Early Water Seal of Chest Tubes Following Video-Assisted Thoracic Surgery Pleurodesis.

INTRODUCTION: Early water seal following minimally invasive pulmonary lobectomy has been shown to reduce chest tube duration and postoperative length of stay (LOS). We evaluated chest tube duration and postoperative LOS following a standardized chest tube management protocol change (water seal on postoperative day 1) after video-assisted thoracic surgery (VATS) pleurodesis. METHODS: We identified adult patients undergoing VATS pleurodesis from August 2013 to December 2021. The chest tube protocol was changed in January 2017 such that patients were placed to water seal on the morning of postoperative day 1. Patients were divided into two groups, before the change (Group 1: August 2013-December 2016) and after (Group 2: January 2017-December 2021). We compared demographics, clinical characteristics, operative details, postoperative chest tube duration and output, and postoperative LOS between the groups. Descriptive statistics and log-transformed multivariable linear regression models were used to identify differences in patient outcomes that were associated with the protocol change. RESULTS: A total of 488 patients underwent VATS pleurodesis during the study period (Group 1: 329 patients; Group 2: 159 patients). The median age was 61 y (interquartile range [IQR] 49-68), 51% were females, 69% were White, and 29% were Black. For postoperative LOS, Group 1 had an IQR of 3-7 d, while Group 2 had an IQR of 2-6 d (P < 0.001). The multivariable log-transformed linear regression models demonstrated that the practice change was associated with reduced chest tube duration (0.77 times the chest tube duration before the change; P < 0.001) and reduced LOS (0.81 times the LOS before the change; P = 0.006). There was an associated reduction in patients needing to return to the operating room (P = 0.048) and needing postoperative extended ventilatory support (P = 0.035). CONCLUSIONS: Development of a standardized protocol to water seal chest tubes on postoperative day 1 following VATS pleurodesis is associated with reduced chest tube duration and LOS without an increase in postoperative complication rates.

Improving imaging strategies in pediatric appendicitis: a quality improvement initiative.

BACKGROUND: Data from the American College of Surgeons National Surgical Quality Improvement Program identified our hospital as an outlier for preoperative computed tomography (CT) use in the diagnosis of acute appendicitis in children. We performed a quality improvement project to reduce this utilization in favor of ultrasound-based diagnoses (ultrasonography [US]) through creation and implementation of an evidence-based appendicitis algorithm. METHODS: Over a 2-y period (1 y preceding and 1 y following institution of the algorithm), the clinical information of all pediatric patients operated on for suspicion of acute appendicitis following imaging studies in our institution was collated. Basic characteristics were compared before and after protocol implementation using the chi-square test for categorical variables and the nonparametric, independent sample test of medians for numerical variables. Imaging modalities used and clinical outcomes were compared using chi-square analysis. RESULTS: A total of 227 patients (117 preprotocol and 110 postprotocol implementation) were evaluated in our emergency department and operated on for suspicion of acute appendicitis. There were no differences in age, sex, race, or body mass index between the two periods. There were also no differences in length of stay (P = 0.27), acute and perforated appendicitis rates (P = 0.59), negative appendectomy rates (P = 0.40), or postoperative complications (P = 0.19). There was a significant reduction in the utilization of CT, from 65.8% to 22.0%, with a concurrent increase in the utilization of US (P < 0.001). CONCLUSIONS: With the implementation of a standardized, multidisciplinary algorithm, CT utilization was decreased and concurrently US utilization was increased without sacrificing diagnostic accuracy or patient outcomes.

Hereditary spastic paraplegia-linked REEP1 modulates endoplasmic reticulum/mitochondria contacts.

