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Importance Previous research has suggested that intrawound vancomycin powder reduces deep surgical site infections among patients with periarticular tibial fractures at high risk of infection. It is unknown whether the addition of tobramycin powder further decreases infection rates. Objective To compare whether the combination of tobramycin plus vancomycin vs vancomycin alone delivered as intrawound powder at the time of definitive fixation reduces deep surgical site infections. Design, Setting, and Participants Open-label, assessor-masked, randomized clinical trial conducted at 39 US trauma centers. Eligible patients were adults with an operatively treated periarticular tibial fracture (either tibial plateau or pilon) who met 1 of 3 criteria for elevated infection risk. Enrollment occurred between June 18, 2021, and December 12, 2024 (final follow-up, July 15, 2025). Interventions Intrawound tobramycin (1.2 g) plus vancomycin (1.0 g) powder vs intrawound vancomycin (1.0 g) powder delivered at the time of definitive fixation. Main Outcomes and Measures The primary outcome was a deep surgical site infection requiring surgical management within 182 days of definitive fracture fixation. Secondary outcomes included deep surgical site infections with pathogens that were gram-negative only, deep surgical site infections with at least 1 pathogen that was gram-positive, deep surgical site infections with polymicrobial cultures, deep surgical site infections with negative culture results, and cellulitis or skin infections treated only with antibiotics. Results Among the 1660 participants randomized, 1528 (mean age, 47.0 [SD, 14.3] years; 603 female [39.5%]; 925 male [60.5%]) were included in the primary analysis. Deep surgical site infections occurred in 51 of 753 participants (182-day probability, 7.4%) in the tobramycin plus vancomycin group and 47 of 775 participants (182-day probability, 6.6%) in the vancomycin alone group (hazard ratio, 1.11; 95% bayesian credible interval, 0.75-1.66; posterior probability of superiority, 29.7%). The threshold required for superiority was not reached for any secondary outcome. Conclusions and Relevance Among patients with operatively treated periarticular tibial fractures at high risk of infection, adding intrawound tobramycin powder to vancomycin powder at the time of definitive fixation did not reduce deep surgical site infections compared with vancomycin powder alone. Trial Registration ClinicalTrials.gov Identifier: NCT02227446
Gastric volvulus is a rare but potentially life-threatening complication of a hiatal hernia that can result in gastric ischemia or necrosis if not promptly recognized and treated. A 51-year-old man presented with several hours of severe nausea, vomiting, and chest pain. Physical examination was notable for signs of acute distress, and the patient reported dark-colored emesis. Initial laboratory evaluation demonstrated leukocytosis and elevated serum lactate levels. Computed tomography of the chest and abdomen revealed a large hiatal hernia with herniation of the majority of the stomach into the thoracic cavity and findings concerning for mesoaxial gastric volvulus. Esophagogastroduodenoscopy demonstrated ischemic changes involving the gastric cardia. Given concern for gastric ischemia, the patient underwent urgent surgical intervention, including reduction of the hiatal hernia, cruroplasty reinforced with bio-synthetic mesh, and gastropexy to prevent re-torsion. The patient tolerated the procedure without intraoperative complications and demonstrated clinical improvement postoperatively, with resolution of symptoms and stabilization of laboratory abnormalities. This case highlights the importance of early recognition of gastric volvulus as a complication of a hiatal hernia and underscores the role of prompt imaging and surgical intervention to prevent gastric ischemia and necrosis.
Anxiety is a common concern among patients undergoing endoscopic procedures, affecting up to 70
Purpose/Objective(s) To report the incidence of hypothyroidism, impaired left ventricular ejection fraction (LVEF), and worsening pulmonary function tests (PFTs) following consolidative radiotherapy (RT) for lymphoma at a single institution and compare thyroid outcomes with published data using earlier RT dose paradigms and technologies. Materials/Methods From 1/2017 to 1/2025, 51 pediatric and young adult Hodgkin lymphoma (HL) and Primary Mediastinal B-cell lymphoma (PMBCL) patients who received consolidative RT after systemic therapy were evaluated. Annual thyroid-stimulating hormone (TSH) with reflex free thyroxine (T4) levels were recommended in patients treated with neck/supraclavicular RT. LVEF was measured before RT and during follow-up with frequency specified by anthracycline exposure. PFTs were performed at baseline and 2-3 years after RT and were repeated as needed. Pre-specified treatment planning directives for organs at risk (OAR) were prospectively employed. OAR doses were extracted from RT plans. Results Median follow-up was 4.1 years (Range: 1.0-8.8 years). Median age at RT was 17 years (Range 12-39) and included 47 HL and 4 PMBCL patients. Seven HL patients had early-stage favorable, 5 early-stage unfavorable, and 33 advanced stage disease; all 4 PMBCL patients were Stage IIB-X. Median dose was 30 Gy RBE (Range 20-50) delivered at 1.5-2 Gy per fraction (80.4% intensity modulated proton therapy [IMPT], 17.6% intensity modulated RT [IMRT], 2% 3D conformal RT). Mean dose to the thyroid, heart, and lungs were 10.72 Gy (Range 0-28.43), 5.7 Gy (Range 0-18.9), and 5.28 Gy (Range 0.1-15.61), respectively. The 4-year relapse-free and overall survival rates were 95.6% and 97.8%, respectively. The 4-year estimated rate of hypothyroidism was 4.1%, with two events documented in patients who received a mean thyroid dose of 21 Gy. With low event probabilities, no dosimetric factors were significantly associated with hypothyroidism. Hypothyroidism rates in this series were compared to published data identified by Pubmed search in the table. No patients developed LVEF ≤50% during follow-up; one patient with LVEF 45% before RT improved to 55% after treatment. No patients developed worsening PFTs, defined as a 10% reduction in FEV1, FVC, or DLCO. One patient with restrictive lung disease before RT maintained similar PFTs at 3 years follow-up. Conclusion In this contemporary series, early rates of hypothyroidism were low and compared favorably to historical data. Long-term surveillance is ongoing, but early results underscore the value of modern IMRT/IMPT and pre-specified OAR constraint-based planning to minimize late effects.
