CT-guided transcutaneous drainage of peritonsillar abscess after failed ultrasound-guided drainage: A case report.

Peritonsillar abscess (PTA) is the most common deep neck infection in the United States. Timely treatment of PTA with antibiotics and aspiration or drainage is paramount, as delay in management may lead to further complications. The oral approach is the preferred route of drainage however may not always be accessible, warranting consideration of other routes of drainage. To the best of our knowledge, CT guidance for aspiration or drainage of a PTA has not been previously described. We present a 50-year-old patient with a PTA who initially presented with throat pain and dysphagia, rapidly developed upper airway obstruction, and required intubation. After the failure of clinical improvement and unsuccessful PTA aspiration via the conventional oral route, successful CT-guided percutaneous needle aspiration was performed by neuroradiology. Shortly thereafter, the patient clinically improved and was discharged with an oral course of antibiotics and follow-up on an as-needed basis. Total hospital length of stay was seven days. The complex patient may not allow for simple incision and drainage or needle aspiration of a suspected PTA. Assistance with ultrasound guidance is often utilized, however, challenges may persist depending on the anatomical location of the PTA and patient comorbidities. In cases where external drainage is considered and conventional ultrasound imaging is particularly challenging, CT-guided percutaneous aspiration may provide a useful alternative. PTAs are common with the possibility of complication. Although the usual route of drainage is oral, there are instances in which this cannot be performed. This case exhibits an uncommon approach to PTA aspiration via an external CT-guided percutaneous approach with rapid subsequent clinical improvement, exhibiting the utility of CT guidance.

Analysis of Superficial Subcutaneous Fat Camper's and Scarpa's Fascia in a United States Cohort.

Together, the Camper's and Scarpa's fasciae form the superficial fat layer of the abdominal wall. Though they have clinical and surgical relevance, little is known about their role in body composition across diverse patient populations. This study aimed to determine the relationship between patient characteristics, including sex and body mass index, and the distribution of Camper's and Scarpa's fascial layers in the abdominal wall. A total of 458 patients' abdominal CT examinations were segmented via CoreSlicer 1.0 to determine the surface area of each patient's Camper's, Scarpa's, and visceral fascia layers. The reproducibility of segmentation was corroborated by an inter-rater analysis of segmented data for 20 randomly chosen patients divided between three study investigators. Pearson correlation and Student's t-test analyses were performed to characterize the relationship between fascia distribution and demographic factors. The ratios of Camper's fascia, both as a proportion of superficial fat (r = -0.44 and p < 0.0001) and as a proportion of total body fat (r = -0.34 and p < 0.0001), showed statistically significant negative correlations with BMI. In contrast, the ratios of Scarpa's fascia, both as a proportion of superficial fat (r = 0.44 and p < 0.0001) and as a proportion of total body fat (r = 0.41 and p < 0.0001), exhibited statistically significant positive correlations with BMI. Between sexes, the females had a higher ratio of Scarpa's facia to total body fat compared to the males (36.9% vs. 31% and p < 0.0001). The ICC values for the visceral fat, Scarpa fascia, and Camper fascia were 0.995, 0.991, and 0.995, respectively, which were all within the 'almost perfect' range (ICC = 0.81-1.00). These findings contribute novel insights by revealing that as BMI increases the proportion of Camper's fascia decreases, while the ratio of Scarpa's fascia increases. Such insights expand the scope of body composition studies, which typically focus solely on superficial and visceral fat ratios.

Subcutaneous and visceral fat are associated with worse outcomes in gunshot injuries but not stab injuries to the torso.

