Heather M. Grossman Verner

Background: Acute pain due to rib fractures causes significant in-hospital morbidity and impacts patients’ quality of life after discharge. Intraoperative transthoracic cryoneurolysis of the intercostal nerves can improve postoperative pain; however, non-surgical patients are provided limited analgesia options. Here, we describe our experience with a bedside cryoanalgesia technique for management of acute rib fracture pain. Methods: Five patients at a single level I trauma center completed bedside intercostal nerve cryoneurolysis (INC) using a handheld cryotherapy device and ultrasound guidance. Relative pain ratings (scale 0–10/10) and maximal incentive spirometry (IS_max) volumes were taken prior to the procedure as a baseline. Patients were observed for 24 hours after procedure, with relative pain ratings and IS_max recorded at 1, 8, 16, and 24 hours after procedure. Results: Our patients were 29–88 years old and had one to five single-sided rib fractures. At baseline, they had high pre-procedure pain ratings (7–10/10) and IS_max volumes of 800–2000 mL. Many had improvements in their pain rating but little change in their IS_max at 1 hour (1–5/10 and 1000–2000 mL, respectively) and 8 hours (1–5/10 and 1250–2400 mL, respectively). IS_max volumes improved by 16 hours (1500–2400 mL) with comparable pain ratings (0–5/10). At 24 hours, pain ratings and IS_max ranged from 0 to 8/10 and from 1500 mL to 2400 mL, respectively. Each patient had improved pain control and IS_max volumes compared with their pre-procedure values. All patients reported the procedure as an asset to their recovery at discharge. Conclusions: Our study demonstrates patients with rib fractures may experience improved pain ratings and IS_max values after INC. Percutaneous INC appears to be a viable adjunct to multimodal pain control for patients with rib fractures and should be considered in patients with difficult pain control. Further studies are required to fully assess INC safety, efficacy, post-discharge outcomes, and utility in patients with altered mental status or on mechanical ventilation. Level of evidence: Level V, case series.

Cholecystocolonic fistula (CCF) is a rare complication of biliary tract disease. Increased use of imaging has aided in diagnosing these fistulae preoperatively and has established laparoscopy as a safe alternative to laparotomy. Here, we present a 79-year-old male who presented to the emergency room with abdominal pain and was diagnosed with choledocholithiasis. CT scan revealed a CCF, and he underwent endoscopic retrograde cholangiopancreatography (ERCP). He was followed closely to allow maturation of the fistula, and then, da Vinci® Xi robotic cholecystectomy and ligation were performed. Although current comparisons to laparoscopy have yet to demonstrate a clinical advantage, robotic assistance enhances dexterity, visualization, and ergonomics. Our case is one of the first documented successful operative management of CCF using the da Vinci^® Xi robot.

Endometriosis is a well-described pathology, with anatomic location of endometrial cell implantation extending both intraperitoneal and rarely extraperitoneal. Interestingly, previous reports indicated that the spleen enjoys immunity to endometriosis. Here, we present a patient with unremitting abdominal pain who, upon further workup, revealed multicystic disease of the spleen. The patient underwent an open splenectomy with pathology revealing intraparenchymal endometriosis likely due to seeding from traumatic splenorrhaphy. Two-week follow-up demonstrated resolution of symptoms and a well-healing incision with no postoperative complications.

Background Uncompensated care (UC) is healthcare provided with no payment from the patient or an insurance provider. UC directly contributes to escalating healthcare costs in the USA and potentially impacts patient care. In Texas, there has been a steady increase in the number of trauma centers and UC volumes without an increase in trauma funding of UC. The method of calculating UC trauma funds in Texas is imprecise as it is driven by Medicaid volumes and not actual trauma care costs. Methods Five years of annual trauma UC disbursement reports from the Texas Department of State Health Services were used to determine changes in UC economic considerations for level I, II, and III trauma centers in the largest urban trauma service areas (TSAs). Data for UC costs, compensation, and TSA demographics were used to assess variations. Statistical significance was determined using a Kruskal-Wallis test with Dunn’s pairwise comparison post-hoc analysis and logistic regression. Results TSA-E (Dallas-Fort Worth area) has 33% of the level I trauma centers in Texas (n=6) and yet serves only 27% of the total state population across 14 metropolitan and 5 non-metropolitan counties. Since 2015, TSA-E has shown higher UC costs (pDiscussion The unregulated expansion of trauma centers in Texas has led to an unprecedented increase in hospitals participating in trauma care. The unbalanced allocation of UC funding could lead to further economic instability, compromise resource allocation, and negatively impact patient care in an already fragile healthcare environment. Level of evidence Level IV; Retrospective economic analysis and evaluation.

Multiple mechanisms contribute to cancer cell progression and metastatic activity, including changes in endocytic trafficking and signaling of cell surface receptors downstream of gain-of-function (GOF) mutant p53. We report that dynamin-1 (Dyn1) is up-regulated at both the mRNA and protein levels in a manner dependent on expression of GOF mutant p53. Dyn1 is required for the recruitment and accumulation of the signaling scaffold, APPL1, to a spatially localized subpopulation of endosomes at the cell perimeter. We developed new tools to quantify peripherally localized early endosomes and measure the rapid recycling of integrins. We report that these perimeter APPL1 endosomes modulate Akt signaling and activate Dyn1 to create a positive feedback loop required for rapid recycling of EGFR and β1 integrins, increased focal adhesion turnover, and cell migration. Thus, Dyn1- and Akt-dependent perimeter APPL1 endosomes function as a nexus that integrates signaling and receptor trafficking, which can be co-opted and amplified in mutant p53–driven cancer cells to increase migration and invasion.