Highlights Case report of an umbilical urachal cyst presenting as an infected umbilical hernia. Congenital abnormalities such as these may present as a periumbilical soft tissue infection. Complete excision of the urachal cyst for pathologic examination is recommended. Patients can be successfully treated with short course of antibiotics and total excision.

BACKGROUND Traumatic brain injury (TBI) continues to be a deadly injury. Universally accepted guidelines regarding the use of venous thromboembolism (VTE) chemoprophylaxis in trauma patients presenting with TBI have not been established. The purpose of this review was to identify and review the current literature and present the evidence for anticoagulant chemoprophylaxis regimens in patients with TBI. METHODS A search of five databases including PubMed, Web of Science, Google Scholar, JAMA Network, and Cochrane Journals was conducted for studies evaluating the safety and efficacy of venous thromboembolism prophylaxis regimens according to the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria were used for quality of evidence assessment. RESULTS Seventeen studies were included in this review: 1 randomized controlled trial, 2 prospective observational studies, 10 retrospective reviews, and 5 systematic reviews. Most studies demonstrated that early chemoprophylactic administration is associated with a decreased incidence of VTE in patients with TBI without an increase in intracranial bleed. CONCLUSION For patients with TBI resulting in intracranial hemorrhages, administration of VTE chemoprophylaxis is warranted for those patients with stable repeat computed tomography scans. Early chemoprophylaxis, at 24 to 72 hours is associated with reduced VTE incidence without a corresponding increase or exacerbation of intracranial hemorrhage in patients with TBI who have a stable repeat head computed tomography scan. More studies are needed to establish guidelines for the safety and efficacy of VTE prophylaxis protocols in adult patients with TBI. LEVEL OF EVIDENCE Systematic review, level III.

Highlights Urinary bladder rupture is uncommon, occurring in 0.36% of blunt abdominal trauma. Intraperitoneal ruptures are emergencies with >20% mortality when undiagnosed. CT and plain film cystography are the most sensitive and specific diagnostic imaging. Indwelling bladder catheters should remain in for at least 7 days postoperatively.

BACKGROUND Venous thromboembolism (VTE) continues to be a devastating source of morbidity and mortality in obese patients who suffer traumatic injuries or obese surgery patients. High incidence rates in VTE despite adherence to prevention protocols have stirred interest in new dosing regimens. The purpose of this study was to systematically review the literature and present the existing VTE chemoprophylaxis regimens for obese trauma and surgical patients in terms of efficacy and safety as measured by the incidence of VTE, anti-factor Xa levels, and the occurrence of bleeding events. METHODS An online search of seven literature databases including PubMed, Excerpta Medica Database, GoogleScholar, JAMA Network, CINAHL, Cochrane, and SAGE Journals was performed for original studies evaluating the safety and efficacy of VTE chemoprophylaxis dosing regimens according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. The risk of bias was assessed using the Cochrane Risk of Bias Tool and the quality of evidence was determined using the GRADE Working Group criteria. RESULTS Of the 5,083 citations identified, 45 studies with 27,717 patients met inclusion criteria. In this group, six studies evaluated weight-based dosing regimens, four used a weight-stratified or weight-tiered strategy, five used a body mass index–stratified approach, 29 assessed fixed-dose regimens, and two used continuous infusions. The majority of the studies evaluated anti-factor Xa levels as their primary outcome rather than reduction in VTE. CONCLUSION Weight-based and high fixed-dose chemoprophylaxis regimens achieved target anti-Xa concentrations more frequently than standard fixed-dose regimens but were not associated with a reduction in VTE. Additionally, high fixed-dose approaches are associated with increased bleeding complications. Further evaluation with large randomized trials is warranted in trauma and surgery patients with obesity. LEVEL OF EVIDENCE Systematic review, level III.

The effect of timing in patients requiring tracheostomy varies in the literature. The purpose of this study was to evaluate the impact of early tracheostomy on outcomes in trauma patients with and without traumatic brain injury (TBI). This study is a four-year review of trauma patients undergoing tracheostomy. Patients were divided into two groups based on TBI/non-TBI. Each group was divided into three subgroups based on tracheostomy timing: zero to three days, four to seven days, and greater than seven days postadmission. TBI patients were stratified by the Glasgow Coma Scale (GCS), and non-TBI patients were stratified by the Injury Severity Score (ISS). The primary outcome was ventilator-free days (VFDs). Significance was defined as P < 0.05. Two hundred eighty-nine trauma patients met the study criteria: 151 had TBI (55.2%) versus 138 (47.8%) non-TBI. There were no significant differences in demographics within and between groups. In TBI patients, statistically significant increases in VFDs were observed with GCS 13 to 15 for tracheostomies performed in four to seven versus greater than seven days ( P = 0.005). For GCS <8 and 8 to 12, there were significant increases in VFDs for tracheostomies performed at days 1 to 3 and 4 to 7 versus greater than seven days (P << 0.05 for both). For non-TBI tracheostomies, only ISS ≥ 25 with tracheostomies performed at zero to three days versus greater than seven days was associated with improved VFDs. Early tracheostomies in TBI patients were associated with improved VFDs. In trauma patients with no TBI, early tracheostomy was associated with improved VFDs only in patients with ISS ≥ 25. Future research studies should investigate reasons TBI and non-TBI patients may differ.

