Operative Intervention Research Articles

Outcomes of Surgical Repair of Adult Naso-Orbital-Ethmoid Fractures: A Systematic Review and Meta-Analysis.

Adult naso-orbital-ethmoid (NOE) fractures are estimated to account for 5% of all adult facial fractures without published consensus on management. The purpose of this investigation was to assess the available literature regarding the treatment and outcomes of adult naso-orbital-ethmoid fractures. Cochrane Library, PubMed, Scopus, and CINAHL. Following PRISMA guidelines, databases were searched from inception through July 25, 2024 for studies pertaining to the treatment of NOE fractures. Measures of interest included patient demographics, associated fractures, type of intervention, and complications. A total of 16 studies were included for meta-analysis, consisting of 459 patients. The patients included in the analysis had a mean age of 30.6 years (95% CI: 26.9-34.3 years) with a male-to-female gender ratio of 2.7:1. Operative intervention, specifically open reduction and internal fixation (ORIF) (90.1%; 95: CI: 76.6-98.1%), was the most commonly performed management. Closed reduction has been reported for all three types. The most frequently reported complications included nasolacrimal duct obstruction (38.6%; 95% CI: 10.6-71.7%), postoperative epiphora (24.9%; 95% CI: 6.4-50.4%), and telecanthus (20.9%; 95% CI: 1.7-53.5%). Surgical intervention can be considered for all NOE types. Despite surgical intervention, NOE fractures remain difficult to treat, and inadequate repair may result in complications. Laryngoscope, 2024.

Management of the Infected Tissue Expander.

Tissue expander (TE) infection is a critical postoperative complication in two-stage implant-based breast reconstruction (IBBR). We assessed risk factors associated with TE infection and reconstructive loss and examined reconstructive salvage rates. We retrospectively reviewed patients who underwent IBBR with TE placement from 2017 to 2022. Included were patients with TE infection treated with admission and IV antibiotics, interventional radiology (IR) drainage, and/or operative management (washout with or without TE removal and TE replacement, TE removal and replacement with implant, and/or TE removal without replacement). Reconstructive success was defined as maintenance of breast reconstruction for 1 year after TE placement. Of 4,498 patients who underwent IBBR, 305 (338 TEs) met the inclusion criteria. Cox modeling showed higher body mass index, hypertension, radiation, bilateral TEs, acellular dermal matrix use, increasing mastectomy weight, and nipple sparing mastectomy were associated with increased hazard of TE infection. Patients with TE infection had a 54% reconstructive failure rate within 1 year; Cox modeling showed Black race and gram-negative cultures were associated with increased hazard of reconstructive failure within 1 year. Patients who underwent TE replacement with an implant had the most favorable success rate following infection. Overall, 46% of patients admitted with a periprosthetic infection had successful salvage. Patients with TE infection should be started on IV antibiotics with a low threshold for operative intervention based on exam and culture data. While IR can guide operative intervention of periprosthetic infections, our practice has shifted away from IR drainage towards definitive operative management.

Growth dynamics of Rathke's Cleft cyst: a risk score system for surgical decision making

