 ng/kg/min) plus ß-aminopropionitrile (BAPN) in the drinking water for 28 d to test the effects of gender on AAA rupture. Separately, a second group of male apolipoprotein E-deficient mice underwent AngII infusion + BAPN while being fed high-fat phytoestrogen free or a high-fat phytoestrogen diet to assess effects of phytoestrogens on rupture. In a third group, female mice either underwent oophorectomy or sham operation 4 wk before infusion of AngII and BAPN to further test the effects of female hormones on AA rupture. Surviving mice abdominal aorta were collected for histology, cytokine array, and gelatin zymography on postoperative day 28. RESULTS: Female mice had decreased AAA rupture rates (16% versus 46%; P = 0.029). Female mice expressed fewer elastin breaks (P = 0.0079) and decreased smooth muscle cell degradation (P = 0.0057). Multiple cytokines were also decreased in the female group. Gelatin zymography demonstrated significantly decreased pro-matrix metalloproteinase 2 in female mice (P = 0.001). Male mice fed a high dose phytoestrogen diet failed to decrease AAA rupture. Female mice undergoing oophorectomy did not have accelerated aortic rupture. CONCLUSIONS: These data are the first to attempt to tease out hormonal effects on AAA rupture and the possible role of gender in rupture.

Porcine Model of Infrarenal Abdominal Aortic Aneurysm.

Large animal models to study abdominal aortic aneurysms are sparse. The purpose of this model is to create reproducible, clinically significant infrarenal abdominal aortic aneurysms (AAA) in swine. To achieve this, we use a combination of balloon angioplasty, elastase and collagenase, and a lysyl oxidase inhibitor, called ß-aminopropionitrile (BAPN), to create clinically significant infrarenal aortic aneurysms, analogous to human disease. Noncastrated male swine are fed BAPN for 7 days prior to surgery to achieve a steady state in the blood. A midline laparotomy is performed and the infrarenal aorta is circumferentially dissected. An initial measurement is recorded prior to aneurysm induction with a combination of balloon angioplasty, elastase (500 units)/collagenase (8000 units) perfusion, and topical elastase application. Swine are fed BAPN daily until terminal procedure on either postoperative day 7, 14, or 28, at which time the aneurysm is measured, and tissue procured. BAPN + surgery pigs are compared to pigs that underwent surgery alone. Swine treated with BAPN and surgery had a mean aortic dilation of 89.9% ± 47.4% at day 7, 105.4% ± 58.1% at day 14, and 113.5% ± 30.2% at day 28. Pigs treated with surgery alone had significantly smaller aneurysms compared to BAPN + surgery animals at day 28 (p < 0.0003). The BAPN + surgery group had macroscopic and immunohistochemical evidence of end stage aneurysmal disease. Clinically significant infrarenal AAA can be induced using balloon angioplasty, elastase/collagenase perfusion and topical application, supplemented with oral BAPN. This model creates large, clinically significant AAA with hallmarks of human disease. This has important implications for the elucidation of AAA pathogenesis and testing of novel therapies and devices for the treatment of AAA. Limitations of the model include variation in BAPN ingested by swine, quality of elastase perfusion, and cost of BAPN.

Too Young to Undergo Temporal Artery Biopsy? Calciphylaxis-Related Anterior Ischemic Optic Neuropathy.

A 39-year-old male patient with end-stage renal failure presented with unexplained isolated unilateral anterior ischemic optic neuropathy, high sedimentation rate, and high CRP. Despite the relatively young age of the patient, an ipsilateral temporal artery biopsy was performed, disclosing calciphylaxis, a highly morbid condition associated with end-stage renal failure, which requires urgent, specific management.

Clinical Characteristics and Longitudinal Outcomes of Primary Mycotic Aortic Aneurysms.

Medical therapy for mycotic aortic aneurysms (MAA) is almost universally fatal, while surgical and endovascular repair carry high morbidity and mortality. The purpose of this study was to compare outcomes between patients receiving treatment for MAA. Records were obtained and patients with MAA were stratified by intervention: endovascular repair, open surgery, and medical therapy. Primary outcomes were aneurysm-related mortality and survival. Risk-adjusted associations with mortality were assessed using time-to-event analysis. Thirty-eight patients were identified (median age, 67). Twenty-one underwent endovascular repair,10 had open surgery and 7 received medical therapy alone. Overall mortality was 47% (n = 18), with 94% aneurysm related. Median survival was significantly longer in the endovascular group (747.0 [161-1249]) vs open surgery and medical therapy (507.5 [34-806] and 66 [13-146] days, respectively; P = .02). The endovascular group had significantly fewer perioperative complications (43% vs 80%, P < .01). However, 4 endovascular patients experienced reinfection versus no open surgery patients. Mortality risk factors included medical therapy (hazard ratio [HR]: 5.3, P < .01) and aneurysm size (HR: 1.4 per 1-cm increase in diameter, P = .03). Endovascular repair of MAA was associated with the best long-term survival and lowest perioperative complication rate, although it is associated with greater reinfection. These tradeoffs should be considered when selecting which procedure is best for a patient.