Summa Akron City Hospital

IMPORTANCE: Hereditary cancer syndromes infer high cancer risks and require intensive cancer surveillance, yet the prevalence and spectrum of these conditions among unselected patients with early-onset colorectal cancer (CRC) is largely undetermined. OBJECTIVE: To determine the frequency and spectrum of cancer susceptibility gene mutations among patients with early-onset CRC. DESIGN, SETTING, AND PARTICIPANTS: Overall, 450 patients diagnosed with colorectal cancer younger than 50 years were prospectively accrued from 51 hospitals into the Ohio Colorectal Cancer Prevention Initiative from January 1, 2013, to June 20, 2016. Mismatch repair (MMR) deficiency was determined by microsatellite instability and/or immunohistochemistry. Germline DNA was tested for mutations in 25 cancer susceptibility genes using next-generation sequencing. MAIN OUTCOMES AND MEASURES: Mutation prevalence and spectrum in patients with early-onset CRC was determined. Clinical characteristics were assessed by mutation status. RESULTS: In total 450 patients younger than 50 years were included in the study, and 75 gene mutations were found in 72 patients (16%). Forty-eight patients (10.7%) had MMR-deficient tumors, and 40 patients (83.3%) had at least 1 gene mutation: 37 had Lynch syndrome (13, MLH1 [including one with constitutional MLH1 methylation]; 16, MSH2; 1, MSH2/monoallelic MUTYH; 2, MSH6; 5, PMS2); 1 patient had the APC c.3920T>A, p.I1307K mutation and a PMS2 variant; 9 patients (18.8%) had double somatic MMR mutations (including 2 with germline biallelic MUTYH mutations); and 1 patient had somatic MLH1 methylation. Four hundred two patients (89.3%) had MMR-proficient tumors, and 32 patients (8%) had at least 1 gene mutation: 9 had mutations in high-penetrance CRC genes (5, APC; 1, APC/PMS2; 2, biallelic MUTYH; 1, SMAD4); 13 patients had mutations in high- or moderate-penetrance genes not traditionally associated with CRC (3, ATM; 1, ATM/CHEK2; 2, BRCA1; 4, BRCA2; 1, CDKN2A; 2, PALB2); 10 patients had mutations in low-penetrance CRC genes (3, APC c.3920T>A, p.I1307K; 7, monoallelic MUTYH). Importantly, 24 of 72 patients (33.3%) who were mutation positive did not meet established genetic testing criteria for the gene(s) in which they had a mutation. CONCLUSIONS AND RELEVANCE: Of 450 patients with early-onset CRC, 72 (16%) had gene mutations. Given the high frequency and wide spectrum of mutations, genetic counseling and testing with a multigene panel could be considered for all patients with early-onset CRC.

RATIONALE: We recently reported two novel biomarkers for acute kidney injury (AKI), tissue inhibitor of metalloproteinases (TIMP)-2 and insulin-like growth factor binding protein 7 (IGFBP7), both related to G1 cell cycle arrest. OBJECTIVES: We now validate a clinical test for urinary [TIMP-2]·[IGFBP7] at a high-sensitivity cutoff greater than 0.3 for AKI risk stratification in a diverse population of critically ill patients. METHODS: We conducted a prospective multicenter study of 420 critically ill patients. The primary analysis was the ability of urinary [TIMP-2]·[IGFBP7] to predict moderate to severe AKI within 12 hours. AKI was adjudicated by a committee of three independent expert nephrologists who were masked to the results of the test. MEASUREMENTS AND MAIN RESULTS: Urinary TIMP-2 and IGFBP7 were measured using a clinical immunoassay platform. The primary endpoint was reached in 17% of patients. For a single urinary [TIMP-2]·[IGFBP7] test, sensitivity at the prespecified high-sensitivity cutoff of 0.3 (ng/ml)(2)/1,000 was 92% (95% confidence interval [CI], 85-98%) with a negative likelihood ratio of 0.18 (95% CI, 0.06-0.33). Critically ill patients with urinary [TIMP-2]·[IGFBP7] greater than 0.3 had seven times the risk for AKI (95% CI, 4-22) compared with critically ill patients with a test result below 0.3. In a multivariate model including clinical information, urinary [TIMP-2]·[IGFBP7] remained statistically significant and a strong predictor of AKI (area under the curve, 0.70, 95% CI, 0.63-0.76 for clinical variables alone, vs. area under the curve, 0.86, 95% CI, 0.80-0.90 for clinical variables plus [TIMP-2]·[IGFBP7]). CONCLUSIONS: Urinary [TIMP-2]·[IGFBP7] greater than 0.3 (ng/ml)(2)/1,000 identifies patients at risk for imminent AKI. Clinical trial registered with www.clinicaltrials.gov (NCT 01573962).

