Riverside University Health System - Medical Center

INTRODUCTION: Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are common pelvic floor disorders that significantly affect quality of life in reproductive-age d and post-menopausal women. Shared risk factors include age, parity, obesity, connective tissue dysfunctions, chronic straining, and a history of pelvic surgery. As obesity rates continue to rise, disproportionately among women, recurrence of SUI and POP is a growing concern. Midurethral sling (MUS) is one of the most effective treatments for SUI, while surgical options for POP include sacrospinous ligament suspension, uterosacral suspension, sacrocolpopexy, vaginal hysterectomy, and related reconstructive procedures. Outcomes in severely obese women remain poorly defined. While some studies report higher rates of MUS failure or POP recurrence with BMI ≥40, others show no difference. No study has specifically evaluated BMI ≥45 as a threshold. This study examines the association between obesity and surgical outcomes after MUS and POP repair, focusing on reoperation, recurrence, and need for additional treatment in women with BMI ≥45. OBJECTIVE: To evaluate the association between obesity and surgical outcomes after MUS and procedures for pelvic organ prolapse, with a focus on reoperation, recurrence, and the need for additional treatment in women with BMI ≥45. METHODS: We conducted a retrospective cohort study using the TriNetX U.S. Collaborative Network, a database of de-identified electronic health records from 68 healthcare organizations. Patients with POP who underwent related surgical procedures, including MUS, were included. A BMI cutoff of ≥45 kg/m2 was applied. Propensity score matching (1:1) was used to balance age, comorbidities, and prior pelvic surgeries. Outcomes assessed over 10 years included prolapse recurrence, reoperation, repeat sling, additional treatments (e.g., bladder Botox, bulking agent injection, high-intensity focused ultrasound), and pessary use. RESULTS: Among women undergoing MUS, BMI ≥45 was not associated with differences in pessary use, procedure reversal, repeat sling, or overall failure, excluding sling. However, women with BMI ≥45 had higher rates of additional treatment (4.2% vs 2.2%, p=0.006). For POP repair, BMI ≥45 likewise did not affect pessary use, procedure reversal, repeat sling, or overall failure excluding sling, but was associated with an increased risk of additional treatment (2.8% vs 1.4%, p=0.016). No other statistically significant differences were identified between groups. CONCLUSIONS: In this large, multicenter cohort, morbid obesity (BMI ≥45) was not associated with an increased risk of structural failure after MUS or POP repair. However, women with BMI ≥45 were more likely to require additional treatment interventions, suggesting that while surgical durability is preserved, obesity may contribute to persistent or recurrent lower urinary tract symptoms. These findings underscore the importance of preoperative counseling, close postoperative follow-up, and individualized management for women with severe obesity undergoing pelvic floor reconstructive surgery.Table 1Table 2

Infectious Diseases Society of America guidelines recommend vancomycin plus an antipseudomonal beta-lactam (cefepime, ceftazidime or meropenem) in most cases, with adjustments based on local susceptibility patterns. The objective of this study was to determine patterns of inpatient antibiotic use in children undergoing empiric treatment of cerebrospinal (CSF) shunt infection. Retrospective, observational cohort study at 6 tertiary care children's hospitals among children who developed first shunt infection following initial CSF shunt placement surgery between 2007 and 2012. Primary outcome was use of antimicrobials as empiric therapy, defined as any antibiotic order on the day prior, day of and day after the neurosurgical procedure to treat the infection (ie, occurring before culture results typically guide antibiotic selection). We conducted analyses at the infection and hospital levels from 2007 to 2015. The 181 children who received empiric antibiotics most received vancomycin (n = 155, 85.6%), cefazolin (n = 65, 35.9%), ceftriaxone (n = 55, 30.4%), cefotaxime (n = 43, 23.8%) and cefepime (n = 36, 19.9%). Few children received combinations of empiric antibiotic combinations recommended by the Infectious Diseases Society of America guidelines: vancomycin and cefepime (n = 7, 3.6%), vancomycin and ceftazidime (n = 0, 0%) or vancomycin and meropenem (n = 1, 0.5%). There was no evidence indicating a change in antimicrobial coverage over the study period. Empiric therapy for CSF shunt infections represents a key opportunity for antimicrobial stewardship programs to ensure guideline concordance and promote appropriate antibiotic use.

