Background: Tension pneumothorax is a serious, potentially life-threatening condition with numerous etiologies. Hypopharyngeal injury, a possible complication of endotracheal intubation, can lead to tension pneumothorax. We describe a hypopharyngeal injury that occurred during endotracheal intubation that resulted in tension pneumothorax.Case Report: A 30-year-old female underwent emergent chest tube placement after sustaining an intraoperative tension pneumothorax caused by pyriform sinus tract injury during traumatic intubation for an elective fistulectomy, debridement of a previous fracture site, and removal and replacement of hardware 4 months from the time of the initial injury. A timely chest x-ray aided in the discovery of the pneumothorax. Postoperatively, the patient's tension pneumothorax resolved, her chest tube was removed, and she was extubated during her stay in the trauma intensive care unit. The patient was discharged without any other major complications.Conclusion: Tension pneumothorax is a rare but reported complication that can occur during intubation and intraoperatively. Early recognition of hypopharyngeal perforation is crucial to successful management. Anticipation of a difficult airway can suggest the use of alternative methods of intubation that may reduce the risk of hypopharyngeal perforation.

Background: Sickle cell disease (SCD) is an inherited hemoglobinopathy associated with severe morbidity, impaired quality of life, and premature mortality. Hematopoietic stem cell transplantation (HSCT) is the only curative treatment available for patients with SCD and has a >90% event-free survival when a matched related donor is used. However, availability of human leukocyte antigen (HLA)-identical sibling donors for the SCD population is limited. The use of HLA-matched unrelated donors or related haploidentical donors has the potential to expand the donor pool. Methods: We reviewed the current literature on the indications for SCD transplantation, donor options, and the emerging use of gene therapy as a treatment option. Google Scholar and PubMed were searched using the terms SCD, bone marrow transplantation, donor sources, gene therapy, HSCT, and HLA matching. Additional articles were identified from the bibliographies of retrieved articles. All articles were reviewed for pertinent information related to SCD and transplantation. Results: HSCT has the potential to establish donor-derived normal erythropoiesis with stable long-term engraftment, amelioration of symptoms, and stabilization of organ damage. The majority of HSCT has been performed in children from HLA-identical sibling donors and has resulted in excellent rates of survival. The use of alternate donors such as HLA-matched unrelated donors and haploidentical donors has the potential to expand the applicability of HSCT for SCD. Early results in gene therapy for SCD are encouraging. Conclusion: Evaluation of the long-term benefits of curative therapies for SCD requires comparative clinical trials and studies of late effects.

A new era of cancer immunotherapy has begun. Chimeric antigen receptor T (CAR-T) cells, with T cells genetically engineered to recognize CD-19 antigens of B cells, have been confirmed to successfully treat relapsed and refractory B cell malignancies in various clinical trials.[1][1] However, this

Background: Our previous work demonstrated that application of transforming growth factor beta 1 (TGF-β1) and forskolin to the repair site after chronic denervation and axotomy has a mitogenic effect, reactivates Schwann cells (SCs), and supports axonal regeneration. We found decreased expression of fibroblast growth factor 7 (FGF-7), a factor involved in synaptic organization and maintenance. Using an in vitro system, we examined the molecular mechanism of TGF-β1 and forskolin on the regulation of FGF-7 expression in SCs. Methods: SCs were prepared from the sciatic nerve and stimulated with forskolin (0.5 μM), TGF-β1 (1 ng/mL), or TGF-β1 + forskolin for 6 or 24 hours. SCs were also pretreated with LY2109761 (0.5 μM), a TGF-β receptor inhibitor, prior to stimulation with TGF-β1 + forskolin for 6 hours. Real-time TaqMan quantitative polymerase chain reaction analyses for FGF-7, myelin basic protein, and peripheral myelin protein 22 expression were performed. Cycle threshold (Ct) data were normalized to a reference gene, and fold changes relative to untreated SCs were determined using the 2-ΔΔCt method. Statistical analysis was done using t test (P<0.05). Results: TGF-β1 alone or in combination with forskolin for 24 hours resulted in a 3.3- and 2.8-fold decrease in FGF-7 expression in SCs, respectively. No change in FGF-7 expression was found with forskolin alone. TGF-β1 + forskolin treatment for 6 hours resulted in a 4.0-fold decrease in FGF-7 expression, while the addition of LY2109761 resulted in a 2.7-fold decrease in FGF-7 expression. Conclusion: We showed that SC expression of FGF-7 is regulated by TGF-β1. The positive effect of TGF-β1 and forskolin on SC reactivation and axonal regeneration may involve modulation of FGF-7 expression and activity in SCs.