Importance: Optimizing radiation therapy techniques for localized prostate cancer can affect patient outcomes. Dose escalation improves biochemical control, but no prior trials were powered to detect overall survival (OS) differences. Objective: To determine whether radiation dose escalation to 79.2 Gy compared with 70.2 Gy would improve OS and other outcomes in prostate cancer. Design, Setting, and Participants: The NRG Oncology/RTOG 0126 randomized clinical trial randomized 1532 patients from 104 North American Radiation Therapy Oncology Group institutions March 2002 through August 2008. Men with stage cT1b to T2b, Gleason score 2 to 6, and prostate-specific antigen (PSA) level of 10 or greater and less than 20 or Gleason score of 7 and PSA less than 15 received 3-dimensional conformal radiation therapy or intensity-modulated radiation therapy to 79.2 Gy in 44 fractions or 70.2 Gy in 39 fractions. Main Outcomes and Measures: Time to OS measured from randomization to death due to any cause. American Society for Therapeutic Radiology and Oncology (ASTRO)/Phoenix definitions were used for biochemical failure. Acute (≤90 days of treatment start) and late radiation therapy toxic effects (>90 days) were graded using the National Cancer Institute Common Toxicity Criteria, version 2.0, and the RTOG/European Organisation for the Research and Treatment of Cancer Late Radiation Morbidity Scoring Scheme, respectively. Results: With a median follow-up of 8.4 (range, 0.02-13.0) years in 1499 patients (median [range] age, 71 [33-87] years; 70% had PSA <10 ng/mL, 84% Gleason score of 7, 57% T1 disease), there was no difference in OS between the 751 men in the 79.2-Gy arm and the 748 men in the 70.2-Gy arm. The 8-year rates of OS were 76% with 79.2 Gy and 75% with 70.2 Gy (hazard ratio [HR], 1.00; 95% CI, 0.83-1.20; P = .98). The 8-year cumulative rates of distant metastases were 4% for the 79.2-Gy arm and 6% for the 70.2-Gy arm (HR, 0.65; 95% CI, 0.42-1.01; P = .05). The ASTRO and Phoenix biochemical failure rates at 5 and 8 years were 31% and 20% with 79.2 Gy and 47% and 35% with 70.2 Gy, respectively (both P < .001; ASTRO: HR, 0.59; 95% CI, 0.50-0.70; Phoenix: HR, 0.54; 95% CI, 0.44-0.65). The high-dose arm had a lower rate of salvage therapy use. The 5-year rates of late grade 2 or greater gastrointestinal and/or genitourinary toxic effects were 21% and 12% with 79.2 Gy and 15% and 7% with 70.2 Gy (P = .006 [HR, 1.39; 95% CI, 1.10-1.77] and P = .003 [HR, 1.59; 95% CI, 1.17-2.16], respectively). Conclusions and Relevance: Despite improvements in biochemical failure and distant metastases, dose escalation did not improve OS. High doses caused more late toxic effects but lower rates of salvage therapy. Trial Registration: clinicaltrials.gov Identifier: NCT00033631.

Central venous access is a common procedure performed in many clinical settings for a variety of indications. Central lines are not without risk, and there are a multitude of complications that are associated with their placement. Complications can present in an immediate or delayed fashion and vary based on type of central venous access. Significant morbidity and mortality can result from complications related to central venous access. These complications can cause a significant healthcare burden in cost, hospital days, and patient quality of life. Advances in imaging, access technique, and medical devices have reduced and altered the types of complications encountered in clinical practice; but most complications still center around vascular injury, infection, and misplacement. Recognition and management of central line complications is important when caring for patients with vascular access, but prevention is the ultimate goal. This article discusses common and rare complications associated with central venous access, as well as techniques to recognize, manage, and prevent complications.