ObjectiveRathke's cleft cysts (RCCs) exhibit variable growth patterns, thus posing a challenge in predicting progression. While some RCCs may not cause symptoms, others can insidiously cause pituitary dysfunction, which is often irreversible, even following surgery. Hence, it is crucial to identify asymptomatic RCCs that grow rapidly and pose a higher risk of causing endocrinologic dysfunction. This enables timely surgical intervention to prevent permanent damage. Our study examines the growth rate of RCCs, identifies factors that accelerate growth, and discusses the clinical implications of these findings.MethodsA retrospective analysis of a prospectively maintained electronic database revealed 45 patients aged 18–80 years who underwent endoscopic endonasal surgery (EEA) for RCCs between 2010 and 2022 at our center. Of these, 20 required early operative intervention. The remaining 25 patients were followed closely clinically and radiologically before requiring surgery (initial conservative management group). We conducted an analysis of the factors predicting growth over time in this group. Using a regression model, we constructed a risk score system to predict RCC growth over time.ResultsPatients in the initial conservative group had smaller cysts and were generally older than those in the early surgery group. Patients with preoperative pituitary dysfunction showed a higher median growth of 1.0 mm in the longest diameter compared to those with normal pituitary function, with an increase of 0.5 mm. A sum of annual cyst growth of all (z, y, x) diameters, at a rate of 3 mm or greater, was associated with a clinically significant increase in the risk of pituitary dysfunction, exceeding 50%.The most significant factors predicting rapid growth in RCCs were smoking status, age, and T1-weighted magnetic resonance imaging (MRI) intensity of cysts. Smoking was the most critical risk factor for rapid cyst growth (p = < .001). Our risk score system accurately predicted RCC growth with a 74% accuracy rate, 73% sensitivity, and 75% specificity.ConclusionOur analysis showed a strong link between active smoking and the rapid growth of RCC. This novel finding has significant preventive implications but needs validation by a large population database. Surgical intervention for RCC currently is often reserved for symptomatic cases. However, utilizing our risk-based scoring system to predict rapidly growing cysts may indicate early surgery in minimally symptomatic patients, thereby potentially preserving pituitary function.

THE NUMBER OF DISTAL RADIAL FRACTURES IN THE ELDERLY WILL INCREASE BY MORE THAN HALF BY 2040: PREDICTION MODELLING USING NATIONAL DATA

The aim was to predict the number and incidence of distal radius fractures in Scotland over the next two decades according to age group, categorised into under 65yrs(65) and 65yrs and older (65), and estimate the potential increased operative burden.The number of distal radius fractures in Scotland was isolated from the Global Burden of Disease database and this was used, in addition to historic population data and published population estimates, to create a multivariable model allowing incorporation of age group, sex and time. A Negative Binomial distribution was used to predict incidence in 2030 and 2040 and calculate projected number of fractures. A 20.4% operative intervention rate was assumed (local data).In terms of number of fractures, there was a projected 61% rise in the 65 group with an overall increase of 2099 fractures per year from 3417 in 2020 (95% confidence interval (CI) 2960 – 3463) to 5516 in 2040 (95% CI 4155 – 5675). This was associated with 428 additional operative interventions per year for those 65yrs. The projected increase between 2020 and 2040 was similar in both sexes (60% in females, 63% in males), however the absolute increase in fracture number was higher in females. There was a 4% projected fall in the number of fractures in those 65.Incidence of distal radius fractures is expected to considerably increase over the next two decades due to a projected increase in the number of fractures in the elderly. This has implications for associated morbidity and healthcare resource use.

An Updated Evaluation of the Management of Nerve Gaps: Autografts, Allografts, and Nerve Transfers.

Within the past decade, there have been multiple innovations in the field of nerve surgery. In this review, we highlight critical changes and innovations that have helped advance the field and present opportunities for further study. This includes the modification and clarification of the classification schema for nerve injuries which informs prognosis and treatment, and a refined understanding and application of electrodiagnostic studies to guide patient selection. We provide indications for operative intervention based on this nerve injury classification and propose strategies best contoured for varying injury presentations at differing time points. Lastly, we discuss new developments in surgical techniques and approaches based on these advancements.

Patellar Tendon Ruptures after Total Knee Arthroplasty.

Patellar tendon (PT) rupture following total knee arthroplasty (TKA) is a rare, but devastating complication. These injuries occur most frequently in the acute period following TKA due to trauma to the knee. PT ruptures that disrupt the extensor mechanism create a marked functional deficit, impacting every facet of daily life. In complete ruptures of the PT, repair or reconstruction is typically indicated; however, complication rates following intervention remain high. Operative intervention remains the mainstay of treatment, with only certain specific situations where nonoperative intervention is appropriate. Operative techniques are chosen based on the acuity, location of disruption, and status of the residual soft tissues. Treatment options include repair with or without augmentation or reconstruction. Augmentation does reduce the high risk of complications, bringing rates down from 63 to 25%. Augmentation options include autografts, allografts, synthetic grafts, or synthetic meshes. Despite advancements, outcomes are unpredictable and complications are common, highlighting the need for further research to improve treatment protocols. This article provides an overview of PT ruptures following TKA, the various treatment options, and the recommendations of the M.M., R.D., G.S. for each common type of PT injury encountered.

