Brandon Regional Health Authority

Introduction: Acute aortic occlusion (AAO) is rare but frequently fatal due to diagnostic delays. Clinical presentations often mimic more common neurologic, cardiac, or gastrointestinal emergencies. Association with underlying vasculitis, such as Buerger’s disease, is rarely recognized but crucial for early diagnosis. Description: A 66-year-old female with COPD, Buerger’s disease, recurrent diverticulitis, and recent below-knee amputation presented with altered mental status, severe abdominal pain, and shock, triggering stroke and STEMI alerts. She had severe lactic acidosis, hyperkalemia, and absent femoral pulses. CT angiography demonstrated complete infrarenal aortic occlusion, widespread thromboembolism, severe mesenteric ischemia, and multiorgan infarctions. Despite aggressive supportive care, surgical teams determined she was too unstable for intervention. She rapidly deteriorated andand succumbed to cardiac arrest. Discussion: A critical and novel element in this presentation was the patient’s known diagnosis of Buerger’s disease (thromboangiitis obliterans), a rare vasculitis classically affecting small-to-medium-sized vessels and primarily associated with peripheral arterial disease and distal limb ischemia. Although large-vessel involvement is exceedingly rare and only scarcely documented in the literature, systemic inflammation, chronic endothelial dysfunction, and enhanced thrombotic risk inherent in Buerger’s disease may predispose patients to catastrophic thromboembolic events involving major arteries.Notably, recent limb amputation, prolonged immobilization, and underlying inflammatory conditions likely heightened this patient’s risk profile, potentially explaining the unusual involvement of the infrarenal aorta and visceral arteries observed in this case. This case underscores the diagnostic pitfalls in Acute aortic occlusion presentations and highlights Buerger’s disease as a potential contributor to rare large-vessel thrombosis. Early suspicion, vascular imaging, and multidisciplinary management are paramount to survival.

Loss of community dwelling status is frequent after hospitalization for traumatic injuries in older adults. Arranging placement to a skilled nursing facility or an inpatient rehabilitation facility often causes a delay in discharge after the patient is medically stable, exacerbating bed capacity issues in health systems and unnecessarily exposing patients to hospital-related complications. This study aimed to identify characteristics associated with delayed discharge and to quantify temporal trends in discharge delays at a high-volume trauma center. We retrospectively analyzed all trauma patients from 2018 to 2023 in our Level I trauma registry, excluding in-hospital mortalities. Patients living greater than 70 miles from our trauma center were excluded due to the need for long-distance transport. Patients were stratified by delayed discharge time vs discharge at medical readiness. Of 17,886 patients, 1,091 (6.1%) had a delay in discharge, waiting an average of 4.9 days after medical readiness. Patients with delayed discharge were more likely to be older (65.1 vs 53.2 years, p < 0.001), female (50.1% vs 38.8%, p < 0.001), have a higher Injury Severity Score (12.4 vs 8.6, p < 0.001), and blunt mechanism (92.7% vs 80.4%, p < 0.001). In a multivariate analysis, Medicare beneficiary status and skilled nursing facility placement remained associated with delayed discharge. The time of the week that the patient was medically ready for discharge did not significantly affect the discharge delay duration. Trauma patients with Medicare experience significant delays in discharge. Currently, an average of 5 patients await disposition in our trauma center, which has increased yearly from a low of 0.5 patients in 2018. Further investigation is needed to determine causes of increased delays, including insurance denial of inpatient rehabilitation.

LentiGlobin, an innovative gene therapy, introduces a modified beta-globin gene that yields an anti-sickling hemoglobin variant. It boosts total hemoglobin levels, mitigates hemolysis, curtails inflammation, and addresses iron overload by reducing transfusion requirements. These changes, in turn, provide insights into disease mechanisms and treatment outcomes. Alterations in serum markers, such as hemoglobin levels and inflammatory biomarkers, can illuminate the therapeutic effectiveness of LentiGlobin and its impact on mitigating complications such as vaso-occlusive crises. Therefore, the purpose of this narrative review is to discuss the effects of LentiGlobin administration on diverse serum biomarkers and its correlation with vaso-occlusive crises in individuals with sickle cell disease (SCD).

A 43 year old male presented to a community hospital emergency department for evaluation of sudden onset shortness of breath, tachycardia, and hypertension. Initial evaluation showed an adrenal mass on chest computed tomography. There was biochemical evidence of multi organ damage. Patient had elevated plasma metanephrine and normametanephrine levels.

