Recurrent laryngeal nerve (RLN) damage in infants leads to increased dysphagia and aspiration pneumonia. Recent work has shown that intra oral transport and swallow kinematics change following RLN lesion, suggesting potential changes in bolus formation prior to the swallow. In this study we used geometric morphometrics to understand the effect of bolus shape on penetration and aspiration in infants with and without RLN lesion. We hypothesized 1) that geometric bolus properties are related to airway protection outcomes and 2) that in infants with RLN lesion, the relationship between geometric bolus properties and dysphagia is changed. In five infant pigs, dysphagia in 188 swallows was assessed using the Infant Mammalian Penetration Aspiration Score (IMPAS). Using images from high-speed VFSS, bolus shape, bolus area, and tongue outline were quantified digitally. Bolus shape was analyzed using elliptical Fourier analysis, and tongue outline using polynomial curve fitting. Despite large inter-individual differences, significant within individual effects of bolus shape and bolus area on airway protection exist. The relationship between penetration-aspiration score and both bolus area and shape changed post lesion. Tongue shape differed between pre and post lesion swallows, and between swallows with different IMPAS scores. Bolus shape and area affect airway protection outcomes. RLN lesion changes that relationship, indicating that proper bolus formation and control by the tongue requires intact laryngeal sensation. The impact of RLN lesion on dysphagia is pervasive.

Subtalar dislocations are rare injuries that typically occur from high-energy injuries. All subtalar dislocations should be attempted to be closed reduced, however, ~32% are irreducible requiring open reduction. We present an irreducible medial subtalar dislocation following a motor vehicle accident with no associated fractures demonstrated on radiograph. However, open reduction revealed an incarcerated anterior talar head fracture that was reduced and stabilized with retrograde K-wires.

Mantle cell lymphoma (MCL) is a type of non-Hodgkin (B-cell) lymphoma (NHL) with manifestations ranging from indolent to aggressive disease. This type of NHL is predominately found in western countries and affects men more often than women (M:F 2:1). The median age of diagnosis with the disease is around 60 years of age. In this report, the patient is a 68-year-old female who had an atraumatic splenic rupture with no past medical history of trauma. She presented to the emergency department with severe abdominal pain in her left upper quadrant. An emergency splenectomy was executed successfully, and the patient was stabilized. In this case report, we will discuss the pathogenesis, clinical presentation, known clinical treatment, diagnostic testing, and atraumatic splenic rupture.

Highlights Two problems of non-healing sacral ulcer and an incarcerated ventral hernia. Creation of diverting ostomy and incarcerated ventral hernia repair in one. The patient achieved a good outcome. Wound healing improved and hernia did not recur.

Introduction and importance: Colonoscopies are a common procedure performed today as an outpatient procedure. Currently, colonoscopy is the gold standard for diagnosis and surveillance of colon cancer. Colonoscopies are a safe procedure with a low complication risk; however, that risk varies based on if any interventions were performed, such as a polypectomy. A systematic review for the US Preventive Services Task Force noted that serious harm occurred in 2.8 per 1000 screening colonoscopies. Other studies have demonstrated a perforation rate of 0.5 per 1000 colonoscopies, post-colonoscopy bleeding rate of 2.6 per 1000 colonoscopies, and a mortality rate of 2.9 per 100,000 colonoscopies. A recent systematic review also noted post-colonoscopy diverticulitis as a potential complication, with time to diagnosis ranging from 2 h to 30 days, necessitating early recognition to help guide appropriate treatment. In this case report, we describe a patient who developed post-colonoscopy diverticulitis who presented to the emergency room with perforated diverticulitis requiring emergency sigmoid colectomy with end colostomy. Case presentation: A 63-year-old male who presented as an outpatient to the surgery clinic in need of a screening colonoscopy for a history of polyps and family history of colon cancer. He underwent an outpatient colonoscopy, which demonstrated sigmoid and ascending diverticula with no polyps or acute inflammation. One week later, he presented to the emergency room with left lower quadrant pain. He was subsequently diagnosed with perforated diverticulitis and was taken to the operating room for a sigmoid colectomy with an end colostomy. Clinical discussion: Although serious complications after a colonoscopy are rare, they do occur, and therefore, patients should be counseled preoperatively regarding the potential risks of the procedure. It is unclear what factors contributed to the patient's post-colonoscopy diverticulitis. He denied any previous abdominal surgeries or previous episodes of diverticulitis. He did have a history of colon polyps, but this colonoscopy did not include a polypectomy or any interventions. He also was taking daily prednisone, which may have increased his risk for an emergency procedure when presenting with diverticulitis. Given the limited data describing post-colonoscopy diverticulitis, further studies are needed to better characterize patients at risk and to decrease the occurrence. Conclusion: This case highlights the importance of a thorough discussion of potential complications before any procedure, even if the overall risks are low. In the emergency room, obtaining a detailed patient history, physical exam, laboratory work, and proper imaging lead to a proper diagnosis of post-colonoscopy diverticulitis despite the rare presentation.

Lung cancer is the leading cause of cancer death in the United States, with more than 230,000 new cases, and approximately 150,000 deaths estimated for 2018. Lung cancer most commonly metastasizes to the brain, liver, lungs, bone, and adrenal system; however, there have been several cases of spread to soft tissues, with an incidence rate of approximately 0.75-9%. The objective of this case report is to highlight an unusual presentation of metastatic adenocarcinoma of the lung. In this case report, patient presented with a 3 × 3  cm soft tissue mass on the back. The mass was slowly growing but had become more painful and wished to have it excised. Preoperatively, the mass was suspected to be a sebaceous cyst but intraoperatively had deep attachments and other suspicious findings. Pathology had a positive immunoprofile for metastatic adenocarcinoma favoring a lung primary. Given this presentation of metastases, the prognosis is poor with a survival time decreasing to around 5 months. Overall, this case reinforces the importance of sending all soft tissue masses for final pathology with accurate labeling and the importance of immunohistochemical testing in aiding the identification of the primary.

Large bowel obstruction (LBO) accounts for nearly 25% of all bowel occlusions. LBO is managed as a surgical emergency due to its increased risk of bowel perforation. Nearly, 2% to 4% of all surgical admissions are a result of LBO. The most common pathological development of LBO remains colonic malignancy, representing approximately 60% of cases. Other etiology includes abdominal adhesions, diverticulosis, hernia, inflammatory bowel disease (IBD), and in rare cases endometriosis. In this report, the patient is a 36year-old female with an LBO, originally thought to be a complication of diverticulitis. However, it was confirmed that the obstruction was a result of endometriosis tissue adherence to the colonic wall narrowing the intestinal lumen. The patient presented to the emergency department (ED) with nausea, vomiting, and abdominal pain that started six weeks prior. In this case report, we will discuss the rare complication of endometriosis causing LBO, clinical presentation, diagnosis, and management.

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