Recipient and Graft Outcomes in Simultaneous Kidney and Pancreas Transplantation With Steroid Avoidance in the United States.

BACKGROUND: Steroid avoidance in kidney transplantation has been proven noninferior. Long-term outcome data on steroid avoidance in simultaneous pancreas-kidney (SPK) remains scant. METHODS: Utilizing the Scientific Registry of Transplant Recipients between 2000 and 2020, we studied all primary crossmatch negative SPK recipients (N = 5683) who received antithymocyte globulin induction and were discharged alive with functioning grafts on tacrolimus and mycophenolate ± steroid maintenance. Recipients were grouped according to steroid use into 2 groups: steroid maintenance (n = 4191) and steroid avoidance (n = 1492). Kaplan-Meier curves censored at 10 y were generated for recipient and allograft survival by steroid maintenance. Predictors for recipient and graft survival were examined using Cox Proportional Hazards. Models were adjusted for age, body mass index, ethnicity, diabetes type, human leukocyte-antigen mismatches, cold ischemia time, transplant era, preemptive transplantation, and pancreas donor risk index with the transplant center included as a random effect. RESULTS: Steroid avoidance gained popularity over time, accounting for over one-fourth of the studied cohort. One-year acute rejection rates by steroid avoidance were comparable for kidney (8.6% versus 9%, P = 0.783); however, the pancreas rejection rate was lower in the steroid avoidance group (7.9% versus 10%; P = 0.035). After adjustment, steroid avoidance did not influence recipient survival (lower level of confidence interval, adjusted hazard ratio, upper level of confidence interval: 0.94, 1.15, 1.39), pancreas (0.75, 0.93, 1.16), or kidney (0.95, 1.18, 1.45) death-censored survival, compared with steroid maintenance. CONCLUSIONS: Accounting for the recipient and graft characteristics, steroid avoidance is associated with similar recipient, pancreas, and kidney graft outcomes compared with steroid maintenance in SPK recipients after antithymocyte globulin induction with tacrolimus and mycophenolate maintenance.

Outcomes of Primary Simultaneous Pancreas-kidney Transplants by Induction Agent in the United States.

Long-term outcome data by induction type in simultaneous pancreas-kidney (SPK) is limited. Methods: Utilizing the Scientific Registry of Transplant Recipients, we examined all primary SPK transplants between 2000 and 2020, excluding crossmatch-positive recipients. We grouped recipients according to induction regimen into 3 groups: rabbit anti-thymocyte globulin (r-ATG) (n = 5678), alemtuzumab (n = 1199), and interleukin-2 receptor antagonist (IL-2RA; n = 1593). We analyzed the 10-y recipient and composite (kidney and pancreas) graft survival using the Kaplan-Meier survival function. Cox-proportion hazard models were generated to examine the association between induction type, the 10-y recipient, and graft survival. Models were adjusted for recipient age, sex, ethnicity, HLA-mismatch, diabetes type, dialysis dependency, cold-ischemia time, local versus imported organs, panel reactive antibody, steroid maintenance, and Pancreas Donor Risk Index. Results: r-ATG was associated with the lowest 1-y kidney and pancreas rejection rates compared with other agents (P < 0.001). In the univariable analysis, induction type was not associated with recipient (log-rank P = 0.11) or graft survival (log-rank P = 0.36). In the multivariable model for the composite graft survival, alemtuzumab use was associated with 22% increased kidney or pancreas graft loss compared with r-ATG (adjusted hazard ratio, 1.22; 95% confidence interval, 1.05-1.42), whereas IL-2RA use was not a predictor of graft survival. Induction type did not influence recipient survival in the adjusted model. Conclusions: r-ATG use was associated with the lowest SPK rejection rates. Compared with r-ATG, alemtuzumab but not IL-2RA was associated with worse long-term death-censored SPK graft outcome. Our analysis supports the common use of r-ATG for induction in US primary SPK recipients.

Clinical Course of Mechanically Ventilated COVID-19 Patients With Pneumothoraces.