Models are increasing in size and complexity in the hunt for SOTA. But what if those 2% increase in performance does not make a difference in a production use case? Maybe benefits from a smaller, faster model outweigh those slight performance gains. Also, equally good performance across languages in multilingual tasks is more important than SOTA results on a single one. We present the biggest, unified, multilingual collection of sentiment analysis datasets. We use these to assess 11 models and 80 high-quality sentiment datasets (out of 342 raw datasets collected) in 27 languages and included results on the internally annotated datasets. We deeply evaluate multiple setups, including fine-tuning transformer-based models for measuring performance. We compare results in numerous dimensions addressing the imbalance in both languages coverage and dataset sizes. Finally, we present some best practices for working with such a massive collection of datasets and models from a multilingual perspective.

BackgroundWhether non‐sentinel lymph node (SLN)‐positive melanoma patients can benefit from completion lymph node dissection (CLND) is still unclear. The current study was performed to identify the prognostic role of non‐SLN status in SLN‐positive melanoma and to investigate the predictive factors of non‐SLN metastasis in acral and cutaneous melanoma patients.MethodsThe records of 328 SLN‐positive melanoma patients who underwent radical surgery at four cancer centers from September 2009 to August 2017 were reviewed. Clinicopathological data including age, gender, Clark level, Breslow index, ulceration, the number of positive SLNs, non‐SLN status, and adjuvant therapy were included for survival analyses. Patients were followed up until death or June 30, 2019. Multivariable logistic regression modeling was performed to identify factors associated with non‐SLN positivity. Log‐rank analysis and Cox regression analysis were used to identify the prognostic factors for disease‐free survival (DFS) and overall survival (OS).ResultsAmong all enrolled patients, 220 (67.1%) had acral melanoma and 108 (32.9%) had cutaneous melanoma. The 5‐year DFS and OS rate of the entire cohort was 31.5% and 54.1%, respectively. More than 1 positive SLNs were found in 123 (37.5%) patients. Positive non‐SLNs were found in 99 (30.2%) patients. Patients with positive non‐SLNs had significantly worse DFS and OS (log‐rank P < 0.001). Non‐SLN status (P = 0.003), number of positive SLNs (P = 0.016), and adjuvant therapy (P = 0.025) were independent prognostic factors for DFS, while non‐SLN status (P = 0.002), the Breslow index (P = 0.027), Clark level (P = 0.006), ulceration (P = 0.004), number of positive SLNs (P = 0.001), and adjuvant therapy (P = 0.007) were independent prognostic factors for OS. The Breslow index (P = 0.020), Clark level (P = 0.012), and number of positive SLNs (P = 0.031) were independently related to positive non‐SLNs and could be used to develop more personalized surgical strategy.ConclusionsNon‐SLN‐positive melanoma patients had worse DFS and OS even after immediate CLND than those with non‐SLN‐negative melanoma. The Breslow index, Clark level, and number of positive SLNs were independent predictive factors for non‐SLN status.

INTRODUCTION: We present a case of triplets, one diagnosed with an Autism Spectrum Disorder (ASD). While patients with ASD are characterized by deficits in language and social interaction, these are often accompanied by gastrointestinal (GI) symptoms. Approximately half of a children with ASD have GI problems as well, and there appears to be a positive correlation in severity of GI symptoms and autistic severity. Trials of vancomycin and fecal microbiota transplant (FMT) have shown that altering the microbiome of the gut has success in improving both GI and ASD symptoms. The purpose of this study was to compare the microbiome of an autistic child with that of the child’s biological siblings and mother, in the hopes of elucidating perturbations possibly associated with ASD. METHODS: Next-generation sequencing was performed on fecal samples from a mother and her 3 siblings, two healthy and one with ASD (Sibling #3). Following stool collection, DNA was then extracted, quantitated, and normalized for downstream library fabrication utilizing shotgun methodology. Prepared and indexed libraries were subsequently pooled and sequenced on the Illumina NextSeq 550 System. Metagenomic readout data was analyzed for relative abundances of defined bacteria and overall microbiome diversity as measured by Shannon index. RESULTS: The ASD patient (Sibling #3) was found to possess lower Bifidobacteria and Prevotella to the patient’s healthy mother, and overall lower biodiversity as measured by the Shannon Index. Additionally, healthy Sibling #1 was found to have greater bacterial diversity than the mother, more Prevotella and Bifidobacter than Sibling #2. CONCLUSION: Our findings demonstrate the role of dysbiosis in ASD, and the utility of microbiome sequencing in order to draw conclusions regarding etiology and potential treatment modalities. Sequencing of the microbiome also presents potential insights in determining the optimal donor for a patient. As highlighted in Figure 1, Sibling #1 has greater microbial diversity and more Bifidobacterium than the mother, and more Prevotella than Sibling #2 and Sibling #3.Figure 1.: Comparative diversity of the gut microbiome of a patient with ASD (Sibling #3) and the patient’s biological siblings and mother.