Cases of Legionnaires' disease have been categorized as definitive and presumptive. The sensitivity and specificity of antibody titers of > or = 256 and of urinary antigen ratios of > or = 3 were evaluated in 68 patients with "definitive" Legionnaires' disease and in 636 patients with pneumonia who had negative cultures and did not have fourfold rises in titers of antibody to Legionella pneumophila. An acute-phase antibody titer of > or = 256 did not discriminate between cases and noncases (10% vs. 6%; P = .29). The urinary antigen assay gave a positive result in fewer than 1% of noncases but was positive in 55.9% of all cases. This assay was most sensitive (80%) in cases in which L. pneumophila serogroup 1 was isolated. We propose that the case definition for definitive Legionnaires' disease be expanded to include positive urinary antigen assays and that the category of presumptive Legionnaires' disease--based on acute-phase or standing antibody titers of > or = 256 in the nonoutbreak setting--be discarded. The urinary antigen assay will be a valuable tool in the prompt diagnosis of Legionnaires' disease.

Thirty-nine patients who had a malignant or an aggressive benign bone tumor about the knee were managed with a resection arthrodesis with use of an intercalary allograft fixed with an intramedullary nail. In thirty-one patients, this was the method chosen for the initial reconstruction after resection of the tumor. In eight patients, another type of reconstruction had already failed. Both the proximal and the distal allograft-host junction healed and the functional outcome was satisfactory in thirty-two patients. Non-union developed in seven patients: at one junction in six patients and at both junctions in one. In five patients, the non-union healed after bone-grafting, repeat internal fixation, or replacement of the allograft. An above-the-knee amputation was done for two patients, both of whom had had a chronic non-union. One patient had a local recurrence, and it was treated with an above-the-knee amputation.

Abstract Infections in pregnancy with Ureaplasma urealyticum have been associated with a wide range of adverse outcomes, such as early abortion, stillbirth, prematurity, and neonatal morbidity and mortality. Causality has been difficult to demonstrate secondary to the high prevalence of asymptomatic lower genital tract (LGT) colonization and culture data from inaccessible or potentially contaminated sites. Between 1985 and 1989, 2461 second‐trimester genetic amniocenteses were evaluated at the cytogenetics section of the Children's Hospital Medical Center of Akron. All were cultured for the genital mycoplasmas: Mycoplasma hominis and Ureaplasma urealyticum . A total of nine patients were positive, all for Ureaplasma urealyticum , with one patient excluded because of subsequent therapeutic abortion. In addition, complete follow‐up data, such as indication for amniocentesis, serum alpha‐fetoprotein levels, gestational age at parturition, and out‐ come of pregnancy, were available on 86 Ureaplasma ‐negative (U –) patients during an approximate 2‐year span within the time‐frame of the study. This was in part due to physician response to a questionnaire sent after amniocentesis. Of the eight positive cultures, 100 per cent were associated with an adverse outcome, defined as fetal loss or premature delivery. This was significant compared with the U–group ( p &lt;0.001) with a more than eight times greater risk of adverse outcome. Six (75 per cent) resulted in spontaneous miscarriage within 4 weeks of amniocentesis and at less than 21 weeks' gestation. Two (25 per cent) delivered prematurely, with one (12.5 per cent) neonatal death at 24+ weeks. Histological examination of all eight placentae and the seven fetuses revealed a 100 per cent incidence of chorioamnionitis and pneumonia, respectively. In addition, in four of the five cases (80 per cent), cultures were positive for Ureaplasma urealyticum in pure culture from either placenta, fetal lung, or both tissues. The remaining case (20 per cent) was negative for aerobes, anaerobes, and mycoplasmas. The study demonstrates a significant association and supports a causal relationship between isolation of Ureaplasma from mid‐trimester amniotic fluid with fetal wastage and premature birth.

SEVERAL reports describing complications directly related to subclavian venipuncture have appeared in the literature.1 2 3 Although air embolus has been mentioned as a possible complication,1 , 4 this is the first documented fatal case to be reported.Case ReportLaparotomy on a 64-year-old dehydrated man showed metastatic carcinoma of the stomach with perforation and gastric-outlet obstruction. Surgical repair of the gastric perforation was performed.To assist postoperative fluid administration, a long central-venous-pressure (CVP) catheter was inserted into the brachial vein by percutaneous puncture at the antecubital fossa. Initial and subsequent CVP determinations were persistently in the range of -3 cm of water. The . . .

In the United States and around the world, effective, efficient, and reliable strategies to provide emergency care to aging adults is challenging crowded emergency departments (EDs) and strained healthcare systems. In response, geriatric emergency medicine clinicians, educators, and researchers collaborated with the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine to develop guidelines intended to improve ED geriatric care by enhancing expertise, educational, and quality improvement expectations, equipment, policies, and protocols. These Geriatric Emergency Department Guidelines represent the first formal society-led attempt to characterize the essential attributes of the geriatric ED and received formal approval from the boards of directors of each of the four societies in 2013 and 2014. This article is intended to introduce emergency medicine and geriatric healthcare providers to the guidelines while providing recommendations for continued refinement of these proposals through educational dissemination, formal effectiveness evaluations, cost-effectiveness studies, and eventually institutional credentialing.