Return to play after UCL injury in gymnasts

ABSTRACT Background Injuries to the ulnar collateral ligament (UCL) are commonly reported in traditional overhead sports. Conversely, there is a lack of evidence outlining management and return to play (RTP) outcomes for gymnasts. This study aimed to evaluate RTP and patient reported outcomes (PROs) in gymnasts after operative and non-operative treatment of UCL injuries. Methods Gymnasts who presented with UCL injury and underwent operative and non-operative treatment were evaluated. Patient reported outcomes were collected via telephone: Conway-Jobe Scale, Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) Score, Mayo Elbow Performance (MEP) Score, quick DASH (qDASH) and Timmerman-Andrews (TA) Elbow Score. Results Nine patients met inclusion criteria and were available for follow-up. Five were initially treated operatively and 4 were initially treated non-operatively. The operative group initially consisted of 3 ulnar collateral ligament reconstructions (UCLR) and 2 UCL repairs with internal bracing. One patient crossed over to the operative group after failing non-operative treatment and underwent UCLR 4 months post injury. Overall, 66.7% and 100% of operatively and non-operatively treated gymnasts were able to return to play, respectively. At final follow-up, the operative groups’ mean KJOC, MEP, TA and qDASH scores were: 68.4 ± 7.7, 97.5 ± 2.7, 90.8 ± 10.7 and 1.9 ± 3.0, respectively. For the non-operative group, the mean scores were 67.4 ± 9.0, 71.7 ± 5.8, 71.7 ± 14.4 and 11.4 ± 9.9, respectively. Treatment satisfaction for the operative group was 81.7 ± 27.5 compared to 80.6 ± 34.5 in the non-operative group. Odds ratios indicated no differences between groups. Conclusion Both operative and non-operative interventions for UCL injuries in gymnasts can provide favorable outcomes with respect to return to play and subjective patient-reported outcomes. Further research is warranted to determine optimal treatment, especially regarding indications for operative vs. nonoperative treatment, of UCL injury based on injury severity and location in gymnasts. Level of Evidence Level III

The Clinical Value of Computed Tomography of Facial Bone Injuries in Pediatric Trauma Patients.

Head trauma is responsible for significant morbidity and mortality in the pediatric trauma population. There are validated guidelines which indicate the necessity for computed tomography of the head (CTH), but the indication for a dedicated CT of the facial bones (CTF) is less clear. We sought to identify our population of head trauma patients who would clinically benefit from the addition of CTF. Using the electronic medical record, pediatric trauma patients who underwent CTH and/or CTF from 2016 to 2021 were identified. We collected information on demographics, traumatic mechanism, subspecialty consultation, and operative and procedural interventions. 2117 pediatric patients were evaluated. A total of 372 patients received CTH and 173 patients received both CTH + CTF. Patients with CTH + CTF were older (P < 0.001), involved in high-velocity blunt trauma (P < 0.001), and had a longer length of stay (P < 0.001). There were no fractures identified in 73 (42.2%) patients with both CTH + CTF. Of patients with fractures, there were 204 fractures identified and 73.0% (149/204) of fractures were seen on both the CTH + CTF. There were 19.6% (40/204) read only on CTF and 10 patients (5.7%) had a fracture requiring intervention. 8 of the 10 fractures requiring operative intervention were mandibular bone fractures. Computed tomography of the head can be used as a screening tool for facial fractures. A negative CTH can eliminate the need for additional radiation from a CTF. Computed tomography of the facial bones will identify more fractures, but few requiring intervention. We suggest that CTF be limited to a subset of pediatric trauma patients with facial injury.

Outcomes and Management of Dislocated Hip Hemiarthroplasty.

