Appendicitis in an Appendicostomy.

A 25-year-old man presented with right lower quadrant abdominal wall erythema, a punctum of purulence, and localized pain at the site of a previous appendicostomy. Cross-sectional imaging revealed appendicitis at his previous appendicostomy with a fecalith near the skin. He was managed with appendectomy. The surgical approach mimicked a loop ileostomy reversal by circumferentially dissecting the tissue around the appendicostomy to the level of the fascia and then dividing the appendix at the base of the cecum through a small two-centimeter incision. Appendicitis in a previous appendicostomy is uncommon and has only been described in three previous case reports (two adults and one child) and was surgically approached through a low-midline laparotomy. Our case is unique as it is an uncommon presentation of a common disease managed with a minimally invasive approach not previously described.

Live Quality Assurance: Using a Multimedia Messaging Service Group Chat to Instantly Grade Intraoperative Images.

BACKGROUND: The technique for attaining photographic evidence of the critical view of safety (CVS) in laparoscopic cholecystectomy (LC) has previously been defined; however, the consistency, accuracy, and feasibility of CVS in practice is unknown. The aim of this study was to use an already established image sharing and grading system to determine the feasibility of timely feedback after sharing intraoperative images of the CVS and to evaluate if and how cholecystitis affects the ability to attain a CVS. STUDY DESIGN: We studied 193 laparoscopic cholecystectomies performed by 14 surgeons between August 2017 and January 2019. Anterior and posterior intraoperative CVS images were shared using a standard multimedia messaging system (MMS). Images were graded remotely by members of the group using an established scoring system, and their times to response and scores were recorded. Response data were analyzed for the ability to attain timely and consistent CVS scores. RESULTS: There were 74 urgent laparoscopic cholecystectomies for acute cholecystitis and 119 nonurgent cholecystectomies performed during the study period. Scoring of shared images occurred in less than 5 minutes, and peer review (mean 3 responses) showed agreement that was not significantly different. In patients with acute cholecystitis, a small but significant difference was observed between anterior and posterior image scoring agreement. CONCLUSIONS: An established image sharing and grading system for CVS can be used for real-time intraoperative feedback without increasing operative time or compromising private health information. The CVS is almost always attainable; however, decreases in CVS quality and grading agreement are observed in patients with acute cholecystitis.

Predicting Mortality and Independence at Discharge in the Aging Traumatic Brain Injury Population Using Data Available at Admission.

BACKGROUND: Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients. STUDY DESIGN: Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes. RESULTS: Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p < 0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality). CONCLUSIONS: These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.

Embolization for pediatric blunt splenic injury is an alternative to splenectomy when observation fails.

BACKGROUND: Management of splenic injury has shifted from operative to nonoperative management in both children and adults with reports of high success rates. Benefits of splenic conservation include decreased hospital stay, blood transfusion, and mortality, as well as avoidance of infectious complications. Angiography with embolization is an innovative adjunct to nonoperative management and has resulted in increased splenic salvage in adults; however, data in the pediatric population are scant. METHODS: A retrospective comparative study of a single-hospital trauma registry reviewed from 1999 to 2009. Patients 18 years and younger admitted with injury to the spleen were included. Children with penetrating injury were excluded. Children were divided into three categories by initial treatment: observation, embolization, or splenectomy. Data recorded include age, radiographic grade of injury, and Injury Severity Score (ISS). Groups were analyzed for success of initial treatment, requirement for transfusion of packed red blood cells, splenic salvage, and mortality. RESULTS: Registry review identified 259 children with blunt splenic injury. Initial treatment was observation in 227, embolization in 15, and splenectomy in 17. In the observation group, 9 (4%) of 227 children failed initial treatment; 8 of these underwent embolization, while 1 unerwent splenectomy. In the embolization group, 1 (7%) of 15 failed initial treatment and underwent splenectomy. Blood transfusion was required by 38 (17%) of 227 in the observation group, 6 (40%) of 15 (p = 0.02) in the embolization group, and 15 (88%) of 17 (p < 0.01) in the splenectomy group. Overall splenic salvage rate was 237 (92%) of 259. Three children died in the observation group, and four children died in the splenectomy group. There was no death in the embolization group. CONCLUSION: Splenic artery embolization for blunt trauma in children is associated with a higher blood transfusion rate compared with observation but offers a safe, intermediate alternative to splenectomy when observation fails. LEVEL OF EVIDENCE: Therapeutic study, level IV.

A noncommercial polymerase chain reaction-based method to approach one hundred percent recombinant clone selection efficiency.

Molecular cloning is an important procedure in molecular biology, but this is often a rate-limiting step and can be very time-consuming, possibly due to low ligation efficiency. Here, we describe a simple polymerase chain reaction (PCR)-based strategy to approach 100% selection efficiency. The post-ligation mixture containing the recombinant was subjected to insert-specific primer-mediated PCR amplification using a high-fidelity DNA Pfu polymerase generating a plasmid containing staggered nicks. The PCR mixture was then digested with endonuclease DpnI, which digests the methylated and hemimethylated parental DNA template. The nicked vector was transformed into XL1 blue supercompetent cells where the nicks were repaired, thus amplifying and selecting only the newly amplified recombinant clones.