Background: Patella instability and medial patellofemoral ligament (MPFL) injury are frequently encountered in pediatric patients. MPFL reconstruction is often chosen to treat this condition with good results; however, no consensus has been reached about which graft or technique to use. The purpose of this study was to evaluate the differences in graft survivorship, clinical outcomes (assessed with Kujala scores), and cost between autograft and allograft usage in MPFL reconstruction in pediatric patients. Methods: In this retrospective review of patients who underwent MPFL reconstruction between 2012-2015, autograft gracilis tendon was used for Group 1, and allograft gracilis tendon was used for Group 2. Outcomes were graft survivorship, postoperative Kujala scores, operative time, costs, graft size, and tibial tubercle-trochlear groove distance. Results: Fifty-six patients were included in this study, 21 in Group 1 and 35 in Group 2. No differences in age, sex, or chronicity were seen between the groups. Patients in Group 1 had longer operative times (134.5 minutes vs 97.3 minutes, P=0.0002), higher rates of graft failure (28.6% vs 0%, P=0.0037), and lower Kujala scores (80.3 vs 92.1, P=0.0032) compared to Group 2. All graft failures occurred in patients with chronic patella dislocations and occurred an average of 13.8 months postoperatively. Overall, autograft was costlier than allograft because of the cost of reoperation. Conclusion: This study supports the use of allograft for chronic patellar instability because of improved graft survivorship and clinical outcome scores, as well as the lower cost and reoperation rate.

Background: Emergency medical service (EMS) personnel are regularly exposed to traumatic incidents and experience higher rates of symptoms of posttraumatic stress disorder (PTSD) than the general population. Grit is a construct proposed to be associated with achievement, but it has demonstrated preliminary evidence of an association with resilience. The current study examined the relationship between grit and resilience among EMS workers. Methods: A link to an online survey was sent to East Baton Rouge Parish Emergency Medical Services personnel via an email distribution list. Demographic variables and the following self-report measures were assessed: the PTSD Checklist for DSM-5 (PCL-5), the Grit Scale, the Brief COPE scale, and the Professional Exposure to Traumatic Experiences scale (modified from the Life Events Checklist). Results: PCL-5 scores were significantly and negatively correlated with the Grit Scale score (r=-0.57, P<0.01). Hierarchical regression revealed that grit and coping mechanisms were predictive of self-reported PTSD symptoms (adjusted R2=68.7%, F(15,67)=9.81, P<0.001). Examination of the coefficients revealed that lower total Grit Scale scores and higher scores on the following Brief COPE scales were significant predictors of PCL-5 scores: denial, substance abuse, disengagement, and self-blame. Conclusion: This study examined the relationship between grit and resilience, measured by self-reported PTSD symptoms. Our results demonstrate a significant relationship between grit and resilience. Grit is related to, but distinct from, other constructs that predict resilience, such as coping mechanisms. Large prospective studies could have significant implications for hiring practices and building grit in existing personnel to bolster resilience.