Purpose and aims Hip hemiarthroplasty (HHA) is a common procedure undertaken to manage intracapsular neck of femur fractures. Dislocation of HHA is one of the most dreadful complications. There is a paucity of clinical evidence to guide decision-making for managing these patients. The aim of this study was to describe the operative management and outcomes of patients with dislocated hemiarthroplasties of the hip and outline a treatment strategy for their management. Methods We conducted a retrospective analysis of all the patients presenting to University Hospitals of Derby and Burton, UK with hip fractures between 2016-2022. We included all the patients who underwent a hemiarthroplasty for their fracture. We excluded patients who had malignancy and if clinical data was missing. Each operative intervention and subsequent dislocationswere recorded. We recorded the following outcome measures: dislocation, surgical interventions, mortality, revision surgery, cognition status, residential status, and mobility. We also compare these outcomes with the patients who had HHA and did not sustain any dislocation. Results Of the 1134 patients treated with HHA during this period, 33 patients sustained dislocation. Of the 33 patients, 29 were female and 4 were male with mean ages of87.4±7.4 and89.25±9.54,​ respectively. Following the first dislocation, 25 patients were treated with closed reduction, six patients had excision arthroplasty (EA), and two patients were treated non-operatively. About 21 patients went on to have second and third dislocations, none of these had EA and others had conversion to total hip replacement (THR). Nearly 80% of dislocations occurred within two months of the initial procedure. The mean mental test score was 7.91±2.01 (p=0.001) and was significantly higher in patients who underwent conversion to THR. The average ASA grade was significantly higher in patients who had closed reduction (2.93±0.25, p=0.001)and EA (3.28±0.46, p=0.002)compared to the patients who had no dislocation. Patients who underwent EA had significantly higher acute length of hospital stay23.5±13.5(p=0.02) and mortality (p=0.001)compared to other groups. We found no significant difference in dislocation rates where the initial procedure was carried out by registrars or consultants (p=0.567). Conclusion We concluded that the dislocation risk is higher in females and within the first two months of the index procedure. More than 80% of patients had a second dislocation following a successful closed reduction. In our cohort, 45% of patients had EA (Girdlestone procedure) and 36% had a conversion to THR. EA was associated with increased mortality rates, acute length of hospital stays, and significant change to premorbid mobility status. Amultidisciplinary team (MDT) approachis necessary following the second dislocation to prevent further morbidity associated with recurrent dislocations.

Mandible Fracture Outcome Disparities in the Incarcerated Patient Population.

Inmates represent a vulnerable health care population within the United States, with inconsistent access to surgical specialty care. Facial fractures are common among the incarcerated population, comprising approximately 14% of all traumatic injuries. However, few studies have evaluated facial fracture outcomes in this population. The aim of this study is to identify disparities in mandible fracture outcomes in the incarcerated population. A retrospective review of all isolated traumatic mandible fractures at a single academic medical center from 2018 to 2023 was conducted. Mandible fractures were treated by plastic surgery, otolaryngology, or oral and maxillofacial surgery. Outcome measures such as rates of persistent malocclusion, motor deficits, surgical site infection, reoperation, and readmission were compared between inmate and civilian subgroups. A total of 205 patients (mean age, 33.1 years; 81.5% male) who were treated for isolated traumatic mandible fracture were included. A minority of patients (11.7%; n = 24) were inmates, whereas 88.3% (n = 181) were civilians. The mean time to operative intervention was 10.2 days in the incarcerated group and 4.4 days in the civilian group (P < 0.05). Persistent subjective malocclusion after surgery was noted in 20.8% (n = 5) of incarcerated patients and 7.2% (n = 13) of civilian patients (P < 0.05). There were no significant differences in rates of surgical site infection, reoperation, persistent motor deficits, or readmissions within 30 days. Incarcerated patients with traumatic mandible fractures have increased time to operative intervention and increased rates of subjective malocclusion postoperatively. Increased time to operative intervention may reflect barriers in access to specialty surgical care, which could adversely affect patient outcomes.

The management of idiopathic toe walking.