Bacterial skin infections occur commonly and range in severity from mild to life threatening. The severity of skin infections, and their management and prognosis, can depend on the mechanism of infection, the skin structures involved and the infecting organism or organisms. Primary skin infections result from invasion of microorganisms through tiny breaks in the epidermis or from the spread of microorganisms through the bloodstream. Secondary infections arise from pre-existing trauma, burns or surgical wounds; infections involving the soft tissues underlying the skin are also discussed. These also frequently occur in areas of trauma, operation or ischemia. The cause, bacteriologic factors and management of skin infections were studied, with special attention to pyodermas, infections of the foot in diabetic patients and necrotizing soft tissue infections. Choice of appropriate antibiotic agents depends in large part on the infecting organism and patterns of antibiotic susceptibility. In necrotizing soft tissue infections, survival or limb salvage may depend on prompt surgical intervention. In these instances and in some of advanced primary skin infections in which bacteremia is involved, parenteral antibiotics are required. The available options are discussed and a report on the data with the combination agent ticarcillin disodium and clavulanate potassium is presented.

The effect of the quality of the bone and of the cement pressurization magnitude and duration on the fixation achieved with polymethylmethacrylate (PMMA) bone cement is studied in vitro. Seventy-one cement-bone interface specimens, prepared under various conditions of pressurization of low-viscosity bone cement, are tested in tension. The load at failure and the maximum cement penetration are measured to assess the fixation achieved, and the quality of the bone is assessed by determining the compressive strength of each of the bone specimens. Statistical analysis of the data indicates that the pressure magnitude is the most influential of the factors considered in the cement penetration behavior and in the development of failure load capacity. The duration of the pressure does not appear to be a significant factor. The cement penetration is a decreasing function of the bone strength, reflecting a decrease in the porosity and an increase in the area fraction. Although not directly measured in these tests, these latter bone properties are indirectly measured by the bone compressive strength. The effect of increasing bone strength on the failure load is nonlinear. The development of adequate failure load capacity is the result of a balance between the cement penetration allowed by the porosity of the bone and the inherent strength of the cancellous bone itself. Weak bone, although adequately penetrated by cement, cannot provide strong fixation. Stronger, denser bone limits cement penetration, but pressurization enhances development of failure load capacity through more complete infusion and interlocking of the cement in the available pore space. The strength of the fixation achievable for any bone is limited by the intrinsic strength of the bone.(ABSTRACT TRUNCATED AT 250 WORDS)

A retrospective review of 299 total knee arthroplasties performed between 1973 and 1983 revealed 170 knees in which postoperative suction drainage was used and 129 knees in which drains were not used. Comparison between these two groups revealed no statistically significant difference in wound problems, postoperative temperatures, or resulting range of motion. However, blood transfusions were given more than twice as often to the patients whose knees were drained (39% compared to 16%, p less than .01). The drained group also had a greater decrease in hemoglobin than the nondrained group (3.1 gm compared to 2.6 gm, p less than .01). In a review of these patients, no advantage was found for the use of postoperative suction drainage in the uncomplicated total knee arthroplasty.

PURPOSE In oncology trials, the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) is the standard tool for reporting adverse events (AEs), but it may underreport symptoms experienced by patients. This analysis of the NRG Oncology RTOG 1203 compared symptom reporting by patients and clinicians during radiotherapy (RT). PATIENTS AND METHODS Patients with cervical or endometrial cancer requiring postoperative RT were randomly assigned to standard 4-field RT or intensity-modulated RT (IMRT). Patients completed the 6-item patient-reported outcomes version of the CTCAE (PRO-CTCAE) for GI toxicity assessing abdominal pain, diarrhea, and fecal incontinence at various time points. Patients reported symptoms on a 5-point scale. Clinicians recorded these AEs as CTCAE grades 1 to 5. Clinician- and patient-reported AEs were compared using McNemar’s test for rates &gt; 0%. RESULTS Of 278 eligible patients, 234 consented and completed the PRO-CTCAE. Patients reported high-grade abdominal pain 19.1% ( P &lt; .0001), high-grade diarrhea 38.5% ( P &lt; .0001), and fecal incontinence 6.8% more frequently than clinicians. Similar effects were seen between grade ≥ 1 CTCAE toxicity and any-grade patient-reported toxicity. Between-arm comparison of patient-reported high-grade AEs revealed that at 5 weeks of RT, patients who received IMRT experienced fewer GI AEs than patients who received 4-field pelvic RT with regard to frequency of diarrhea (18.2% difference; P = .01), frequency of fecal incontinence (8.2% difference; P = .01), and interference of fecal incontinence (8.5% difference; P = .04). CONCLUSION Patient-reported AEs showed a reduction in symptoms with IMRT compared with standard RT, whereas clinician-reported AEs revealed no difference. Clinicians also underreported symptomatic GI AEs compared with patients. This suggests that patient-reported symptomatic AEs are important to assess in this disease setting.