Introduction Pneumothoraces in mechanically ventilated patients with COVID-19 indicate severe lung damage from inflammatory injury and barotrauma. These patients have a high mortality rate, and additional factors may further alter their clinical course. Methods We conducted a retrospective review of patients admitted to 11 public hospitals in New York City between March 6 and April 9, 2020, diagnosed with COVID-19. We identified 39 patients who developed pneumothoraces immediately after intubation or after a period of time on mechanical ventilation. Our study population was divided into various groups using demographic and clinical characteristics. Statistical analyses were conducted using SPSS software (IBM Inc., Armonk, USA) and paired t-tests to compare clinical outcomes between the various groups. P values < 0.05 were considered statistically significant. Results Our population was comprised of 28 male (72%) and 11 female patients; 36 out of 39 patients (92.3%) died with a median time of 10 days from admission to death and a median time of 2 days from pneumothorax to death. The remaining three were discharged home or to another facility. Pneumothoraces developed immediately after intubation in 18 patients and after a period of time on mechanical ventilation in 21 patients. Factors associated with a worse clinical course included age greater than 65 years (time from admission to pneumothorax 4.81 vs 8.35 days; p = 0.011) and presence of one or more comorbidities (time from admission to intubation 2.3 days vs 4.8 days; p = 0.041). Other factors that may worsen clinical course include previous smoking (time from admission to pneumothorax 4.4 vs 8.54 days; p = 0.074) and use of positive end-expiratory pressure (PEEP) greater than 15 cm H2O (time from intubation to pneumothorax 3.89 vs 6.42 days; p = 0.14). Conclusions Based on the findings in our retrospective review, COVID-19 patients who develop pneumothoraces on mechanical ventilation have a mortality rate in excess of 90%. Older patients and those with comorbidities have a more fulminant clinical course.

Outcomes of COVID-19 Admissions in the New York City Public Health System and Variations by Hospitals and Boroughs During the Initial Pandemic Response.

Introduction: In the initial pandemic regional differences may have existed in COVID-19 hospitalizations and patient outcomes in New York City. Whether these patterns were present in public hospitals is unknown. The aim of this brief study was to investigate COVID-19 hospitalizations and outcomes in the public health system during the initial pandemic response. Methods: A retrospective review was conducted on COVID-19 admissions in New York City public hospitals during the exponential phase of the pandemic. All data were collected from an integrated electronic medical records system (Epic Health Systems, Verona, WI). Overall, 5,422 patients with at least one admission each for COVID-19 were reviewed, with a study of demographic characteristics (including age, gender, race, BMI), pregnancy status, comorbidities, facility activity, and outcomes. Data related to hospitalization and mortality trends were also collected from City of New York website. These data often involved more than one facility and/or service line resulting in more location or treatment facility counts than patients due to utilization of services at more than one location and transfers between locations and facilities. Results: Higher mortality was associated with increasing age with the highest death rate (51.9%) noted in the age group >75 years (OR 7.88, 95%CI 6.32-10.08). Comorbidities with higher mortality included diabetes (OR 1.5, 95% CI 1.33-1.70), hypertension (OR 1.62, 95% CI 1.44-1.83), cardiovascular conditions (OR 1.66, 95% CI 1.47-1.87), COPD (OR 1.86, 95% CI 1.39-2.50). It was deduced that 20% of all New York City COVID-19 positive admissions were in public health system during this timeframe. A high proportion of admissions (21.26%) and deaths (19.93%) were at Elmhurst Hospital in Queens. Bellevue and Metropolitan Hospitals had the lowest number of deaths, both in borough of Manhattan. Mortality in public hospitals in Brooklyn was 29.9%, Queens 28.1%, Manhattan 20.4%. Conclusion: Significant variations existed in COVID-19 hospitalizations and outcomes in the public health system in New York City during the initial pandemic. Although outcomes are worse with older age and those with comorbidities, variations in hospitals and boroughs outside of Manhattan are targets to investigate and strategize efforts.

COVID-19 Complicated by Spontaneous Pneumothorax.