The aim of this study was to gain a consensus for best practice of the assessment and management of children with idiopathic toe walking (ITW) in order to provide a benchmark for practitioners and guide the best consistent care. An established Delphi approach with predetermined steps and degree of agreement based on a standardized protocol was used to determine consensus. The steering group members and Delphi survey participants included members from the British Society of Children's Orthopaedic Surgery (BSCOS) and the Association of Paediatric Chartered Physiotherapists (APCP). The statements included definition, assessment, treatment indications, nonoperative and operative interventions, and outcomes. Descriptive statistics were used for analysis of the Delphi survey results. The AGREE checklist was followed for reporting the results. A total of 227 participants (54% APCP and 46% BSCOS members) completed the first round, and 222 participants (98%) completed the second round. Out of 54 proposed statements included in the first round Delphi, 17 reached 'consensus in', no statements reached 'consensus out', and 37 reached 'no consensus'. These 37 statements were then discussed, reworded, amalgamated, or deleted before the second round Delphi of 29 statements. A total of 12 statements reached 'consensus in', four 'consensus out', and 13 'no consensus'. In the final consensus meeting, 13 statements were voted upon. Five were accepted, resulting in a total of 31 approved statements. In the aspects of practice where sufficient evidence is not available, a consensus statement can provide a strong body of opinion that acts as a benchmark for excellence in clinical care. This statement can assist clinicians managing children with ITW to ensure consistent and reliable practice, and reduce geographical variability in practice and outcomes. It will enable those treating ITW to share the published consensus document with both carers and patient groups.

Role of preoperative CT imaging in penetrating thoraco-abdominal injuries: A multicenter study of urban trauma centers

IntroductionManagement of penetrating thoracoabdominal (PTA) injuries with signs of hemorrhage have warranted operative intervention but improved imaging capabilities have redefined interventions required. We examined outcomes of hemodynamically stable patients undergoing preoperative CT imaging with the hypothesis that CT imaging would decrease OR time without delaying OR arrival. MethodsA retrospective multicenter study was performed amongst four urban trauma centers examining hemodynamically stable patients with PTA injuries requiring operative intervention from January 2017–December 2021. The primary outcome was OR time. Secondary outcomes included length of stay (LOS), ICU LOS, and mortality. A multivariable logistic regression with random intercept for trauma center was fit to assess whether preoperative CT affected time in the OR. ResultsOf 534 hemodynamically stable patients with penetrating injuries, 322 (60.3 ​%) received preoperative CT. The median time in OR were 130 (IQR: 84,180) and 140 (IQR: 100, 180) minutes for patients with and without preoperative CT, respectively. Median time to OR was 68 (IQR: 47, 110) and 26 (IQR 17,38) minutes in patients with and without preop CT, respectively. Median ICU LOS were 0 vs 1 day, the median hospital LOS were 7 vs 8 days for patients with and without pre-op imaging respectively. The multivariable model showed that obtaining a pre-op CT scanning was not independently associated with time spent in OR. (Adjusted OR:0.94; 95 ​% CI: 0.85, 1.04). ConclusionIn patients with PTA injuries and hemodynamic stability, preoperative CT scanning was not associated with decreased OR time, postoperative complications, or mortality.

High-pressure core meltdown and hydrogen generation during In-vessel and Ex-vessel phases of VVER-1000 nuclear reactor and effect of heat structures

