IntroductionAs hospitals strive to reduce their environmental footprint, there is an ongoing debate over the environmental implications of reusable versus disposable linens in operating rooms (ORs). This research aimed to compare the environmental impact of reusable versus single-use OR bed covers and lift sheets using life cycle assessment (LCA) methodology.MethodsLCA is an established tool with rigorous methodology that uses science-based processes to measure environmental impact. This study compared the impacts of three independent system scenarios at a single large academic hospital: reusable bed covers with 50 laundry cycles and subsequent landfill disposal (System 1), single-use bed covers with waste landfill disposal (System 2), and single-use bed covers with waste disposal using incineration (System 3).ResultsThe total carbon footprint of System 1 for 50 uses was 19.83 ​kg carbon dioxide equivalents (CO2-eq). System 2 generated 64.99 ​kg CO2-eq. For System 3, the total carbon footprint was 108.98 ​kg CO2-eq. The raw material extraction for all the material to produce an equivalent 50 single-use OR bed cover kits was tenfold more carbon-intensive than the reusable bed cover. Laundering one reusable OR bed cover 50 times was more carbon intensive (12.12 ​kg CO2-eq) than landfill disposal of 50 single-use OR bed covers (2.52 ​kg CO2-eq).DiscussionOur analysis demonstrates that one reusable fabric-based OR bed cover laundered 50 times, despite the carbon and water-intensive laundering process, exhibits a markedly lower carbon footprint than its single-use counterparts. The net difference is 45.16 ​kg CO2-eq, equivalent to driving 115 miles in an average gasoline-powered passenger vehicle. This stark contrast underscores the efficacy of adopting reusable solutions to mitigate environmental impact within healthcare facilities.

Diversity in the health care workforce plays an important role in reducing health disparities, promotes innovative research to address health access and outcomes of marginalized communities, and has been linked to better patient outcomes.1 Nevertheless, women and underrepresented minorities (URM), including individuals from certain racial or ethnic backgrounds, religious groups, sexual orientations, and those with disabilities, to name a few, remain disproportionately underrepresented in gastroenterology.

OBJECTIVES:It is unclear whether improvements in the delivery of trauma care over the last decade have diminished racial disparities in mortality after firearm injuries. METHODS:The American College of Surgeons Trauma Quality Improvement Program was queried for patients (≥18 years old) who experienced penetrating firearm assault injuries between 2008 and 2018. Multivariable logistic regression was used to assess the association between mortality and race, controlling for demographics, comorbidities, shock index, injury severity score injury location, and hospital characteristics. RESULTS:This retrospective cohort study included 261,116 patients who experienced firearm injuries secondary to assault between 2008 and 2018. Patients most frequently identified as Black (64.1%, n = 167,494), followed by White (16.3%, n = 42,649), Hispanic/Latino (15.7%, n = 41,044), and other racial groups (3.8%, n = 9,929). On multivariable logistic regression, Black patients (odds ratio, 1.53; 95% confidence interval, 1.45-1.62), and Hispanic/Latino patients (odds ratio, 1.11; 95% confidence interval, 1.03-1.19) were more likely to die after a firearm assault injury than White patients. Black patients were more likely to die in the emergency department (62.2%, n = 13,438) compared with White patients (52.7%, n = 2,838), Hispanic/Latino patients (53.0%, n = 2,635), and patients of other races (54.8%, n = 681). Across all years of the study period, Black patients had a greater risk-adjusted mortality rate than White patients and Hispanic/Latino patients. CONCLUSION:Significant racial disparities in mortality after firearm assault continue to persist. Early death within the emergency department appears to be a significant driver of these persistent disparities.

OBJECTIVESince the inception of Ken Lee Memorial Fellowship (KLMF) in 2013, our institution has achieved 10 years of trainee led sustainability projects. The ability of health care organizations to drive sustainability depends on organizational and human capacity. This qualitative study presents the first decade of sustainability fellows’ projects, the challenges associated with implementing them, and the environmental and cost impact of these initiatives.DESIGN, SETTING, PARTICIPANTSAll residents in the General Surgery residency program at the Cleveland Clinic, a quaternary hospital, regardless of postgraduate year (PGY) level, are invited to apply for the KLMF program with a short project proposal. One fellow is selected per year. Each project since the program's inception was reviewed qualitatively, relying on data derived from observation, interview of prior fellows, and supervising staff, and analysis of documentation from the annual fellow presentation and abstract, Grand Rounds recording, and fellowship leadership.RESULTSA targeted approach by each sustainability fellow is encouraged, with the following action cycle for change implementation throughout the 1-year fellowship: identification and discovery of an issue, collaborative planning of an intervention, implementation of the intervention, and evaluation. Projects range from water and waste reduction to education of surgical staff, with positive implications for environmental stewardship in our hospital. However, multiple barriers to completing, scaling, and maintaining sustainability initiatives remain, as demonstrated by challenges faced by our Ken Lee Fellows.CONCLUSIONSOur goal is that this intensive educational experience within the framework of a graduate medical education curriculum will ensure future generations of surgeons who are thoughtful leaders in environmental stewardship.