Over the last few months, the coronavirus disease 2019 (COVID-19) pandemic has created overwhelming challenges for physicians across the world. While much has been described in the literature about lung infiltrates and respiratory failure associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), pneumothorax remains a relatively rare presentation with current literature indicating a rate of one percent. We describe a case series of three patients each of whom tested positive for SARS-CoV-2 on reverse-transcriptase polymerase chain reaction testing of nasopharyngeal swab specimens and presented with pneumothorax. These patients were treated at the New York City Health and Hospitals (NYC H+H) system, a network of eleven hospitals in four different boroughs of New York City. None of these patients had a history of lung disease and one patient was a previous smoker. One out of three patients died. Inflammatory markers were noted to be elevated in each of these patients to levels that have been associated with severe COVID-19 infection. CT scans in these patients showed bilateral air space disease consistent with COVID-19 pneumonia and pneumothorax with other features including pneumomediastinum, subcutaneous emphysema, and pneumatoceles. This may indicate the underlying pathogenesis of pneumothorax in these patients to involve inflammation-induced pulmonary parenchymal injury and necrosis with subsequent development of air leaks into the pleural cavity, a mechanism similar to that noted in patients during the severe acute respiratory syndrome (SARS) outbreak in 2003. Conservative management with chest tube drainage or observation was adequate for two of three patients while one patient developed multi-organ system dysfunction and eventual death.

A Rare Forehead Mass: The Chondroid Syringoma.

The chondroid syringoma is an extremely rare skin tumor most commonly found in the area of the head and neck region. Its rarity, potential for malignancy, and frequent misdiagnosis for other more common tumors can impart unique challenges in diagnosis and management. Diagnosis is usually revealed by excision followed by histologic examination. We report a case of a 42-year-old male with no prior medical history diagnosed with chondroid syringoma of the forehead and review the relevant literature.

Management of Incidental Hernia Discovered During Abdominal Contouring in Post-Bariatric Surgery Patients.

PURPOSE: An increase in bariatric surgery has led to a rise in postbariatric contouring procedures. Despite a comprehensive preoperative assessment, body habitus in these patients may significantly limit the abdominal exam. Abdominal contouring procedures typically elevate large portions of the skin and fat off the abdominal wall, and unexpected hernia may be discovered intraoperatively. No study to date has characterized such hernia discovery at the time of body contouring surgery. We reviewed our experience of management of incidental hernia found during abdominoplasty or panniculectomy after laparoscopic bariatric surgery. METHODS: Records of all post-bariatric surgery patients undergoing abdominal contouring procedures between 2007 and 2017 were reviewed to identify patients with incidental hernias discovered intraoperatively. These patients were further examined by reviewing operative details, patient-specific factors, and outcomes. RESULTS: Six hundred eighty-one post-bariatric surgery patients underwent abdominal body contouring procedures with incidental ventral hernia discovered in 36 patients (5.3% [45 hernias]). At the time of plastic surgery, average age was 49 years (range, 25-64 years), and body mass index was 30.7 kg/m (range 25-43 kg/m). Of 36 patients with incidental hernia, 26 patients (72.2%) had a single hernia, and the remainder had multiple (27.8%). Mean hernia size was 4.1 cm (range, 0.25-24 cm). Most hernias were located paraumbilical/umbilical (46.7%) or epigastric (37.8%). Ninety-eight percent of hernias were repaired primarily (n = 44) by the plastic surgeon, and in 1 case (2%), mesh repair was performed by a consulting general surgeon. Average follow-up was 1.9 ± 0.3 years. Only 1 patient (2.8%) developed hernia recurrence after 48 months. Other postoperative complications included superficial wound healing problems (19.4%), seroma (16.7%), suture abscess (5.6%), and cellulitis that resolved with antibiotics (5.6%). CONCLUSIONS: This is the first study to characterize incidental hernia discovered at the time of body contouring in the post-bariatric surgery patient. The body contouring surgeon should be aware of this common finding. Hernias typically discovered during panniculectomy or abdominoplasty arise in umbilical or epigastric regions, likely from prior laparoscopic port sites, and can be safely repaired by the plastic surgeon with low overall complication rates.