Cognitive impairment is common in heart failure (HF) and believed to be the result of cerebral hypoperfusion and subsequent brain changes including white matter hyperintensities (WMHs). The current study examined the association between cerebral blood flow and WMHs in patients with HF and the relationship between WMHs and cognitive impairment. Sixty-nine patients with HF completed the Mini-Mental State Examination (MMSE) and underwent echocardiography, transcranial Doppler sonography for cerebral blood flow velocity of the middle cerebral artery, and brain magnetic resonance imaging. Multivariable hierarchical regression analyses controlling for medical and demographic characteristics as well as intracranial volume showed reduced cerebral blood flow velocity of the middle cerebral artery was associated with greater WMHs (β=-0.34, P=.02). Follow-up regression analyses adjusting for the same medical and demographic factors in addition to cerebral perfusion also revealed marginal significance between increased WMHs and poorer performance on the MMSE (β=-0.26, P=.05). This study suggests that reduced cerebral perfusion is associated with greater WMHs in older adults with HF. These findings support the widely proposed mechanism of cognitive impairment in HF patients and prospective studies are needed to confirm these results.

We investigated stress, coping, and employment status in 92, mostly European American pregnant women. Conservation of Resources (COR) theory (Hobfoll, 1988, 1989) was applied as a specification of role-quality theory to examine the stressful influences of women's multiple roles. Women's resource loss predicted psychological distress better than either their resource gains or their employment status (i.e., multiple versus single roles). Full-time employed women were significantly more distressed under high loss conditions than were part-time or nonemployed women. Examining women's coping strategies based on a communal model of coping, we found that active, prosocial coping was associated with better emotional outcomes. A significant interaction was found for the effects of loss × cautious action such that loss was related to greater depression, but only among women who did not employ cautious action.

Importance: Spine metastasis can be treated with high-dose radiation therapy with advanced delivery technology for long-term tumor and pain control. Objective: To assess whether patient-reported pain relief was improved with stereotactic radiosurgery (SRS) as compared with conventional external beam radiotherapy (cEBRT) for patients with 1 to 3 sites of vertebral metastases. Design, Setting, and Participants: In this randomized clinical trial, patients with 1 to 3 vertebral metastases were randomized 2:1 to the SRS or cEBRT groups. This NRG 0631 phase 3 study was performed as multi-institutional enrollment within NRG Oncology. Eligibility criteria included the following: (1) solitary vertebral metastasis, (2) 2 contiguous vertebral levels involved, or (3) maximum of 3 separate sites. Each site may involve up to 2 contiguous vertebral bodies. A total of 353 patients enrolled in the trial, and 339 patients were analyzed. This analysis includes data extracted on March 9, 2020. Interventions: Patients randomized to the SRS group were treated with a single dose of 16 or 18 Gy (to convert to rad, multiply by 100) given to the involved vertebral level(s) only, not including any additional spine levels. Patients assigned to cEBRT were treated with 8 Gy given to the involved vertebra plus 1 additional vertebra above and below. Main Outcomes and Measures: The primary end point was patient-reported pain response defined as at least a 3-point improvement on the Numerical Rating Pain Scale (NRPS) without worsening in pain at the secondary site(s) or the use of pain medication. Secondary end points included treatment-related toxic effects, quality of life, and long-term effects on vertebral bone and spinal cord. Results: A total of 339 patients (mean [SD] age of SRS group vs cEBRT group, respectively, 61.9 [13.1] years vs 63.7 [11.9] years; 114 [54.5%] male in SRS group vs 70 [53.8%] male in cEBRT group) were analyzed. The baseline mean (SD) pain score at the index vertebra was 6.06 (2.61) in the SRS group and 5.88 (2.41) in the cEBRT group. The primary end point of pain response at 3 months favored cEBRT (41.3% for SRS vs 60.5% for cEBRT; difference, -19 percentage points; 95% CI, -32.9 to -5.5; 1-sided P = .99; 2-sided P = .01). Zubrod score (a measure of performance status ranging from 0 to 4, with 0 being fully functional and asymptomatic, and 4 being bedridden) was the significant factor influencing pain response. There were no differences in the proportion of acute or late adverse effects. Vertebral compression fracture at 24 months was 19.5% with SRS and 21.6% with cEBRT (P = .59). There were no spinal cord complications reported at 24 months. Conclusions and Relevance: In this randomized clinical trial, superiority of SRS for the primary end point of patient-reported pain response at 3 months was not found, and there were no spinal cord complications at 2 years after SRS. This finding may inform further investigation of using spine radiosurgery in the setting of oligometastases, where durability of cancer control is essential. Trial Registration: ClinicalTrials.gov Identifier: NCT00922974.