BACKGROUND Recent studies have evaluated outcomes associated with duration of antimicrobial treatment for complicated intra-abdominal infections (cIAI). The goal of this guideline was to help clinicians better define appropriate antimicrobial duration in patients who have undergone definitive source control for cIAI. METHODS A working group of Eastern Association for the Surgery of Trauma (EAST) performed a systematic review and meta-analyses of the available data pertaining to the duration of antibiotics after definitive source control of cIAI in adult patients. Only studies that compared patients treated with short vs. long duration antibiotic regimens were included. The critical outcomes of interest were selected by the group. Noninferiority of short compared with long duration of antimicrobial treatment was defined as an indicator for a potential recommendation in favor of shorter antibiotics course. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of the evidence and to formulate recommendations. RESULTS Sixteen studies were included. The short duration ranged from 1 dose to ≤10 days, with an average of 4 days, and the long duration ranged >1 day to 28 days, with an average of 8 days. There were no differences between short and long duration of antibiotics in terms of mortality (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.56–1.44), rate of surgical site infection (OR, 0.88; 95% CI, 0.56–1.38); persistent/recurrent abscess (OR, 0.76; 95% CI, 0.45–1.29); unplanned interventions (OR, 0.53; 95% CI, 0.12–2.26); hospital length of stay (mean difference, −2.62 days; CI, −7.08 to 1.83 days); or readmissions (OR, 0.92; 95% CI, 0.50–1.69). The level of evidence was assessed as very low. CONCLUSION The group made a recommendation for shorter (four or less days) versus longer duration (eight or more days) of antimicrobial treatment in adult patients with cIAIs who had definitive source control. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.

We present a case of a 48-year-old patient with multiple penetrating stab wounds of the heart after a suicide attempt with a nail gun. The patient was admitted in stable condition. A chest radiograph (Figure 1A) and computed tomography scan (Figures 1B, 1C [Ao, aorta; LA, left atrium]) revealed 21 nails penetrating the heart and major vascular structures.

OBJECTIVE: The healthcare system accounts for 8%-10% of all greenhouse gas emissions in the United States and hospital buildings are significant contributors. Operating rooms account for 20%-33% of all hospital waste. This may contribute to significant climate change and negatively affect public health. Physicians and surgeons must act to reduce our collective carbon footprint to improve the health of our patients. The traditional graduate medical education curriculum does not routinely train future generations of physicians in healthcare sustain ability. We describes a fellowship program designed to change this. DESIGN AND SETTING: The Cleveland Clinic surgical residency has implemented a unique educational program. Here we describe the 5-year results of our novel fellowship program in health care sustainability, primarily focused on greening the operating room. PARTICIPANTS: Selected General Surgery residents interested in healthcare sustainability and greening the operating room. RESULTS: We have successfully implemented a novel resident focused fellowship program in healthcare sustainability. Fellowship projects have led to significant reductions in our hospitals' collective carbon footprint. CONCLUSIONS: Surgeons have a unique responsibility to reduce the carbon footprint of the Operating Room. Implementing a dedicated fellowship program or similar intensive educational experience in healthcare sustain ability within the framework of a graduate medical education curriculum will help to ensure future generations of surgeons are thoughtful leaders in environmental stewardship. (C) 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Background Antibiotic prophylaxis is routinely administered for most operative procedures, but their utility for certain bedside procedures remains controversial. We performed a systematic review and meta-analysis and developed evidence-based recommendations on whether trauma patients receiving tube thoracostomy (TT) for traumatic hemothorax or pneumothorax should receive antibiotic prophylaxis. Methods Published literature was searched through MEDLINE (via PubMed), Embase (via Elsevier), Cochrane Central Register of Controlled Trials (via Wiley), Web of Science and ClinicalTrials.gov databases by a professional librarian. The date ranges for our literature search were January 1900 to March 2020. A systematic review and meta-analysis of currently available evidence were performed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Results Fourteen relevant studies were identified and analyzed. All but one were prospective, with eight being prospective randomized control studies. Antibiotic prophylaxis protocols ranged from a single dose at insertion to 48 hours post-TT removal. The pooled data showed that patients who received antibiotic prophylaxis were significantly less likely to develop empyema (OR 0.47, 95% CI 0.25 to 0.86, p=0.01). The benefit was greater in patients with penetrating injuries (penetrating OR 0.25, 95% CI 0.10 to 0.59, p=0.002, vs blunt OR 0.25, 95% CI 0.06 to 1.12, p=0.07). Administration of antibiotic prophylaxis did not significantly affect pneumonia incidence or mortality. Discussion In adult trauma patients who require TT insertion, we conditionally recommend antibiotic prophylaxis be given at the time of insertion to reduce incidence of empyema. PROSPERO registration number CRD42018088759.