Our Inner-city Children Inflicted With Burns: A Retrospective Analysis of Pediatric Burn Admissions at Harlem Hospital, NY.

Pediatric burns in the urban environment present special problems. Communities in the inner-city may be unique with hardships due to various socioeconomic factors. Few, if any, papers have specifically sought to analyze pediatric burns in the inner-city, and there has been no report to date reviewing Harlem New York City, one of the most challenged areas in the nation. The aim of this study is to understand the prehospital circumstances and socioeconomic factors of affected patients, hospital care, and management of pediatric patients admitted with burns in Harlem. A retrospective review was performed of all the patients aged 0 to 18 years old admitted to the burn care unit from January 2006 to May 2017. Data collected included age, gender, ethnicity, burn mechanism, total burn surface area, first aid and management, socioeconomic factors including parental supervision, single or binary parenting, caregiver financial and employment status, New York City Administration for Children's Services (ACS) child protective services reporting for child abuse or neglect. Analysis was done using Microsoft Excel 2016 and SPSS statistics v23. A total of 177 pediatric burn patient admissions were included. The majority of the patients were toddlers (1-5 years of age). The most common type was scald burns. The average TBSA burnt was approximately 9%. Nearly all the injuries occurred at home with more being during winter months. Strikingly, the majority of patients, over 75%, did not receive appropriate first aid measures. Moreover, socioeconomic issues were significant with 60% of patients having single parents, approximately 35% with lack of supervision and neglect or abuse reported in 25% of these cases. Unemployment rate of the caregiver was high, with 50% unemployed or in between jobs. In 73% of the patients, their parents were receiving some form of social aid for childcare and sustenance of family needs. Pediatric burns are a major public health issue. An understanding of community variations with these injuries is essential taking into account socioeconomic challenges that these children face. Our inner-city hospital pediatric burn admissions have substantial caregiver and socioeconomic challenges in excess of traditionally reported in the literature. Most injuries occurred at home and the majority lacked proper prehospital first aid care. This analysis is informative, providing professionals and caregivers topics of consideration regarding safe practices at home, appropriate first aid measures, prevalent socioeconomic issues in our community in Harlem. There is a need to address socioeconomic factors which may potentially prevent pediatric burn admissions in these inner-city communities.

Scrotal Reconstruction with Integra Following Necrotizing Fasciitis.

Scrotal loss from Fournier's gangrene can be a devastating injury with esthetic and functional consequences. Local reconstructive options can be limited by the presence of infection or the loss of neighboring tissue from debridement. IntegraTM bilayer matrix wound dressing is a well-established reconstructive modality, but only one report exists of its use in scrotal reconstruction and this was not in the setting of Fournier's gangrene. We report the successful use of Integra and a subsequent split-thickness skin graft for reconstruction of the anterior scrotum and coverage of the exposed testes in a 43-year-old man who developed Group A Streptococcus necrotizing fasciitis of his right lower extremity, groin, and scrotum requiring serial operative debridements. Stable testicular coverage was achieved with closely matched skin and minimal donor-site morbidity. Further study and a larger sample size will be necessary to better understand the advantages and disadvantages of scrotal reconstruction with Integra.

ReShape Intragastric Balloon Complicated by Gastric Perforation and Peritonitis.

BACKGROUND: Obesity is a growing global epidemic with tremendous financial burden and health care costs worldwide. Restrictive surgery has emerged as the definitive treatment option to combat morbid obesity and its associated comorbidities. The advent of endoscopy has new grounds in obesity with the introduction of inflatable balloon placed in the stomach that decreases satiety by volume restriction. MATERIALS AND METHODS: We report a first case of gastric perforation with peritonitis after ReShape intragastric balloon placement that needed emergent surgical intervention. Decision was made to proceed with exploratory laparotomy, device deflation, and removal with subsequent gastric defect repair. RESULTS: Postoperative period was uneventful, drain was removed on postoperative day 2, and patient tolerated diet and was discharged home subsequently. Biopsy of the perforation site demonstrated mild non-specific chronic gastritis. CONCLUSION: In the modern era of minimal invasiveness, any new approach would roar popularity among patients and hence is of utmost importance for clinicians to be constantly educated on scientific research and innovations in their field.