Background: Uterine cancer (UC) is one of the leading gynecologic neoplastic disorders in the United States (US), of which over 80% are endometrioid adenocarcinomas (EA). In contrast to EA, carcinosarcoma (CS) of the uterus is a sporadic and highly malignant tumor, phylogenetically containing both epithelial and mesenchymal histologic elements. This study sought to analyze demographic, pathological retrospectively, and survival characteristics of a large cohort of CS patients compared to EA patients to identify prognostic factors and treatment approaches that may improve the current clinical management of CS patients. Methods: Demographic and clinical data were abstracted from 88,530 patients diagnosed with uterine malignancy from the Surveillance, Epidemiology, and End Results (SEER) database for 38 years (1973-2010). Extracted variables were analyzed using the Chi-square test, paired t-test, and multivariate analysis, while Kaplan-Meier functions were used to compare survival between groups. Statistical analyses were performed with IBM Statistical Product and Service Solutions (SPSS ©), version 20.2 (IBM Corp., Armonk, NY). Results: A total of 3,706 cases of CS comprised 38.2% of uterine sarcomas (n=9,702), and 4.1% of uterine cancers overall (n=88,530). EA made up 88.6% (n=78,481) of all uterine cancers. CS patients presented later in life (68.3±11.5 years) than EA (61.9±12.5 years). 65.2% of CS and 77.8% of EA occurred in Caucasians. The incidence (per million) of EA was higher in Caucasians compared to African-Americans (AA) (41% vs. 26.8%), while the incidence of CS was higher among AA than Caucasians (4% vs. 1.9%, p<0.001). 33.4% of CS was poorly differentiated at presentation, compared to 13.1% of EA. 27.8% of CS patients presented with a distant disease compared to only 4.7% of EA patients. 29.9% of AA patients with CS presented with metastatic disease, compared to 28.2% of Caucasian patients (p<0.001). Mean survival for CS patients (6.6±0.2 years) was significantly lower than that of EA patients (17.7±0.7 years, p<0.001), and AA CS patients had significantly lower survival than Caucasians CS patients (4.5±0.4 years vs. 7.1±0.3 years, p<0.001). CS patients treated with combined surgery and radiotherapy had the highest survival (9.4±0.5 years, p<0.001), while EA patients treated with surgery alone had the highest survival (20.4±1.2 years, p<0.001). Survival among AA CS patients treated with

Introduction A compartment syndrome (CS) occurs when increased pressure within an anatomic compartment leads to inadequate perfusion. Although rare, gluteal CS can be encountered when an unconscious person has a prolonged period of immobilization. Presentation of case A 20-year-old male with history of polysubstance abuse leading to passing out, presented with right buttock and lower extremity pain, increased creatinine phosphokinase (CPK), and acute renal failure. Physical examination and MRI confirmation supported gluteal CS. Patient was taken to the OR for gluteal fasciotomy. Afterwards, the pain improved, the CPK and creatinine trended to normal. He was discharged home on day 7. Discussion CS can occur in any part of the body with fascial compartments. Increased compartmental pressure causes compression of vessels and nerves in the area that can lead to ischemia and necrosis. CS can occur after trauma, excessive fluid resuscitation, or surgery. It is also reported due to the prolonged periods of immobilization and increasing pressure on dependent areas. Often, intra-compartmental pressure is measured to confirm the diagnosis. The mainstay of treatment is fasciotomy. Conclusion Due to the rarity of gluteal compartment syndrome, the diagnosis is often delayed. If the affected area is ischemic for a significant amount of time, it can lead to sciatic nerve palsy, paresthesias, paralysis and muscle necrosis. Patients may experience irreversible damage after the syndrome and as such providers should be cognizant of this clinical entity to make an early diagnosis of gluteal compartment syndrome.

BackgroundClinicians must maintain an index of suspicion to diagnose an anorectal foreign body (FB). The patient may not be forthcoming with information secondary to embarrassment or possibly psychiatric issues. Providers must express empathy and compassion while maintaining nonjudgmental composure. Despite accounts of anal FB insertion, this pathology is lacking level one evidence-based surgical algorithms.Case presentationA 46-year-old male psychiatric patient presented in septic shock, complaining of lower abdominal/pelvic pain starting 1 week prior. His past medical history was significant for schizophrenia, bipolar disorder, and noncompliance with medications. CT of the abdomen/pelvis revealed a rectal perforation with free air and a FB which appeared to be a screwdriver. Fluid resuscitation and broad-spectrum antibiotics were administered. In the operating room, after unsuccessful transrectal removal, an exploratory laparotomy was performed. The metallic end of the screwdriver had perforated the rectosigmoid. Resection of the perforated rectum with removal of the screwdriver, incision and drainage of a large right buttock abscess and colostomy was performed. The patient recovered and was discharged to behavioral health. At 2 weeks follow-up the patient was doing well with a functioning colostomy and reversal was planned for later this year.ConclusionThis case highlights the importance of maintaining a high index of suspicion when encountering psychiatric patients with nonspecific lower abdominal or anorectal pain with inconsistent presentations. Controversy exists regarding the type of surgical treatment in case of anorectal perforation. More research is needed to provide surgeons with evidence-based standardized methods for dealing with these rare pathologies.