Introduction: Postoperative respiratory failure (PRF) contributes significantly to morbidity and mortality. We sought to identify patient characteristics and perioperative risk factors associated with PRF in patients undergoing elective abdominal surgery to improve patient outcomes. Methods: We retrospectively reviewed patients undergoing elective abdominal surgery from 2011 to 2016 at our institution. An experimental group consisting of adult patients with the Patient Safety Indicator 11 diagnosis of PRF was compared with a time-matched control group. Results: Each group consisted of 233 patients. Comorbidities associated with PRF included ascites, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus type II, hypertension, and hypoalbuminemia (P < 0.05). American Society of Anesthesiologists score IV (20.2% versus 3.95%; P < 0.001), operative time (4.13 versus 2.55 h; P < 0.001), laparotomy with open operation (77.7% versus 45.5%; P < 0.001), and net intraoperative fluid balance (3635 versus 2410 mL; P < 0.001) were higher in patients with PRF. On multivariate analysis, age, American Society of Anesthesiologists score, chronic obstructive pulmonary disease, diabetes mellitus type II, laparotomy, and net intraoperative fluid balance maintained significance (P < 0.05). Conclusions: We identified contributing pre- and intra-operative risk factors for PRF undergoing elective abdominal surgery. These findings may help identify those at increased risk for respiratory failure and mitigate complications. (c) 2022 Elsevier Inc. All rights reserved.

Because of its energy intensive requirements and multi-disciplinary interdependencies, perioperative care, including surgery, anesthesia, and pathology, is one of the greatest contributors to the direct greenhouse gas emissions of healthcare systems. By reducing this contribution, the paradox of harming human health through the delivery of healthcare services can be addressed. Energy use and waste generation are the main underlying factors contributing to these downstream health harms of providing surgical care. On-site energy is consumed primarily by heating ventilation and air conditioning systems, lighting, and equipment. A variety of different types of waste are also generated on-site, including regulated medical waste, healthcare plastic and packaging waste, single-use devices, anesthetic gasses, medication, chemicals, and water. In this review, we discuss practical ways to reduce direct energy use and decrease and avoid waste generation during the surgical experience. Following these environmental best practices supports triple bottom line performance, which delivers significant financial, environmental, and social benefits.

A well-respected surgical professor is the invited speaker for a conference at a large academic surgical department. As part of the events, there is a meet-and-greet to allow residents, fellows, and faculty speak with the professor. Dr. Z is a junior surgeon second-generation American citizen of Ecuadorean descent. The professor turns to Dr. Z and says, “you know, I told my fellow Mohammad to change his name to Matt so he could get a chief job.” The group of residents appear uncomfortable, but no one says anything in response.

Traumatic brain injury (TBI) is acquired from a preceding traumatic event causing injury to the brain. Injuries can be transient or permanent, and focal or diffuse and are generally classified as mild, moderate, or severe. It is a multidisciplinary disease that frequently involves the care and expertise of trauma surgeons, neurosurgeons, neurologists, critical care intensivists, physiatrists, and a host of ancillary specialists. The often acute and changing nature of the disease requires that providers are adept at diagnosis and treatment. Frequently, care delivery and coordination rest on the shoulders of the intensivist. As such, critical care providers should have a firm grasp on the basic principles of brain injury, resuscitation, and treatment.