Abdominal Drains Retrieved Laparoscopically 15 Years Post Laparotomy.

A retained intra-abdominal foreign body is a common occurrence that is frequently underreported due to its medicolegal implications. Sponges, gauzes, surgical instruments, abdominal drains, etc. have been reported in the literature. The most common presentation for a retained intra-abdominal foreign body is postoperative abdominal infections or bleeding, frequently seen in the immediate postoperative period. Most of these foreign bodies are removed by exploratory laparotomy owing to recent abdominal surgeries or presentation as complicated abdominal masses. Here, we report a case with retained intra-abdominal drains for 15 years with minimal symptoms presenting as an intermittent abdominal pain; the drains were removed using laparoscopic intervention.

Retroperitoneal Pseudoaneurysm Mimicking Ureteral Calculus: Pitfalls in Diagnosis.

Arterial aneurysms (AA) can be classified as true aneurysms, characterized by the persistence of all three layers of the arterial wall with progressive dilation and wall thinning; arterial pseudoaneurysms (APAs) are characterized by a tear in the vessel wall and a periarterial hematoma formation. They could occur due to a visceral, retroperitoneal, or peripheral origin. Most AA/APA are usually found incidentally, and it is imperative to be vigilant in order to diagnose and manage them due to their potentially life-threatening complications. We present a case of a 35-year-old woman presenting with right-sided abdominal pain mimicking renal colic with an initial misdiagnosis of ureteral calculus. Post-cystoscopy, a misdiagnosis was confirmed, and subsequently, the patient had a right retroperitoneal mass excision. The histopathology report concluded the calcified retroperitoneal mass to be pseudoaneurysm. Such pitfalls in diagnosis are essential to be shared with the larger medical community for increased vigilance and optimal management of pseudoaneurysms.

Oncological outcome following de-intensification of treatment for stage I and II HPV negative oropharyngeal cancers with transoral robotic surgery (TORS): A prospective trial.

OBJECTIVE: This prospective study aimed to see long-term oncological outcome of Transoral Robotic Surgery as single modality treatment for cT1-T2 N0 HPV negative oropharyngeal malignancies. METHOD: From March 2013 to October 2015, 57 patients with early stage oropharyngeal carcinoma underwent Transoral robotic surgery (TORS) with neck dissection using daVinci® Surgical system. Patients were evaluated for disease free survival, overall survival, locoregional and distant metastasis. RESULTS: 57 patients (48 males and 9 females) underwent TORS for early stage oropharyngeal carcinoma. All patients underwent ipsilateral neck dissection and 12 patients underwent bilateral neck dissection. 49 patients with final histopathology suggestive of stage I and II disease did not received any adjuvant treatment. Mean age at presentation was 59.4years (37-88years). Most common site of involvement was the base of tongue (BOT) in 31 (54.8%) patients. Twenty-four (42.1%) patients were cT1 and 33 (57.9%) were cT2 at presentation. During follow-up, 2 (4.2%) patients recurred locoreginally and 1 (2.1%) patient had distant metastasis. Two patients expired due to causes other than malignancy. Forty-three (89.6%) patients were disease free on an average follow-up of 29months with an overall survival of 93.8% at mean follow-up of 29months. CONCLUSION: Transoral Robotic Surgery as a single modality treatment is a good option for cure in HPV negative early resectable oropharyngeal malignancies which are relatively unresponsive to radiation. TORS can be used to de-intensify the treatment of early stage oropharyngeal carcinoma and thus avoid the early and late toxicities associated with Radiotherapy/Chemoradiotherapy.

Burns from ignited household aerosols in the kitchen: a case series.