Background: The pineal gland, a small, pinecone-shaped organ deep within the brain, is responsible for producing melatonin. The gland consists of pineal parenchymal cells and glial cells that can form neoplasms. Pineal region neoplasms can also arise from germ cells and adjacent structures. This review focuses on detection of serum and cerebrospinal fluid (CSF) biomarkers of germ cell tumors and pineal parenchymal cell tumors, as these types comprise most neoplasms specific to the pineal region. Methods: For this review, we searched PubMed using the following keywords: biomarkers, germ cell tumor, germinoma, melatonin, pineal, pineal gland, pineal neoplasm, pinealoma, pineal parenchymal cell tumor, pineal region, and pineal tumor. We limited our search to full-text English articles and identified other relevant sources from the reference lists of identified articles. Results: Serum and CSF biomarker assays have a role in cases of suspected pineal germ cell or parenchymal neoplasms. Biomarkers including alpha-fetoprotein, beta-human chorionic gonadotropin, and placental alkaline phosphatase inform diagnosis and treatment and are important for monitoring germ cell tumor response to treatment. No biomarkers are currently available that inform diagnosis or treatment of pineal parenchymal tumors, although melatonin assays may have a role in monitoring response to treatment. Conclusion: Serum and CSF biomarkers in conjunction with clinical and radiographic evidence of a pineal region mass can inform the decision whether to undertake stereotactic biopsy or surgical excision or whether to proceed straight to medical treatment.

Background: Meckel diverticulum is the most common congenital gastrointestinal malformation, but it is rarely symptomatic. Peritoneal encapsulation is a rare abnormality of embryonic development and may present with obstruction, although it too is usually asymptomatic. Case Report: We report the case of an 82-year-old male who presented with symptoms and imaging findings consistent with small bowel obstruction. During laparotomy, a peritoneal encapsulation was observed containing the majority of the small bowel. A Meckel diverticulum was discovered tethered to the small bowel mesentery by a mesodiverticular band, preventing egress from the accessory peritoneal membrane and appearing to be the cause of the obstruction. Conclusion: This patient had 3 rare findings-peritoneal encapsulation, Meckel diverticulum, and a mesodiverticular band-contributing to cause an acute small bowel obstruction. The presence of all of these features in one patient is extremely rare, and we believe this is the first description of such a phenomenon.

BACKGROUND: Advocate Illinois Masonic Medical Center (AIMMC) is located in the nation’s first municipally recognized LGBTQ neighborhood and has been named a “Leader in LGBT Healthcare Equality” in the Human Rights Campaign Healthcare Equality Index for the past 7 years. The LGBTQ community is a significant portion of the patient population. Health disparities in the LGBTQ community include (1) decreased access to healthcare/insurance; (2) low rates of pap smears and mammograms; (3) higher rates of suicide, depression, and substance abuse; and (4) an unknown proportion of LGBTQ patients in the practice. METHODS: We administered a 19-question survey assessing participants’ comfort in interacting with LGBTQ patients to 27 providers and staff at the AIMMC – Ravenswood Family Medicine Clinic. Response rates were as follows: attending physicians (26%), resident physicians (26%), medical assistants (19%), nurse practitioners (11%), registered nurses (4%), patient service representatives (7%), and other office ancillary staff (11%). RESULTS: The respondents indicated that the intake forms do not adequately capture gender identity. Providers and staff also signaled their interest in educational opportunities regarding LGBTQ issues. In response, 2 interventions were developed. The first intervention was training in providing an inclusive environment for all patients with topics on sharing difficult patient encounters, addressing patients at the front desk, asking for preferred pronouns, developing comfort discussing gender identity, and taking a complete sexual history. The second intervention was the development of a new intake form. On the current form, all questions are separated by sex. The form does not offer a gender pronoun area for transgender patients, and the number of sexual partners equates to sexual health, resulting in inadequate assessment of risk. The proposed new intake form is unisex and has space for name choice and gender pronoun. The review of systems questions are broad and can be discussed further with individual providers, and the sexual history question is more relevant to sexual risk. Plans are to conduct a follow-up meeting and administer a survey after a trial period of the new form. CONCLUSION: Providers and staff are not confident in their approach to care for LGBTQ patients, but they are eager to learn how to better serve this population. Making changes to the way we address our patients does not have to be painful, and changes can be fluid and incremental.

First identified and named in 1973, carotid webs are nonatherosclerotic fibrous bands that arise along the posterior margin of the carotid bulb.[1][1],[2][2] Histopathologically, these entities are characterized by fibroelastic thickening of the arterial intima. They appear on imaging modalities as