OBJECTIVE: Mutations in receptor expression enhancing protein 1 (REEP1) are associated with hereditary spastic paraplegias (HSPs). Although axonal degeneration is thought to be a predominant feature in HSP, the role of REEP1 mutations in degeneration is largely unknown. Previous studies have implicated a role for REEP1 in the endoplasmic reticulum (ER), whereas others localized REEP1 with mitochondria. We sought to resolve the cellular localization of REEP1 and further elucidate the pathobiology underlying REEP1 mutations in patients. METHODS: A combination of cellular imaging and biochemical approaches was used to refine the cellular localization of REEP1. Next, Reep1 mutations associated with HSP were functionally tested in neuritic growth and degeneration assays using mouse cortical culture. Finally, a novel assay was developed and used with wild-type and mutant Reep1s to measure the interactions between the ER and mitochondria. RESULTS: We found that REEP1 is present at the ER-mitochondria interface, and it contains subdomains for mitochondrial as well as ER localization. Knockdown of Reep1 and expression of pathological Reep1 mutations resulted in neuritic growth defects and degeneration. Finally, using our novel split-RLuc8 assay, we show that REEP1 facilitates ER-mitochondria interactions, a function diminished by disease-associated mutations. INTERPRETATION: Our data potentially reconcile the current conflicting reports regarding REEP1 being either an ER or a mitochondrial protein. Furthermore, our results connect, for the first time, the disrupted ER-mitochondria interactions to a failure in maintaining health of long axons in HSPs. Finally, the split-RLuc8 assay offers a new tool to identify potential drugs for multiple neurodegenerative diseases with ER-mitochondria interaction defects.

Gender Disparities in General Surgery Resident Subspecialization.

BACKGROUND: There are an increasing number of women entering medical school and general surgery residency. Despite this, there remains an underrepresentation of women in some surgical specialties. The purpose of this study is to examine gender differences in fellowship subspecialization of recent general surgery graduates. METHODS: Graduating residents from general surgery residencies from 2016 to 2020 were identified. Referring to each residency's graduating resident website, we noted whether or not listed alumni were reported to have entered a fellowship. If applicants were listed as having completed a fellowship, the fellowship was noted along with each applicant's expressed gender. Differences across groups were analyzed using SPSS. RESULTS: The majority (82.4%) of graduates pursued a fellowship after residency training. Men were more likely to enter fellowships in Cardiothoracic Surgery, Plastic and Reconstructive Surgery, Vascular Surgery, and practice than women. Women were more likely to enter fellowships in Breast Surgery, Acute Care Surgery/Trauma Surgery, Pediatric Surgery, and Endocrine Surgery than men. CONCLUSIONS: The majority of general surgery residency graduates pursue fellowship training. Gender disparities continue for a minority of subspecialties for both men and women.

Endocrine surgery is at the forefront of gender diversity.

BACKGROUND: The purpose of this study is to assess gender diversity across surgical subspecialties, with a focus on endocrine surgery. METHODS: We collected publicly-reported data from Association of American Medical Colleges (AAMC) and American Association of Endocrine Surgeons (AAES) during the 2017 data period. Student's t-test and Analysis of Variance (ANOVA) were used to compare percentages of female surgeons. We analyzed data by geographical regions, excluding states where data was unreported/unavailable. RESULTS: During this period, there were 25,022 general surgeons. Of these, 5157 (20.6%) were female. There were 513 endocrine surgeons, of which 179 (34.8%) were female (p < 0.001). Across the US, endocrine surgery had the greatest percentage of female surgeons (34.8%) compared to other surgical subspecialties (p < 0.001). When comparing geographical regions, the Northeast (22.8%) and West (22.8%) contained the highest percentages of female general surgeons, while the South comprised the greatest proportion of female endocrine surgeons (38.7%). CONCLUSIONS: Endocrine surgery has the most gender diversity of all studied surgical subspecialties. The Southern US has the greatest proportion of female endocrine surgeons.

Analysis of injected cement volume and clinical outcomes following kyphoplasty for vertebral compression fractures.

