Delayed Presentation of Traumatic Right-Sided Diaphragmatic Hernia after Abdominoplasty

Traumatic diaphragmatic hernias are rare and challenging to diagnose. Following trauma, diagnosis may occur immediately or in a delayed fashion. It is believed that left traumatic diaphragmatic hernias are more common as a result of the protective right-sided anatomic lie of the liver. If unrecognized, traumatic diaphragmatic injuries are subject to enlarge over time as a result of the normal pressure changes observed between the thoracic and abdominal cavities. Additionally, abrupt changes to the pressure gradients, such as those which occur with positive pressure ventilation or surgical manipulation of the abdominal wall, can act as a nidus for making an asymptomatic hernia symptomatic. We report our experience with a delayed traumatic right-sided diaphragmatic hernia presenting with large bowel incarceration two months after abdominoplasty. In our review of the literature, we were unable to find any reports of delayed presentation of a traumatic right-sided diaphragmatic hernia occurring acutely following abdominoplasty

Use of Machine Learning Consensus Clustering to Identify Distinct Subtypes of Black Kidney Transplant Recipients and Associated Outcomes

Importance: Among kidney transplant recipients, Black patients continue to have worse graft function and reduced patient and graft survival. Better understanding of different phenotypes and subgroups of Black kidney transplant recipients may help the transplant community to identify individualized strategies to improve outcomes among these vulnerable groups. Objective: To cluster Black kidney transplant recipients in the US using an unsupervised machine learning approach. Design, Setting, and Participants: This cohort study performed consensus cluster analysis based on recipient-, donor-, and transplant-related characteristics in Black kidney transplant recipients in the US from January 1, 2015, to December 31, 2019, in the Organ Procurement and Transplantation Network/United Network for Organ Sharing database. Each cluster\u27s key characteristics were identified using the standardized mean difference, and subsequently the posttransplant outcomes were compared among the clusters. Data were analyzed from June 9 to July 17, 2021. Exposure: Machine learning consensus clustering approach. Main Outcomes and Measures: Death-censored graft failure, patient death within 3 years after kidney transplant, and allograft rejection within 1 year after kidney transplant. Results: Consensus cluster analysis was performed for 22 687 Black kidney transplant recipients (mean [SD] age, 51.4 [12.6] years; 13 635 men [60%]), and 4 distinct clusters that best represented their clinical characteristics were identified. Cluster 1 was characterized by highly sensitized recipients of deceased donor kidney retransplants; cluster 2, by recipients of living donor kidney transplants with no or short prior dialysis; cluster 3, by young recipients with hypertension and without diabetes who received young deceased donor transplants with low kidney donor profile index scores; and cluster 4, by older recipients with diabetes who received kidneys from older donors with high kidney donor profile index scores and extended criteria donors. Cluster 2 had the most favorable outcomes in terms of death-censored graft failure, patient death, and allograft rejection. Compared with cluster 2, all other clusters had a higher risk of death-censored graft failure and death. Higher risk for rejection was found in clusters 1 and 3, but not cluster 4. Conclusions and Relevance: In this cohort study using an unsupervised machine learning approach, the identification of clinically distinct clusters among Black kidney transplant recipients underscores the need for individualized care strategies to improve outcomes among vulnerable patient groups

Delayed Presentation of Traumatic Right-Sided Diaphragmatic Hernia after Abdominoplasty

Traumatic diaphragmatic hernias are rare and challenging to diagnose. Following trauma, diagnosis may occur immediately or in a delayed fashion. It is believed that left traumatic diaphragmatic hernias are more common as a result of the protective right-sided anatomic lie of the liver. If unrecognized, traumatic diaphragmatic injuries are subject to enlarge over time as a result of the normal pressure changes observed between the thoracic and abdominal cavities. Additionally, abrupt changes to the pressure gradients, such as those which occur with positive pressure ventilation or surgical manipulation of the abdominal wall, can act as a nidus for making an asymptomatic hernia symptomatic. We report our experience with a delayed traumatic right-sided diaphragmatic hernia presenting with large bowel incarceration two months after abdominoplasty. In our review of the literature, we were unable to find any reports of delayed presentation of a traumatic right-sided diaphragmatic hernia occurring acutely following abdominoplasty