Aerosol sprays are commonly used products in daily living. Aerosols in kitchen products have prompted for use of 'food grade' or chemically inert propellants; however, they commonly contain gases or gaseous mixtures such as butane, propane and dimethyl ether that are flammable. When such sprays are used near heat sources, such as kitchen appliances, combustibles in these products can result in ignition and burn injury. Given the ubiquity of such sprays, surprisingly burns sustained from household aerosols are not characterised in the literature. We conducted a retrospective search of all burn patients treated at our hospital which contains a burn unit. Three patients were identified with burn wounds due to household aerosol sprays. All three occurred in the kitchen. and were characterized as first-degree and second-degree burns over the head and neck or upper extremities with one requiring inpatient admission. Where it may be perceived a cause of minor injury, household aerosol burns may result in significant burn injury and hospital admission. Household aerosols and burn injury are reviewed.

Inverted Meckel's Diverticulum: Rare Etiology of an Intestinal Obstruction.

Acute gastrointestinal obstruction can have a varied spectrum of clinical presentation and etiologies. It has been studied in detail and the management criteria have been well defined for the most part in our era. The etiologies are usually well defined. However, acute small bowel obstruction (SBO) due to intussusception caused by an inverted Meckel's diverticulum is a rare phenomenon that is often times missed on initial presentation and/or consequently until resected and visualized on pathological examination. We present a case of a 34-year-old presenting with symptoms and signs of acute intestinal obstruction and radiographic exam showing ileo-ileal intussusception. The patient failed to improve initially following conservative management and was taken to the operating room for small bowel resection which then revealed an inverted Meckel's diverticulum.

Hernioscopy in Incarcerated Inguinal Hernia Spontaneously Reduced after General Anesthesia Induction.

Hernioscopy is essentially hernia sac laparoscopy. Hernia repair has evolved over the years with better outcomes; however, strangulated inguinal hernias are acute surgical emergencies which require emergent operative intervention. During anesthesia induction and/or after incision, hernia self-reduction is possible, with or without compromised bowel, back into the abdominal cavity. It is pivotal to examine the bowel to decide on further operative course. A simple alternative to unnecessary laparotomy or standard laparoscopy is hernioscopy, which is quite uncommon. We present a case of an acute symptomatic strangulated left-sided inguinal hernia which got self-reduced during anesthesia induction and was successfully repaired after hernioscopy was used to evaluate the incarcerated hernia content. We provide a brief review of literature about hernioscopy and an algorithm to guide surgeons in emergent cases.

Tongue cleaner, an unusual foreign body in the urethra: A case report.

INTRODUCTION: Various cases of self-inflicted foreign body insertion into the urethra have been reported in adult males. The most common motive for such acts has been postulated as autoerotic stimulation, psychiatric illness or intoxication. CASE PRESENTATION: A 40-year-old male presented with a partially inserted tongue cleaner in his urethra with one end projecting from the urethral meatus and with a history of bleeding and pain. After a gentle attempt of removal using local anaesthetic gel the patient was scheduled for its surgical removal under anaesthesia. CONCLUSION: Large complex foreign bodies may be not amenable to endoscopic removal and may warrant open surgical procedure. Urethral stricture should be suspected in such patients. A psychiatric visit should be recommended for all adult males with self-inflicted foreign body in the urethra.

False positive localisation of C-11 methionine in a colloid nodule.

A 45-year-old female diagnosed with carcinoma of the left breast on histopathological examination underwent both (18)F-flourodeoxyglucose (FDG) and 11C-methionine (MET) positron emission tomography/computed tomography (PET/CT) as part of a protocol comparing the utility of these tracers for predicting a response to neoadjuvant chemotherapy in breast carcinoma. Abnormal FDG and MET accumulation was noted in the left breast primary, left axillary lymph nodes, and also in a well-defined nodule present in the left lobe of the thyroid gland. Keeping in mind the possibility of thyroid neoplasm/metastasis, the patient was referred for fine needle aspiration cytology (FNAC) from the thyroid nodule that revealed features of a simple colloid nodule. Focal thyroid lesions incidentally found on (18)F-FDG PET/CT have a high risk of thyroid malignancy. Non-specific accumulation of FDG in thyroid adenomas is also known. This case highlights a potential cause for false positive on C-11 MET PET/CT in colloid adenomas, which should be kept in mind while using this tracer for oncological indications.