Following unprecedented Fukushima Daiichi severe accident, which significantly amplify the production of hydrogen and the associated risk of explosions, particularly in accidents like station blackout (SBO) that jeopardize containment integrity and reactor safety, a thorough investigation and comprehension of the phenomenon known as high-pressure melt ejection (HPME) are necessary. This study examines how the SBO accident develops without operator intervention or access to emergency diesel generators through full nuclear power plant simulation, including containment, core, primary, and secondary circuits. Accurate time step selection is crucial for the simulation to produce reliable results for high-pressure melt ejection processes. While the process is faster and easier under Low Pressure Melt Ejection (LPME) conditions, time step tuning can significantly lengthen the (HPME) simulation (approximately one month for each scenario). After thorough examinations and analysis of various simulation findings, three cases were evaluated for the ex-vessel phase, illustrating the most likely scenarios of high-pressure molten material splashing into the cavity. The findings demonstrate that during the in-vessel phase, 578 kg of hydrogen is created. Additionally, during the ex-vessel phase, there is a significant increase in the containment’s temperature and pressure due to the high-temperature hydrogen and significant water and steam leakage. The temperature and pressure inside the containment rise well above the safety criteria due to the leakage of 1529 kg of hydrogen from the cavity and lead to hydrogen explosion due to MELCOR message. The calculated amount of hydrogen gas is within the explosion limit range of 18.3% to 59% of the containment atmospheric pressure volume. Moreover, the height and diameter of the cavity alter due to the direct heating and corrosion of the cavity walls, ultimately compromising the integrity of the plant in the alpha mode. Based on the results obtained, it can be seen that if a large portion of the molten material is deposited on the concrete surface (case III) instead of dispersed in the cavity atmosphere (case I), the rate of hydrogen production and therefore the total amount of hydrogen (and its related energy) produced will be increased and could lead to deflagration to detonation situation.

Descriptive Epidemiology and Management of Perilunate Injuries.

Perilunate injuries and dislocations, typically caused by high-impact trauma, can lead to acute compression of the median nerve and subsequent complications if left untreated. This study examines the epidemiology, injury mechanisms, immediate treatment, and need for carpal tunnel release in such cases. Perilunate injuries at a single level 1 trauma center were retrospectively reviewed from 2014 to 2023. Data on patient demographics, injury mechanism, initial management, and operative management were collected. Thirty-three cases were analyzed, averaging 33.9 years in age. Injury mechanisms included falls (24% each from 0 to 10 feet and >10 feet, and motor vehicle accidents), bicycle-auto collisions or assaults (10%), pedestrian-auto collisions (5%), and 1 crush injury (3%). Most cases involved trans-scaphoid perilunate dislocation (predominantly Mayfield 3). Initial reduction in the emergency department succeeded in 60% of cases, with 48% showing median nerve paresthesias. Thirty-three percent underwent surgery within 24 hours, and 95% required operative intervention, including open reduction internal fixation (56%), open reduction with percutaneous pinning (30%), and closed reduction with percutaneous pinning (7%). Fifty-two percent needed carpal tunnel release. Prompt evaluation and treatment are crucial for perilunate injuries. If initial reduction fails, urgent operative intervention is warranted, although delayed management may be appropriate in some cases. Various operative fixation methods exist for realigning carpal bones, emphasizing the importance of tailored approaches to individual cases.

A new aerosol delivery approach for enhanced long-term respiratory care in resource-poor settings

Continuous aerosol therapy is safe, superior, and the mainstay in the therapy of patients with severe asthma, cystic fibrosis, chronic obstructive pulmonary disease (COPD), and coronavirus disease (COVID-19). However, continuous nebulization has been perceived as highly expensive and labor-intensive, which often requires specialized medical equipment. Moreover, it is difficult to maintain consistent aerosol output and particle size delivery over an extended period without operator intervention. This work proposes a simple and reliable continuous nebulization method using a conventional gas jet nebulizer and intravenous (IV) bottle/bag. The present work reports detailed experimental studies on a gas jet nebulizer with Particle image velocimetry (PIV), Particle/droplet Imaging Analysis (PDIA), and Mie scattering techniques to demonstrate the feasibility of the proposed technique. The preliminary investigation shows that the proposed method provides continuous liquid output delivery without external supervision. The liquid delivery rate and mass median diameter (MMD) of the nebulizer mainly depend on the gas flow rate and suction height. The MMD of the primary generated droplets is reported to vary between 100 and 230 μm for a ± 10 cm suction height and 500–1000 mlph nebulization gas flow rate. Most importantly, the nebulizer spray angle, stability, droplet size distribution, and the axial and radial velocities of the droplets are marginally affected by the suction height. Therefore, the proposed system is a versatile, safe, and cost-effective method of continuous nebulization therapy, especially in resource-poor countries or contagious disease outbreak situations.