An in vitro study of eight cadaveric knees was conducted to investigate the effect of initial graft tension on the laxity and full three-dimensional kinematics of the anterior cruciate ligament reconstructed knee. A parallel strand, prototype, expanded polytetrafluoroethylene graft (W. L. Gore and Associates, Flagstaff, AZ, U.S.A.) was used. The graft was placed in the over-the-top position with initial tensions of 18, 36, 54, 72, and 90 N applied with the knee in full extension or at 30 degrees of flexion. The motion of the tibia relative to the femur was measured by a 6 degrees-of-freedom spatial linkage, and the applied forces and moments, the quadriceps force, and the graft tension were measured by load cells. Near normal anterior laxity in the Lachman test was restored with all the tested initial graft tensions. However, over constraint, posterior, lateral, and external tibial subluxation, and abnormalities in joint stiffness developed as the initial graft tension increased. Graft tension-related posterior tibial subluxation resulted in an increase in quadriceps force needed to achieve full extension.

OBJECTIVES: The purpose of this study was to determine the concordance of the Broselow tape with the measured heights and weights of a community-based population of children, especially in light of the increase in obesity in today's children. METHODS: The authors examined more than 7,500 children in a cross-sectional, descriptive study in two different cohorts of children to compare their actual weight with their predicted weight by a color-coded tape measure. RESULTS: In all patients, the percent agreement and kappa values of the Broselow color predicted by height versus the actual color by weight for the 2002A tape were 66.2% and 0.61, respectively. The concordance was best in infants, followed by school-age children, toddlers, and preschoolers (kappa = 0.66, 0.44, 0.39, and 0.39, respectively; percent agreement, 81.3%, 58.2%, 60.7%, and 64.0%, respectively). The tapes accurately predicted (within 10%) medication dosages for resuscitation in 55.3%-60.0% of the children. The number of children who were underdosed (by > or =10%) exceeded those who were overdosed (by > or =10%) by 2.5 to 4.4 times (p < 0.05). The tapes accurately predicted uncuffed endotracheal tube sizes when compared with age-based guidelines in 71% of the children, with undersizing (> or =0.5 mm) exceeding oversizing by threefold to fourfold (p < 0.05). CONCLUSIONS: The Broselow tape color-coded system inaccurately predicted actual weight in one third of children. Caregivers need to take into consideration the accuracy of this device when estimating children's weight during the resuscitation of a child.

Autogenous breast reconstruction with the pedicled TRAM flap has been employed in 500 patients in our series. We have developed and refined indications for use of the single-pedicle TRAM flap and double-pedicle TRAM flap in unilateral breast reconstruction. In our experience with 341 unilateral breast reconstructions, we used a double-pedicle TRAM flap 19 percent of the time; however, in our most recent 50 unilateral modified radical mastectomy reconstructions, the double-pedicle technique has been employed 60 percent of the time. In general, when a TRAM flap is chosen for unilateral reconstruction of a modified radical mastectomy defect, we feel the single-pedicle TRAM flap is the procedure of choice. Carefully selected patients will benefit from the added safety of a double-pedicle TRAM procedure. The indications for the double-pedicle TRAM flap, the technique, and our results are described in detail.

In the last two decades there have been dramatic changes in the epidemiology of Clostridium difficile infection (CDI), with increases in incidence and severity of disease in many countries worldwide. The incidence of CDI has also increased in surgical patients. Optimization of management of C difficile, has therefore become increasingly urgent. An international multidisciplinary panel of experts prepared evidenced-based World Society of Emergency Surgery (WSES) guidelines for management of CDI in surgical patients.