Purpose: The effect of obesity in penetrating trauma outcomes is poorly understood. The purpose of this study was to determine if there is a protective effect of subcutaneous or visceral fat from stab and gunshot wounds. Methods: 443 patients admitted after penetrating traumatic injury of the torso were retrospectively identified from our institution's trauma registry. CT scans performed at presentation were used to determine cross-sectional area of visceral and subcutaneous fat at the level of the umbilicus via manual segmentation. Obesity-associated parameters including body mass index, visceral and subcutaneous fat were compared with injury severity score, length of hospital/intesive care unit (ICU) stay, and number of operating room (OR) visits. Parameters were compared between patients who sustained stab wounds versus gunshot injuries. Results: Comparing all patients with gunshot injuries with those with stab injuries, gunshots resulted in increased hospital and ICU length of stay, and injury severity score (ISS). For patients with gunshot wounds, all obesity-related parameters correlated with increased length of stay and total ICU stay; subcutaneous fat and visceral fat were correlated with increased OR visits, but there was no significant correlation between obesity-related parameters and ISS. In contrast, with stab wounds there were no statistically significant associations between obesity parameters and any of the outcome measures. Conclusion: For penetrating trauma in the torso, obesity is correlated with worse outcomes with gunshot injuries but not in stab injuries. Level of evidence: Level III, prognostic and epidemiological.

Comparative Survival Benefits of Surgery and Adjuvant Chemotherapy in Neuroendocrine Carcinoma of the Gallbladder: A Population-Based Study with Insight into Future Personalized Therapeutic Approach.

BACKGROUND: Neuroendocrine carcinomas of the gallbladder (NECs-GB) are rare tumors, accounting for <0.2% of all neuroendocrine carcinomas of the gastrointestinal tract. They originate from the neuroendocrine cells of the gallbladder epithelium with associated intestinal or gastric metaplasia. The current study is the largest study from the SEER database on NECs-GB that aims to elucidate the demographic, clinical, and pathologic factors influencing the prognosis and comparative survival analysis of different treatment modalities. METHODS: The data from 176 patients with NECs-GB was abstracted from the Surveillance Epidemiology and End Result (SEER) database (2000-2018). Multivariate analysis, non-parametric survival analysis, and a chi-square test were used to analyze the data. RESULTS: NECs-GB had a higher incidence amongst females (72.7%) and Caucasians (72.7%). Most patients had surgery only (N = 52, 29.5%), (N = 40) 22.7% had chemotherapy only, and (N = 23) 13.1% had chemotherapy with surgery. Only (N = 17) 9.7% had trimodaltiy (surgery, chemotherapy, and radiation therapy), and for (N = 41) 23.3% the status of chemotherapy was unknown, and these cases had neither radiation nor surgery. CONCLUSION: NECs-GB more frequently affects Caucasian females after the 6th decade of life. The combination of surgery, radiation, and adjuvant chemotherapy was associated with better long-term (5 years) outcomes, while surgery alone was associated with better short-term (<2 years) outcome survival.

Effect of Disease Severity, Age of Child, and Clinic No-Shows on Unscheduled Healthcare Use for Childhood Asthma at an Academic Medical Center.

This study examines the influence of various individual demographic and risk factors on the use of unscheduled healthcare (emergency and inpatient visits) among pediatric outpatients with asthma over three retrospective timeframes (12, 18, and 24 months) at an academic health center. Out of a total of 410 children who visited an academic medical center for asthma outpatient care between 2019 and 2020, 105 (26%) were users of unscheduled healthcare for childhood asthma over the prior 12 months, 131 (32%) over the prior 18 months, and 147 (36%) over the prior 24 months. multiple logistic regression (MLR) analysis of the effect of individual risk factors revealed that asthma severity, age of child, and clinic no-shows were statistically significant predictors of unscheduled healthcare use for childhood asthma. Children with higher levels of asthma severity were significantly more likely to use unscheduled healthcare (compared to children with lower levels of asthma severity) across all three timeframes. Likewise, children with three to four clinic no-shows were significantly more likely to use unscheduled healthcare compared to children with zero clinic no-shows in the short term (12 and 18 months). In contrast, older children were significantly less likely to use unscheduled healthcare use compared to younger children in the longer term (24 months). By virtue of its scope and design, this study provides a foundation for addressing a need identified in the literature for short- and long-term strategies for improving supported self-management and reducing unscheduled healthcare use for childhood asthma at the patient, provider, and organizational levels, e.g., (1) implementing telehealth services for asthma outpatient care to reduce clinic no-shows across all levels of asthma severity in the short term; (2) developing a provider-patient partnership to enable patient-centered asthma control among younger children with higher asthma severity in the long term; and (3) identifying hospital-community linkages to address social risk factors influencing clinic no-shows and unscheduled healthcare use among younger children with higher asthma severity in the long term.