Critical closing pressure (CCP) and the vascular waterfall have long been used to explain perfusion failure in shock, yet their physiological meaning has been inconsistently interpreted. CCP is frequently treated as a continuous downstream pressure and inserted into formulas such as mean arterial pressure (MAP) - CCP, implying that a collapse threshold behaves like an opposing pressure even when vessels remain open. Drawing on classical vascular mechanics, whole-bed flow studies, microvascular models, and contemporary clinical physiology, we show that this interpretation is incorrect. Tone-dependent arteriolar collapse does not behave as a Starling resistor: CCP is a threshold at which smooth-muscle tension exceeds intraluminal pressure and vessels close, not a pressure governing flow in patent vessels. Perfusion becomes heterogeneous because different vascular beds reach their collapse thresholds at different pressures (via excessive tone, extrinsic compression, or profound hypotension), disconnecting macro-haemodynamics from microcirculatory flow. This explains why systemic variables such as MAP and systemic vascular resistance (SVR) may appear adequate even while tissues are under-perfused, a phenomenon now termed haemodynamic incoherence. Reframing CCP as a binary collapse threshold resolves longstanding contradictions in the literature, clarifies why MAP-centred targets often fail, and unifies the behaviour of shock states within a four-interface model of circulatory coupling. Therapeutically, the aim is not to "restore a waterfall" but to reopen closed vascular territories by lowering excessive tone, relieving external pressure, or raising truly low arterial inflow. This mechanistic reinterpretation provides a more coherent, physiologically grounded approach to personalised perfusion management in critical illness.

Introduction Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, is associated with emergency department (ED) utilization and variable engagement with outpatient gastroenterology (GI) care. We examined ED utilization and outpatient GI care engagement among White and Hispanic patients with IBD within a county health system. Methods We conducted a retrospective cohort study of adult patients (≥18 years) with IBD receiving care within a single county health system between January 1, 2016, and December 31, 2024. Patients self-identifying as non-Hispanic White or Hispanic were included. Primary outcomes included the unadjusted count of IBD-related ED visits per patient duringobserved follow-up. Secondary outcomes included the presence of any ED visit, missed outpatient GI appointments, and GI follow-up within 90 days after an index ED visit among patients with at least one IBD-related ED visit and sufficient follow-up time. Comparisons were performed using chi-square testing for categorical variables and the Wilcoxon rank-sum test for continuous variables. Results Among 138 included patients, Hispanic patients experienced a significantly higher median number of IBD-related ED visits compared with White patients (P = 0.008), while the proportion of patients with at least one ED visit did not differ by race/ethnicity. Rates of missed GI appointments and outpatient GI follow-up within 90 days after ED encounters were similar between groups. Conclusions Within this county health system, Hispanic patients with IBD experienced more frequent ED utilization than White patients, without differences in outpatient GI follow-up following ED encounters.

The clavipectoral fascial plane block (CPB) provides regional anesthesia for clavicular procedures while minimizing complications. Although the hematoma block (HB) is well-established in distal radius fractures, its combination with CPB for clavicle fractures is not widely described. A 72-year-old man presented with a right distal clavicle fracture and elected to undergo surgical fixation. A modified CPB was performed preoperatively, with a portion of the local anesthetic injected into the fracture hematoma. The patient had excellent intraoperative and postoperative analgesia with minimal rescue opioid requirements. This case demonstrates the efficacy of combining a CPB with hematoma injection for distal clavicle fractures.

Advanced practice providers (APPs) are integral members of acute care surgery (ACS) teams, and services are increasingly dependent on APPs. APPs serve in multiple domains, both within and outside of the clinical setting. A pre-session was held at the 83rd annual meeting of the American Association for the Surgery of Trauma in Las Vegas, Nevada, USA, where the topic of successful APP integration into an ACS service was comprehensively discussed. This manuscript provides an overview of how APPs are incorporated within an ACS team in both clinical and non-clinical roles, with a discussion of challenges that may arise and strategies that promote autonomy and allow for retention.