National Trends and Outcomes in the Operative Management of Thyroid Storm.

Thyroid storm is a rare but potentially lethal manifestation of thyrotoxicosis. Guidelines recommend nonoperative management of thyroid storm, but thyroidectomy can be performed if patients fail medical therapy or need immediate resolution of the storm. Outcomes of thyroidectomy for management of thyroid storm remain ill-defined. Using the National Inpatient Sample from 2016 to 2020, a retrospective analysis was conducted of patients admitted with thyroid storm. Outcomes of interest included operative complications and mortality. Multivariable logistic regression was performed to assess factors associated with receiving thyroidectomy and mortality. An estimated 16,175 admissions had a diagnosis of thyroid storm. The incidence of thyroid storm increased from .91 per 100,000 people in 2016 to 1.03 per 100,000 people in 2020, with a concomitant increase in mortality from 2.9% to 5.3% (P < .001). Operative intervention was pursued in 635 (3.9%) cases with a perioperative complication rate of 30%. On multivariable regression, development of acute decompensated heart failure (adjusted odds ratio [AOR] 1.66, 95% Confidence Interval [CI] 1.03-2.68, P = .037) and acute renal failure (AOR 2.10, 95% CI 1.17-3.75, P = .013) increased odds of receiving surgery. The same multivariable model did not show a significant association between thyroidectomy and mortality. The incidence of thyroid storm and associated mortality increased during the study period. Thyroidectomy is rarely performed during the same admission, with an overall perioperative complication rate of 30% and no effect on mortality. Patients with acute decompensated heart failure and renal failure were more likely to receive an operative intervention.

What matters in testicular torsion? Association of hospital transfer, race and socioeconomic factors with testicular outcomes in a single center experience

IntroductionTesticular torsion is a surgical emergency that is managed with either septopexy-only or tunica vaginalis flap with septopexy if the testis is potentially viable or orchiectomy if not. Minimizing time from ischemia onset to surgery maximizes the likelihood of testicular preservation. While factors such as time from door to OR can be easily targeted, others such as inequalities in access to care are more difficult to address. ObjectiveWe sought to determine whether patient transfer affects testicular outcomes intraoperatively and in the long-term. Secondary goals included investigating the impact of race and Child Opportunity Index (COI) on testicular torsion outcomes and defining the optimal time cutoff from symptom onset to presentation that predicts salvage. MethodsWe reviewed our prospective testicular torsion database to identify boys who underwent operative intervention for testicular torsion between January 2015 and March 2022. The association of race and COI with testicular salvage, defined as septopexy-only, was evaluated with univariate and multivariate logistic regression controlling for time to presentation, while the association of transfer with salvage was evaluated with univariate and multivariate logistic regression controlling for age, time to presentation, and time to OR. To determine the optimal cutoff for time to presentation to predict testicular salvage, the Youden index was calculated. ResultsRace and COI were not associated with testicular salvage on either univariate or multivariate logistic regression that controlled for time to presentation. Transfer status was not associated with salvage, while age, time from symptoms to presentation, and time from institutional arrival to OR were associated with salvage. The optimal time cutoff to predict salvage using the Youden index was 10.5 hours from symptom onset to presentation and 14.5 hours from symptom onset to detorsion. DiscussionTime to presentation was the strongest, modifiable risk factor associated with testicular salvage. As it may be difficult for children to accurately communicate their symptoms, diagnosis and prompt management of testicular torsion can be delayed. Improvement in outcomes can be achieved by placing greater efforts into patient, parental, and primary care provider education of the signs and symptoms of testicular torsion. ConclusionsRace, COI, and transfer status were not found to have a statistically significant effect on testicular salvage outcomes in patients presenting with testicular torsion. Despite the common premise of a six-hour window until testicular loss, we found that intervention within the acute window of 14.5 hours from symptom onset is still associated with salvage.