General Surgery Twitter during COVID-19: Tweets, Trends, and Implications for Recruitment Strategies.

BACKGROUND: The COVID-19 pandemic has disrupted traditional resident recruitment practices, requiring virtual interviews and new forms of outreach. Social media, such as Twitter, is one tool programs can use to connect with applicants. This study sought to assess changes in Twitter use during the COVID-19 pandemic among general surgery programs. METHODS: Twitter and residency program websites were queried for public Twitter accounts related to general surgery residency programs. Publicly available tweets for available accounts were reviewed for all posts for the period March 15, 2019-November 25, 2020. Thematic analysis of each tweet was performed, and engagement was determined by likes and retweets on each tweet. RESULTS: The number of programs with active Twitter accounts increased after the onset of COVID-19 pandemic, as did the number of tweets, likes-, and retweets-per-tweet. There was a significant increase in the number of tweets regarding resident promotion, program promotion, and virtual event promotion. Tweets received more likes-per-tweet if the subject was program promotion and resident promotion than tweets regarding virtual events. All results were statistically significant (P < .05). DISCUSSION: Twitter use and engagement with residency programs have increased significantly since pandemic onset. Engagement is highest for tweets regarding program and resident promotion as measured by likes-per-tweet and highest for program promotion and virtual events as measured by retweets-per-tweet. Given the nearly nationwide increase in Twitter engagement after pandemic onset, programs should consider the impact of Twitter as a means of communication with applicants and program branding.

Lipopolysaccharide Pretreatment Prevents Medullary Vascular Congestion following Renal Ischemia by Limiting Early Reperfusion of the Medullary Circulation.

BACKGROUND: Vascular congestion of the renal medulla-trapped red blood cells in the medullary microvasculature-is a hallmark finding at autopsy in patients with ischemic acute tubular necrosis. Despite this, the pathogenesis of vascular congestion is not well defined. METHODS: In this study, to investigate the pathogenesis of vascular congestion and its role in promoting renal injury, we assessed renal vascular congestion and tubular injury after ischemia reperfusion in rats pretreated with low-dose LPS or saline (control). We used laser Doppler flowmetry to determine whether pretreatment with low-dose LPS prevented vascular congestion by altering renal hemodynamics during reperfusion. RESULTS: We found that vascular congestion originated during the ischemic period in the renal venous circulation. In control animals, the return of blood flow was followed by the development of congestion in the capillary plexus of the outer medulla and severe tubular injury early in reperfusion. Laser Doppler flowmetry indicated that blood flow returned rapidly to the medulla, several minutes before recovery of full cortical perfusion. In contrast, LPS pretreatment prevented both the formation of medullary congestion and its associated tubular injury. Laser Doppler flowmetry in LPS-pretreated rats suggested that limiting early reperfusion of the medulla facilitated this protective effect, because it allowed cortical perfusion to recover and clear congestion from the large cortical veins, which also drain the medulla. CONCLUSIONS: Blockage of the renal venous vessels and a mismatch in the timing of cortical and medullary reperfusion results in congestion of the outer medulla's capillary plexus and promotes early tubular injury after renal ischemia. These findings indicate that hemodynamics during reperfusion contribute to the renal medulla's susceptibility to ischemic injury.

Nerve transection repair using laser-activated chitosan in a rat model.

