There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury.

Total extraperitoneal (TEP) repair can be performed with low morbidity and a high level of patient satisfaction. The effects of the learning curve are not to be neglected. The 1-year recurrence rate is 1.6%. Published data on TEP suggest that late recurrences may be less frequent than after open repair.

Diarrhea after bariatric procedures, mainly those with malabsorptive elements including Roux-Y Gastric Bypass and Biliopancreatic Diversion, is common and an essential determinant of quality of life and micro- and macronutrient deficiencies. Bariatric surgery is the only sustainably successful method to address morbid obesity and its comorbidities, particularly gaining more and more importance in the specific treatment of diabetic patients. Approximately half a million procedures are annually performed around the world, with numbers expected to rise drastically in the near future. A multitude of factors exert their influence on bowel habits; preoperative comorbidities and procedure-related aspects are intertwined with postoperative nutritional habits. Diagnosis may be challenging owing to the characteristics of post-bariatric surgery anatomy with hindered accessibility of excluded segments of the small bowel and restriction at the gastric level. Conventional testing measures, if available, generally yield low accuracy and are usually not validated in this specific population. Limited trials of empiric treatment are a practical alternative and oftentimes an indispensable part of the diagnostic process. This review provides an overview of causes for chronic post-bariatric surgery diarrhea and details the particularities of its diagnosis and treatment in this specific patient population. Topics of current interest such as the impact of gut microbiota and the influence of bile acids on morbid obesity and especially their role in diarrhea are highlighted in order to provide a better understanding of the specific problems and chances of future treatment in post-bariatric surgery patients.

The diffusion into the target tissues of ketoprofen (CAS 22071-15-4), a widely used nonsteroidal anti-inflammatory drug, from a new topical patch has been studied after repeated patch application in comparison with its plasma level. Ten patients (5 women and 5 men) with a mean age of 45.0 +/- 12.3 years (mean +/- SD), scheduled for arthroscopic meniscectomy (5 subjects) or endoscopic carpal tunnel decompression (5 subjects), were asked to apply one patch with 100 mg ketoprofen on the affected body site once a day during the 6 days before the scheduled surgery. The last patch was kept for 6 h, and removed just a few minutes before surgery, when venous blood was drawn. Biopsies of the synovial tissue of the medial compartment and of the anterior fat pad (Hoffa's tissue) or of the ulnar bursa were taken during knee arthroscopy or endoscopic carpal tunnel release, respectively. An average plasma value of 52.8 +/- 30.1 (SD) ng/ml of ketoprofen was obtained in the 10 patients. The tissue concentrations of ketoprofen in the 5 subjects undergoing knee arthroscopy were 27.9 +/- 26.1 ng/g (range 7.2-67.1 ng/g) in the anterior fat pad and 239.0 +/- 163.0 ng/g (range 20.0-430.5 ng/g) in the synovial tissue. Drug concentrations up to 1000 times higher were found in the tendon sheath tissue of the ulnar bursa of the five patients undergoing endoscopic carpal tunnel release: average values of 20,107 +/- 7359 ng/g (range 13,004-32,578 ng/g) were obtained in this tissue. Data observed in this trial are consistent with those previously published by other authors, and demonstrate that ketoprofen applied on the skin is able to enter the subcutaneous and intra-articular tissues, reaching concentrations markedly higher than in plasma, and is further able to produce the desired pharmacological activity in situ, whereas plasma concentrations are too low to produce any systemic activity or side effect.

Background In trauma patients, the impact of inter-hospital transfer has been widely studied. However, for patients undergoing emergency abdominal surgery (EAS), the effect of inter-hospital transfer on outcomes is largely unknown. Methods This is a single-center, retrospective observational study. Outcomes of transferred patients undergoing EAS were compared to patients primarily admitted to a tertiary care hospital from 01/2016 to 12/2018 using univariable and multivariable analyses. The primary outcome was in-hospital mortality. Results Some 973 patients with a median (IQR) age of 58.1 (39.4–72.2) years and a median body mass index of 25.8 (22.5–29.3) kg/m2 were included. The transfer group comprised 258 (26.3%) individuals and the non-transfer group 715 (72.7%). The population was stratified in three subgroups: (1) patients with low surgical stress (n = 483, 49.6%), (2) with hollow viscus perforation (n = 188, 19.3%) and (3) with potential bowel ischemia (n = 302, 31.1%). Neither in the low surgical stress nor in the hollow viscus perforation group was the transfer status associated with mortality. However, in the potential bowel ischemia group inter-hospital transfer was a predictor for mortality (OR 3.54, 95%CI 1.03–12.12, p = 0.045). Moreover, in the hollow viscus perforation group inter-hospital transfer was a predictor for reduced hospital length of stay (RC -10.02, 95%CI −18.14/−1.90, p = 0.016) and reduced severe complications (OR 0.38, 95%CI 0.18–0.77, p = 0.008). Conclusion Other than in patients with low surgical stress or hollow viscus perforation, in patients with potential bowel ischemia inter-hospital transfer was an independent predictor for higher mortality. Taking into account the time sensitiveness of bowel ischemia, efforts should be made to avoid inter-hospital transfer in this vulnerable subgroup of patients.

In support of improving patient care, this activity has been planned and implemented by CineMed and the American Association for the Surgery of Trauma. CineMed is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. AMA PRA Category 1 Credits™CineMed designates this enduing material for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. ObjectivesAfter reading the featured articles published in the Journal of Trauma and Acute Care Surgery, participants should be able to demonstrate increased understanding of the material specific to the article. Objectives for each article are featured at the beginning of each article and online. Test questions are at the end of the article, with a critique and specific location in the article referencing the question topic.

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