Diaphragmatic Hernia after Laparoscopic Esophagomyotomy for Esophageal Achalasia in Pregnancy

Background. The optimal treatment for management of esophageal achalasia in pregnancy is controversial. Little information exists about pregnancy outcome after successful myotomy. Case. Achalasia in pregnancy was diagnosed when a patient presented with pneumomediastinum from microrupture of the overdistended esophagus. An attempt at surgical correction failed due to the development of aspiration pneumonia with general anesthesia. Conservative medical therapy was undertaken, but fetal growth restriction developed. The patient underwent interval surgical correction, but subsequent pregnancy 6 months later was complicated by acute diaphragmatic hernia necessitating preterm delivery. Conclusion. Prior to surgery in pregnancy, emptying the dilated esophagus via nasoesophageal tube suctioning maybe warranted to avoid aspiration. Women, despite having undergone successful myotomy, should be counseled on the risks of pregnancy and to avoid pregnancy for at least 1 year thereafter

Prevention of infection and disruption of the pathogen transfer chain in elective surgery

The COVID-19 pandemic has caused us all to stop our normal activities and consider how we can safely return to caring for our patients. There are many common practices (such as an increased use of personal protective equipment) which we are all familiar with that can be easily incorporated into our daily routines. Other actions, such as cleaning more surfaces with solutions such as dilute povidone iodine or changing the air filtration systems used within operating room theaters, may require more extensive efforts on our behalf. In this article, we have attempted to highlight some of the changes that arthroplasty surgeons may need to instigate when we are able to resume elective joint arthroplasty procedures in an effort to disrupt the chain of pathogen transfer

The Effect of Hair Color on the Incorporation of Codeine into Human Hair

The influence of melanin on the binding of xenobiotics in hair will impact the interpretation of drug concentrations determined by hair testing. The purpose of this study was to determine if codeine, as a model compound of abused drugs, would be incorporated into black, brown, blond, or red hair as a function of melanin concentration. Such data would assist in the interpretation of codeine concentrations in hair and help elucidate the potential influence of hair color on incorporation of drugs. Male and female Caucasians with black (n = 6), brown (n = 12), blond (n = 8), or red hair (n = 6) and non-Caucasians with black hair (n = 12) aged 21-40 years were enrolled in the study. Each subject was administered oral codeine phosphate syrup in a dosage of 30 mg three times a day for five days. Twenty-four hours after the end of the treatment period, a 30-mg codeine dose was administered and the subject's plasma area under the concentration time curve (AUC) for codeine was determined. Codeine and melanin were measured in the first 3 cm of hair closest to the vertex region of the scalp prior to and 1, 4, 5, 6, and 7 weeks after dosing. The quantitative and qualitative melanin profiles were determined for each subjects hair to provide an objective measure of hair color. The plasma concentrations of codeine were measured to eliminate differences in the bioavailability and clearance of codeine as factors that might account for the differences in codeine hair concentrations. The subjects were asked not to cut their hair in the vertex region of the scalp or to use any form of chemical treatment on their hair, but otherwise normal hygienic measures were permitted. The mean (± SE) hair codeine concentrations 5 weeks after dosing were 1429 (± 249) pg/mg in black hair; 208 (± 17) pg/mg in brown hair; 99 (± 10) pg/mg in blond hair; and 69 (± 11) in red hair pg/mg. In black hair, codeine concentrations were 2564 (± 170) pg/mg for Asians and 865 (± 162) pg/mg for Caucasians. Similar concentration relationships were observed at weeks 4, 6, and 7. A strong relationship between the hair concentrations of codeine and melanin (R2 = 0.73) was observed. Normalization of the codeine concentration with the melanin concentration reduced the hair color differences observed. These data demonstrate that the interpretation and reporting of hair test results for codeine are influenced by hair color. After this dosing protocol, the proposed federal guideline cutoff of 200 pg/mg of codeine would result in 100% of subjects with black hair and 50% of subjects with brown hair being reported as positive, and subjects with blond or red hair would be reported as negative. The incorporation of these drugs into hair should be studied carefully in humans to ensure the appropriate interpretation of drug concentration

Evaluation of Phage Treatment as a Strategy to Reduce Salmonella Populations in Growing Swine

Salmonella is a foodborne pathogenic bacterium that causes human illnesses and morbidity and mortality in swine. Bacteriophages are viruses that prey on bacteria and are naturally found in many microbial environments, including the gut of food animals, and have been suggested as a potential intervention strategy to reduce Salmonella levels in the live animal. The present study was designed to determine if anti-Salmonella phages isolated from the feces of commercial finishing swine could reduce gastrointestinal populations of the foodborne pathogen Salmonella Typhimurium in artificially inoculated swine. Weaned pigs (n = 48) were randomly assigned to two treatment groups (control or phage-treated). Each pig was inoculated with Salmonella Typhimurium (2 × 1010 colony forming units/pig) via oral gavage at 0 h and fecal samples were collected every 24 h. Swine were inoculated with a phage cocktail via oral gavage (3 × 109 plaque forming units) at 24 and 48 h. Pigs were humanely killed at 96 h, and cecal and rectal intestinal contents were collected for quantitative and qualitative analysis. Fecal Salmonella populations in phage-treated pigs were lower (p \u3c 0.09) than controls after 48 h. Phage treatment reduced intestinal populations of inoculated Salmonella Typhimurium in pigs compared to controls at necropsy. Cecal populations were reduced (p = 0.07) by phage treatment \u3e1.4 log10 colony forming units/g digesta, and rectal populations were numerically reduced. The number of pigs that contained inoculated Salmonella Typhimurium was reduced by phage treatment, but a significant (p \u3c 0.05) reduction was only observed in the rectum. We conclude that phages can be a viable tool to reduce Salmonella in swine. Further research needs to be performed to determine the most efficacious dosing regimens and the most effective combinations of phages targeting the diverse Salmonella population found in swine before they can enter the food supply

Multicenter Evaluation of Telehealth Utilization in Hip and Knee Arthroplasty Before and for One Year During the COVID-19 Pandemic

BackgroundThe Coronavirus Disease 2019 (COVID-19) pandemic has led to an increase in telehealth utilization across the health-care sector. It is unknown if telehealth use among hip and knee arthroplasty clinics has remained an important health-care delivery platform. The purpose of the present study was to analyze telehealth utilization before and for 1 year during the pandemic among four varied hip and knee arthroplasty clinics.MethodsRetrospective data were available from four regionally diverse hip and knee arthroplasty centers. Data on volume of patient visits, demographics, visit types (new visit, follow-up, postoperative visit, other), and visit modality (in-person, telehealth, telephone) were available from January 2020 through April 2021. Data from the centers were analyzed as a total and separately, using chi-squared and Fisher exact tests.ResultsAmong the four centers, there were 296,540 hip and knee arthroplasty outpatient clinic visits between January 2020 and April 2021. Of those, 15,240 (5%) were telehealth visits. Before March 2020, less than 0.1% of visits across centers occurred over telehealth. The highest utilization of telehealth visits occurred in March 2020 (>55%) and April 2020 (>25%). From August 2020 until April 2021, telehealth visits accounted for 2%-3% of total visits. Younger patients (<50 years old) were most likely to use telehealth. Follow-up and postoperative were the most likely telehealth visits.ConclusionTelehealth utilization peaked during March and April of 2020 and has since reverted to near prepandemic levels. Younger patients and lower complexity visits such as postoperative or follow-up visits are more likely to use telehealth