Enhancing Kidney Transplant Care through the Integration of Chatbot

Kidney transplantation is a critical treatment option for end-stage kidney disease patients, offering improved quality of life and increased survival rates. However, the complexities of kidney transplant care necessitate continuous advancements in decision making, patient communication, and operational efficiency. This article explores the potential integration of a sophisticated chatbot, an AI-powered conversational agent, to enhance kidney transplant practice and potentially improve patient outcomes. Chatbots and generative AI have shown promising applications in various domains, including healthcare, by simulating human-like interactions and generating contextually appropriate responses. Noteworthy AI models like ChatGPT by OpenAI, BingChat by Microsoft, and Bard AI by Google exhibit significant potential in supporting evidence-based research and healthcare decision making. The integration of chatbots in kidney transplant care may offer transformative possibilities. As a clinical decision support tool, it could provide healthcare professionals with real-time access to medical literature and guidelines, potentially enabling informed decision making and improved knowledge dissemination. Additionally, the chatbot has the potential to facilitate patient education by offering personalized and understandable information, addressing queries, and providing guidance on post-transplant care. Furthermore, under clinician or transplant pharmacist supervision, it has the potential to support post-transplant care and medication management by analyzing patient data, which may lead to tailored recommendations on dosages, monitoring schedules, and potential drug interactions. However, to fully ascertain its effectiveness and safety in these roles, further studies and validation are required. Its integration with existing clinical decision support systems may enhance risk stratification and treatment planning, contributing to more informed and efficient decision making in kidney transplant care. Given the importance of ethical considerations and bias mitigation in AI integration, future studies may evaluate long-term patient outcomes, cost-effectiveness, user experience, and the generalizability of chatbot recommendations. By addressing these factors and potentially leveraging AI capabilities, the integration of chatbots in kidney transplant care holds promise for potentially improving patient outcomes, enhancing decision making, and fostering the equitable and responsible use of AI in healthcare

Presentation and Surgical Management of Duodenal Duplication in Adults

Duodenal duplications in adults are exceedingly rare and their diagnosis remains difficult as symptoms are largely nonspecific. Clinical presentations include pancreatitis, biliary obstruction, gastrointestinal bleeding from ectopic gastric mucosa, and malignancy. A case of duodenal duplication in a 59-year-old female is presented, and her treatment course is reviewed with description of combined surgical and endoscopic approach to repair, along with a review of historic and current recommendations for management. Traditionally, gastrointestinal duplications have been treated with surgical resection; however, for duodenal duplications, the anatomic proximity to the biliopancreatic ampulla makes surgical management challenging. Recently, advances in endoscopy have improved the clinical success of cystic intraluminal duodenal duplications. Despite these advances, surgical resection is still recommended for extraluminal tubular duplications although combined techniques may be necessary for long tubular duplications. For duodenal duplications, a combined approach of partial excision combined with mucosal stripping may offer advantage

The Nogo-B-PirB axis controls macrophage-mediated vascular remodeling.

Nogo-B mediates vascular protection and facilitates monocyte- and macrophage-dependent vascular remodeling. PirB is an alternate receptor for Nogo-B, but a role for the Nogo-PirB axis within the vascular system has not been previously reported. We examined whether Nogo-B or PirB play a role in regulating macrophage-mediated vascular remodeling and hypothesized that endothelial Nogo-B regulates vein graft macrophage infiltration via its alternate receptor PirB.Vein grafts were performed using Nogo and PirB wild type and knockout mice. Human vein grafts were similarly analyzed. The hindlimb ischemia model was performed in PirB wild type and knockout mice. Accompanying in vitro work included isolation of macrophages from PirB wild type and knockout mice.Increased Nogo-B and PirB mRNA transcripts and protein expression were observed within mouse and human vein grafts. Both Nogo knockout and PirB knockout vein grafts showed increased wall thickness and increased numbers of F4/80-positive macrophages. Macrophages derived from PirB knockout mice had increased adhesion to fibronectin, increased EC-specific binding, and increased numbers of mRNA transcripts of M2 markers as well as MMP3 and MMP9. PirB knockout vein grafts had increased active MMP9 compared to wild type vein grafts. PirB knockout mice had increased recovery from hindlimb ischemia and increased macrophage infiltration compared to wild type mice.Vein graft adaptation shows increased expression of both Nogo-B and PirB. Loss of PirB, or its endothelial ligand Nogo-B, results in increased inflammatory cell infiltration and vein graft wall thickening. These findings suggest that PirB regulates macrophage activity in vein grafts and that Nogo-B in the vein graft limits macrophage infiltration and vein graft thickening. PirB may play a more general role in regulating macrophage responses to vascular injury. Macrophage inhibition via Nogo-PirB interactions may be an important mechanism regulating vein graft adaptation to the arterial circulation