Giant basal cell carcinoma (GBCC) is a rare skin cancer characterized by an aggressive biological behavior with extensive local invasion, frequent metastasis, and associated poor prognosis. Wide local excision with sentinel lymph node biopsy is often warranted for this condition, and reconstruction by local rotational flap is one of the best surgical techniques for repairing similar skin cancers with a relatively large skin defect.A 59-year-old man who was a former construction worker with a significant smoking history presented with a single giant suspicious chronic ulcerating skin lesion measuring 9 x 7 cm that proved to be a basal cell carcinoma (BCC) on his left shoulder. The patient was negative for enlarged or palpable lymph nodes and underwent a wide local excision and primary repair with a local flap. Despite negative margins, his follow-up visits at six, nine, and 10 months revealed numerous suspicious lesions that further required multiple local wide excisions that showed new basal cell carcinoma and recurrence to the left axilla. Given the invasiveness of his skin cancer, he was referred to oncology and later treated by chemoradiation.Patients with multiple risk factors are associated with a higher incidence of more invasive skin cancer due to possible cumulative effects. The therapeutic approach for GBCC should involve multidisciplinary teams, with wide local resection of the tumor with possible sentinel lymph node biopsy, local rotational flap for reconstruction of the wide defect, and adjuvant chemoradiotherapy if necessary.

BackgroundThe aim of this study was to evaluate the differences in the key surgical factors for single-incision robotic cholecystectomy (SIRC) and multi-incision robotic cholecystectomy (MIRC).MethodsA retrospective data review from August 2013 to April 2018 consisting of 104 SIRC and 105 MIRC cases was done considering factors including patient gender, age, operating time (skin incision to skin closure), robotic console time (docking to undocking), the preoperative diagnosis for surgery, any complications in surgery, length of stay (LOS), and estimated blood loss (EBL). Procedures with conversion away from original robotic cholecystectomy approach were excluded. Chi-square analysis (p-value: 0.05) was run between the two data sets.ResultsA total of 209 robotic cholecystectomy cases were reviewed since 2013. We found significantly less time with single-incision compared to multi-incision (single incision = 94.0 minutes, multi-incision = 99.9 minutes, p = 0.016) and EBL (single-incision = 11.52 mL, multi-incision = 17.17 mL, p = 0.004). There was no significant difference in age or robotic console time. The most common indication was symptomatic cholelithiasis overall, with equal cases of dyskinesia in single-incision approach, although there was no significant difference in indication between the two approaches. Intraoperatively, there was marginally significant use of irrigation in multi-incision (multi-incision 45 [42.9%], single-incision 31 [29.8%], p = 0.0499) and no difference in Firefly, perforation, or intraoperative cholangiogram use. LOS results showed significant decreased stay in SIRC cases (single-incision 84 outpatients [80.8%], multi-incision 75 [71.4%]; p = 0.0379).ConclusionsSIRC and MIRC are both safe and feasible ways to remove the inflamed/dysfunctional gallbladder. SIRC is associated with less operative time, less blood loss, and shorter hospital stay.

To evaluate the efficacy, predictability, and safety of combined corneal collagen cross-linking (CXL), intracorneal ring segment (ICRS) implantation, and superficial phototherapeutic keratectomy (PTK) in patients with keratoconus. Fifty-five eyes received ICRS implantation, followed by CXL and PTK combination treatment. Patients were followed up for 6 months. Primary outcomes included Logarithm of the Minimum Angle of Resolution (LogMAR) uncorrected distance VA (UDVA) and corrected distance VA (CDVA), sphere, cylinder, mean spherical equivalent, index of surface variance, index of vertical asymmetry, keratoconus index, central keratoconus index, index of height asymmetry, and index of height decentration. Secondary outcomes were higher-order aberrations (HOAs), including HOA total, coma, spherical, secondary astigmatism, and trefoil. At 6 months, there was a statistically significant improvement in UDVA, CDVA, sphere, and cylinder compared with baseline (P < 0.001). UDVA improved in 14% of the eyes to 20/25 and 96% had at least 20/40 or better spectacle corrected vision; 30.9% of the eyes were within ±0.5 diopter (D), 45.5% of the eyes were within ±1.0 D, and 74.5% of the eyes were within ±2.0 D. For CDVA, 1 eye (2%) lost 3 lines (but gained UDVA), 11% lost 1 line, 38% showed no change, and 49% gained between 1 and 8 lines of vision. Eighty-eight United Arab Emiratespercent of the eyes had at least 1 line of UDVA visual improvement, 79% improved by ≥2 lines, and 69% improved by ≥3 lines. HOA total, coma, spherical aberration, and secondary astigmatism showed improvements of -0.87 (P < 0.001), -0.84 (P < 0.001), -0.10 (P = 0.002), and -0.15 (P = 0.035), respectively. A combined procedure of ICRS implantation, CXL, and PTK is effective, predictable, and apparently safe for patients diagnosed with moderate keratoconus.