INTRODUCTION:Ciliated hepatic foregut cysts (CHFC) are rare congenital hepatic lesions derived from the embryonic foregut. Because of potential transformation to squamous cell carcinoma in adulthood, the mainstay of therapy is surgical resection. To our knowledge, we report the first case of CHFC in a child that was successfully excised laparoscopically. PRESENTATION OF CASE:We report a case of a 4-year-old boy that was diagnosed with an asymptomatic 5-cm liver cyst. After surveillance for 3 years, the cyst grew to 7 cm at which time it was successfully resected laparoscopically. The pathology was consistent with CHFC. DISCUSSION:There have been few previous reports of CHFCs in children, all of which described excision via a laparotomy. This is the first case report of laparoscopic resection of CHFC in a child. CONCLUSION:This case report suggests that laparoscopy may be safe and effective for resection of CHFCs with favorable anatomy such as peripheral location and noninvolvement of key vascular and biliary structures.

Sickle-cell trait is a common genetic abnormality in the African American population. A sickle-cell crisis in a patient with sickle-cell trait is uncommon at best. Abdominal painful crises are typical of patients with sickle cell anemia. The treatment for an abdominal painful crisis is usually medical and rarely surgical. We present the case of a cocaine-induced sickle-cell crisis in a sickle-cell trait patient that resulted in splenic, intestinal, and cerebral infarctions and multisystem organ failure necessitating a splenectomy, subtotal colectomy, and small bowel resection. This case highlights the diagnostic dilemma that abdominal pain can present in the sickle-cell population and illustrates the importance of recognizing the potential for traditionally medically managed illnesses to become surgical emergencies.

Chagas disease, caused by infection with the protozoan parasite Trypanosoma cruzi, is a major public health problem in Central and South America. The pathogenesis of Chagas disease is complex and the natural course of infection is not completely understood. The recent development of bioluminescence imaging technology has facilitated studies of a number of infectious and non-infectious diseases. We developed luminescent T. cruzi to facilitate similar studies of Chagas disease pathogenesis. Luminescent T. cruzi trypomastigotes and amastigotes were imaged in infections of rat myoblast cultures, which demonstrated a clear correlation of photon emission signal strength to the number of parasites used. This was also observed in mice infected with different numbers of luminescent parasites, where a stringent correlation of photon emission to parasite number was observed early at the site of inoculation, followed by dissemination of parasites to different sites over the course of a 25-day infection. Whole animal imaging from ventral, dorsal and lateral perspectives provided clear evidence of parasite dissemination. The tissue distribution of T. cruzi was further determined by imaging heart, spleen, skeletal muscle, lungs, kidneys, liver and intestines ex vivo. These results illustrate the natural dissemination of T. cruzi during infection and unveil a new tool for studying a number of aspects of Chagas disease, including rapid in vitro screening of potential therapeutical agents, roles of parasite and host factors in the outcome of infection, and analysis of differential tissue tropism in various parasite-host strain combinations.

The flagellar calcium-binding protein (FCaBP) of the flagellated protozoan Trypanosoma cruzi associates with the flagellar mem- brane via its N-terminal myristate and palmitate moieties in a cal- cium-modulated, conformation-dependent manner. This mecha- nism of localization is similar to that described for neuronal calcium sensors, which undergo calcium-dependent changes in conforma- tion, which modulate the availability of the acyl groups for mem- brane interaction and partner association. To test whether FCaBP undergoes a calcium-dependent conformational change and to explore the role of such a change in flagellar targeting, we first intro- duced point mutations into each of the two EF-hand calcium-bind- ing sites of FCaBP to define their affinities. Analysis of recombinant EF-3 mutant (E151Q), EF-4 mutant (E188Q), and double mutant proteins showed EF-3 to be the high affinity site (Kd 9 M) and EF-4 the low affinity site (Kd 120 M). These assignments also correlated with partial (E188Q), nearly complete (E151Q), and complete (E151Q,E188Q) disruption of calcium-induced confor- mational changes determined by NMR spectrometry. We next expressed the FCaBP E151Q mutant and the double mutant in T. cruzi epimastigotes. These transproteins localized to the flagellum, suggesting the existence of a calcium-dependent interaction of FCaBP that is independent of its intrinsic calcium binding capacity. Several proteins were identified by FCaBP affinity chromatography that interact with FCaBP in a calcium-dependent manner, but with differential dependence on calcium-binding by FCaBP. These find- ings may have broader implications for the calcium acyl switch mechanism of protein regulation.