OBJECTIVES/HYPOTHESIS: Cranial nerve transection during head and neck surgery is conventionally repaired with microsuture. Previous studies have demonstrated recovery with laser nerve welding (LNW), a novel alternative to microsuture. LNW has been reported to have poorer tensile strength, however. Laser-activated chitosan, an adhesive biopolymer, may promote nerve recovery while enhancing the tensile strength of the repair. Using a rat posterior tibial nerve injury model, we compared four different methods of nerve repair in this pilot study. STUDY DESIGN: Animal study. DESIGN: Animals underwent unilateral posterior tibial nerve transection. The injury was repaired by potassium titanyl phosphate (KTP) laser alone (n = 20), KTP + chitosan (n = 12), microsuture + chitosan (n = 12), and chitosan alone (n = 14). Weekly walking tracks were conducted to measure functional recovery (FR). Tensile strength (TS) was measured at 6 weeks. RESULTS: At 6 weeks, KTP laser alone had the best recovery (FR = 93.4% ± 8.3%). Microsuture + chitosan, KTP + chitosan, and chitosan alone all showed good FR (87.4% ± 13.5%, 84.6% ± 13.0%, and 84.1% ± 10.0%, respectively). One-way analysis of variance was performed (F(3,56) = 2.6, P = .061). A TS threshold of 3.8 N was selected as a control mean recovery. Three groups-KTP alone, KTP + chitosan, and microsuture + chitosan-were found to meet threshold 60% (95% confidence interval [CI]: 23.1%-88.3%), 75% (95% CI: 46.8%-91.1%), and 100% (95% CI: 75.8%-100.0%), respectively. CONCLUSIONS: In the posterior tibial nerve model, all repair methods promoted nerve recovery. Laser-activated chitosan as a biopolymer anchor provided good TS and appears to be a novel alternative to microsuture. This repair method may have surgical utility following cranial nerve injury during head and neck surgery. LEVEL OF EVIDENCE: NA Laryngoscope, 127:E253-E257, 2017.

Potassium titanyl phosphate laser welding following complete nerve transection.

OBJECTIVES/HYPOTHESIS: Cranial nerve transection during head and neck surgery is conventionally repaired by microsuture reanastomosis. Laser nerve welding (LNW), using CO2 laser to spot-weld the epineurium of transected nerve endings, has been shown in animal models to be a novel alternative to microsuture repair. This method avoids needle/suture material and minimizes instrumentation of the nerve. We hypothesized that potassium titanyl phosphate (KTP) laser would be superior to CO2 laser in repairing transected nerves. Using a rat posterior tibial nerve injury model, we compared CO2 laser, KTP laser, and microsuture reanastomosis. STUDY DESIGN: Animal study. METHODS: Animals underwent unilateral posterior tibial nerve transection. The injury was repaired by microsuture repair (n = 15), CO2 laser repair (n = 15), or KTP laser repair (n = 15). Weekly walking tracks were performed to measure functional recovery. Nerve segments were harvested for axon counting. RESULTS: At 6 weeks, the KTP LNW had the best functional recovery (92.4 ± 8.6%) compared to microsuture repair (84.5 ± 10.2%, difference 7.9%, 95% confidence interval [CI]: 0.84%-14.96%). CO2 laser repair had a functional recovery of 86.8 ± 11.2%. KTP LNW had better axon recovery compared to transection/repair (difference 530.7 axons, 95% CI: 329.9-731.5). Operative time for the microsuture repair was 18.2 ± 6.8 minutes, compared to 5.8 ± 3.7 minutes for the LNW groups (difference 12.4 minutes, 95% CI: 8.6-16.2 minutes). CONCLUSIONS: KTP, CO2 , and microsuture repair all showed good functional recovery following complete transection of the posterior tibial nerve. Following complete nerve transection during head and neck surgery, KTP LNW may be a novel alternative to microsuture repair. LEVEL OF EVIDENCE: NA Laryngoscope, 127:1525-1530, 2017.

Calculating binding free energies of host-guest systems using the AMOEBA polarizable force field.

Molecular recognition is of paramount interest in many applications. Here we investigate a series of host-guest systems previously used in the SAMPL4 blind challenge by using molecular simulations and the AMOEBA polarizable force field. The free energy results computed by Bennett's acceptance ratio (BAR) method using the AMOEBA polarizable force field ranked favorably among the entries submitted to the SAMPL4 host-guest competition [Muddana, et al., J. Comput.-Aided Mol. Des., 2014, 28, 305-317]. In this work we conduct an in-depth analysis of the AMOEBA force field host-guest binding thermodynamics by using both BAR and the orthogonal space random walk (OSRW) methods. The binding entropy-enthalpy contributions are analyzed for each host-guest system. For systems of inordinate binding entropy-enthalpy values, we further examine the hydrogen bonding patterns and configurational entropy contribution. The binding mechanism of this series of host-guest systems varies from ligand to ligand, driven by enthalpy and/or entropy changes. Convergence of BAR and OSRW binding free energy methods is discussed. Ultimately, this work illustrates the value of molecular modelling and advanced force fields for the exploration and interpretation of binding thermodynamics.