Workflow improvement and financial gain after integration of high-throughput sample processing system with flow cytometer in a high-volume pathology laboratory: Results from a prospective comparative study using Lean principles

BackgroundHighly efficient clinical laboratories are essential for monitoring many human illnesses. Ampath Laboratory Services, the largest pathology lab in South Africa, analyzes large numbers of peripheral blood samples for CD4 levels yearly. ObjectiveTo assess productivity and quality of a newer integrated automated solution, the BD FACSDuet™ Sample Preparation System/BD FACSLyric™ Flow Cytometer using conventional assessment methods and Lean concepts. Materials and methodsThis prospective study compared the performance of the BD FACS™ Sample Preparation Assistant [SPA] III and BD FACSCanto™ II Flow Cytometer with the newly introduced integrated system (BD FACSDuet™/BD FACSLyric™). They were validated for accuracy, precision, and external quality assessment. Process mapping and Lean assessment helped identify steps leading to waste. An economic model was developed to characterize workflow and economic impact associated with total daily hands-on time, processing time, and reworks. ResultsStrong linear correlation was present between both systems. Precision and accuracy studies revealed that all coefficient of variation (CV)% values were below 20 % of allowable limits. External proficiency assessments were within limits. The fully automated workflow of BD FACSDuet™/BD FACSLyric™ permitted better consistency with significantly shorter processing time and batch processing and reduced operator interventions. Lean assessment identified defects with motion, over-processing, waiting, and non-utilized talent. Significant reductions in hands-on and total daily processing time that could increase daily specimen testing efficiency and fewer reworks were associated with the BD FACSDuet™/BD FACSLyric™. Lean improvements translated to significant economic savings associated with operator costs and unnecessary reagent consumption. ConclusionBD FACSDuet™/BD FACSLyric™ is an accurate, reliable, and cost-effective fully automated system for high-volume flow cytometry labs that perform T-cell enumeration using a single-platform and single-tube approach.

Operative management of a difficult problem: Cervical esophagogastric anastomotic stricture

Cervical esophagogastric anastomotic stricture is a vexing problem both for the patient and the treating surgeon. Given the location of the anastomosis at the thoracic inlet and its proximity to vocal cords and upper esophageal sphincter, management of such a stricture can be challenging. In this comprehensive review, we will first discuss the various endoscopic options that are available for the management of such strictures such as dilation, topical injections, electrocautery incision, and stenting. However, the focus of our chapter is to discuss surgical options for those patients who develop strictures or fistulae that are refractory to endoscopic management and require operative intervention. Surgical options including cervical esophageal reconstruction such as strictureplasty and myocutaneous flaps, as well as alternative conduits will therefore be highlighted. Finally, we will discuss and review the data that potentially explains how to avoid such anastomotic strictures.

Predictors of risk reduction behavior: Evidence in last-mile communities

Despite extensive research using Protection Motivation Theory (PMT) to analyze factors influencing protective behaviors during disasters, understanding how last-mile communities in vulnerable contexts—particularly in the Philippines—respond to early warning messages remains limited. This understanding is crucial, as these communities often bear the brunt of extreme weather events. Drawing data from surveys and semi-structured interviews, this study examined the predictors of risk reduction behaviors before and after Super Typhoon Mangkhut in two last-mile communities in Northern Philippines — Cabalitian and Mapita. Regression analysis demonstrated that all threat appraisal variables—perceived vulnerability, perceived severity, and fear—are predictors of risk reduction behaviors before Mangkhut. Coping appraisal variables, specifically response efficacy and self-efficacy, also positively influenced risk reduction action before Mangkhut. Among socio-demographic variables, only gender and age are predictors of risk reduction behaviors, with their influence varying between the two communities. Expanding the application of PMT, prior typhoon experience, trust, and social network strength also positively and significantly influenced risk reduction behaviors before and after Mangkhut. The study identified key infrastructural, institutional, and operational interventions to enhance coping capacity and reduce vulnerability in these communities, alongside policy implications to inform disaster risk reduction strategies and empower local preparedness efforts.