BACKGROUND: It has been suggested that greater volumes of cement injected during kyphoplasty correlate with improved vertebral body height restoration and kyphotic angulation correction. However, there is little evidence tying cement volume to patient outcomes. Here, we analyzed the association between cement volume and outcome utilizing indices of pain, disability, and quality of life. METHODS: One hundred and thirty-six patients undergoing kyphoplasty were analyzed retrospectively. The total volume of bone cement injected was recorded intraoperatively for each patient; the average total cement volume was 5.44 cc. Pre- and postoperative outcome indices were documented, using the visual analog scale (VAS), Roland-Morris disability index (RMDI), and the EuroQol 5 Dimension instrument (EQ5D). Pearson's correlations and linear regression models were derived for the association of total cement volume with each of the patient outcome measures. This was a retrospective cohort study. RESULTS: The average change in VAS, RMDI, and EQ5D scores for all patients was -6.8, +8.3, and +0.41, respectively. For VAS, RMDI, and EQ5D improvements, neither Pearson's correlations nor multiple linear regression models revealed a correlation or an association with total cement volume. CONCLUSION: For patients undergoing kyphoplasty, outcomes were not associated with the total injected cement volume; all had a significant reduction in pain and most exhibited decreased disability with improved quality of life.

Genetically-engineered pigs as sources for clinical red blood cell transfusion: What pathobiological barriers need to be overcome?

An alternative to human red blood cells (RBCs) for clinical transfusion would be advantageous, particularly in situations of massive acute blood loss (where availability and compatibility are limited) or chronic hematologic diseases requiring frequent transfusions (resulting in alloimmunization). Ideally, any alternative must be neither immunogenic nor pathogenic, but readily available, inexpensive, and physiologically effective. Pig RBCs (pRBCs) provide a promising alternative due to their several similarities with human RBCs, and our increasing ability to genetically-modify pigs to reduce cellular immunogenicity. We briefly summarize the history of xenotransfusion, the progress that has been made in recent years, and the remaining barriers. These barriers include prevention of (i) human natural antibody binding to pRBCs, (ii) their phagocytosis by macrophages, and (iii) the T cell adaptive immune response (in the absence of exogenous immunosuppressive therapy). Although techniques of genetic engineering have advanced in recent years, novel methods to introduce human transgenes into pRBCs (which do not have nuclei) will need to be developed before clinical trials can be initiated.

Vertebral height restoration following kyphoplasty.

BACKGROUND: Kyphoplasty is a minimally invasive surgery developed to restore height and stabilize painful vertebral compression fractures (VCFs). Only small retrospective studies have addressed the correlation between the degree of vertebral height restoration as it relates to pain relief and postoperative activity levels. No definitive correlations have been established. The objective of this analysis is to determine how height restoration correlates with improvements in pain, disability and quality of life. METHODS: We assessed outcomes following kyphoplasty in 59 Medicare-eligible patients with 1-3 painful VCFs between T5 and L5 due to osteoporosis or cancer. Pre and postoperative lateral radiographs were available for fifty-nine patients and were used to measure anterior, middle and posterior vertebral body (VB) heights. The Visual Analog Scale (VAS) [range: 0 (none) to 10 (worst)] was used to prospectively measure back pain pre and post-operatively in all patients. Pre and post-operative measurements of disability and quality of life were retrospectively collected using the Roland Morris Disability Index (RMDI) [range: 0 (no disability) to 24 (high disability)] and EuroQol5-Domain scale (EQ5D) [range: -0.11 (poor quality of life) to 1.0 (perfect health)]. Pearson correlations and linear regression models were analyzed for association of VB height improvement with outcomes. RESULTS: Neither Pearson correlations (r coefficient range: 0.001-0.152) nor linear regression models (R2 value range: 0.0002-0.1133) revealed correlation or association between VB height improvements and outcomes. CONCLUSIONS: This is one of the largest studies to date assessing associations of VB height restoration following kyphoplasty with prospective measurements of pain and retrospective evaluation of disability and quality of life using validated instruments. Although a majority of patients in this cohort demonstrated increased vertebral heights and significant improvements in outcomes, none of the outcomes showed association with height improvements. Regardless of vertebral height improvements, most patients had improved pain, function and quality of life.

Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.