This transjejunal approach is an effective and safe route for a variety of percutaneous biliary procedures in patients with biliary-enteric anastomoses.

Background: Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy. Methods:We performed an observational study of adult traumatic brain injury (TBI) patients requiring intensive care unit (ICU) admission for ≥ 72 h and mechanical ventilation for ≥ 24 h between January 2014 and December 2014 at a level 1 trauma center. Patients who had life-sustaining measures withdrawn were excluded. Multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop predictive models. Inpatient complications prior to day 7 were used to standardize data collection for patients with and without tracheostomy. Patients who received tracheostomy prior to day 7 were excluded from analysis.Results: In total, 209 patients (78% men, mean 48 years old, median Glasgow Coma Scale score (GCS) 8) met study criteria with tracheostomy performed in 94 (45%). Admission predictors of tracheostomy included GCS, chest tube, Injury Severity Score, and Marshall score. Inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (EVD), number of operations, inpatient dialysis, aspiration, GCS on day 5, and reintubation. Multiple logistic regression analysis demonstrated that the number of operation room trips (adjusted odds ratio [AOR], 1.75; 95% CI, 1.04-2.97; P = 0.036), reintubation (AOR, 8.45; 95% CI, 1.91-37.44; P = .005), and placement of an EVD (AOR, 3.48; 95% CI, 1.27-9.58; P = .016) were independently associated with patients undergoing tracheostomy. Higher GCS on hospital day 5 (AOR, 0.52; 95% CI, 0.40-0.68; P < 0.001) was protective against tracheostomy. A model of inpatient variables only had a stronger association with tracheostomy than one with admission variables only (ROC AUC 0.93 vs 0.72, P < 0.001) and did not benefit from the addition of admission variables (ROC AUC 0.93 vs 0.92, P = 0.78). Conclusion:Potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. Multicenter studies are needed to validate the results.

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Background: Intramedullary spinal cavernous malformations (ISCM) account for just 1% of all intramedullary pediatric spinal cord lesions. Pathologically, they are well-circumscribed vascular malformations that typically appear dark blue or reddish-brown, often coming to the spinal cord surface. With regard to the histopathology findings, ISCMs are comprised sinusoidal vascular spaces lined by a single layer of endothelial cells within a loose connective tissue stroma. As these lesions are often misdiagnosed in the pediatric population, appropriate treatment may be unduly delayed. Methods: The authors performed an extensive review of the published literature (PubMed) focusing on ISCM in the pediatric age group. Results: The search yielded 17 articles exclusively pertaining to ISCM affecting the pediatric population. Conclusion: Here, we reviewed the clinical, radiographic, surgical, and outcome data for the treatment of ISCM in the pediatric age groups. Notably, over 50% of pediatric patients with ISCM experienced an improvement in their neurological status after a mean postoperative follow-up duration of 4 years. Future meta-analyses are needed to highlight the potential presence of ISCM and, thereby, decrease the rate of misdiagnosis of these lesions in the pediatric population presenting with recurrent intramedullary spinal cord hemorrhages.

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After sustaining severe traumatic brain injury (TBI), patients frequently require invasive mechanical ventilation (MV). However, up to 26% of patients require tracheostomy due to failure to wean from the ventilator. [1] The decision of when to perform tracheostomy is important as it balances the risk between avoiding prolonged MV and avoiding risk of tracheostomy. Early predictors for tracheostomy, i.e., clinical factors when patients first present to an Emergency Department after trauma or when patient fi rst arrive at a regional trauma center, can help clinicians' medical decision-making process.We retrospectively analyzed the charts of 201 adult patients who sustained severe TBI and received MV >72 hours at our regional trauma center from January to December 2014. Forty-eight (24%) patients were transferred from another hospital's ED and 153 (76%) patients were admitted directly from sites of injury. Mean age was 48±21 years, and mean Injury Severity Score was 29±10. Multivariable logistic regression of significant independent variables, which were defined as P-value≤0.10 in univariate logistic regression, showed that Shock Index (SI) during ED stay <0.5 was associated with higher likelihood for tracheostomy (Odd Ratio [OR] 11, 95% Confidence Interval [CI] 1.4-87, P=0.022) (Table 1

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Since the onset of the novel coronavirus (COVID-19) global health crisis, there has been an unprecedented change to the field of spinal surgery. Comprehensive protocols and algorithms have been implemented globally to maximize available bed space, conserve personal protective equipment, and to minimize exposure. This has resulted in a sharp decline in elective spinal surgery and placed an undue burden on the spinal industry. As the landscape of elective surgery changes, this paper looks to analyze the effects the COVID-19 pandemic has and will have on spinal instrumentation companies, surgeons, and the spinal industry. Changes in government policies, patient care, financial markets, and distribution have all presented an unprecedented strain on spinal instrumentation companies. A narrative literature review was performed using published literature from PubMed. Due to the socioeconomic and financial nature of this review, data collection from financial references was also obtained and cited. With significant financial losses reported throughout the spinal industry and medical field, this paper discusses managing the COVID-19 pandemic and the future prospectus moving forward. As the pandemic continues to unfold, it remains difficult to predict the exact timing for broad resumption of elective medical procedures, and the extent to which the pandemic will affect the industry. Preparation aimed at facilitating efficient resource allocation and communication among surgeons, surgical instrumentation representatives and hospital leadership is essential as we transition forward and reestablish normalcy under the new constraints of COVID-19.