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Background Adrenal incidentalomas are common radiographic findings. Guidelines recommend biochemical and radiographic surveillance of adrenal incidentalomas. We investigated if patients were appropriately referred for outpatient evaluation. Methods Retrospective chart review was performed to identify patients with adrenal masses on imaging between November 7, 2016 and November 7, 2017. Demographic information, medical history, and outpatient referral information was collected. Results 11,723 computed tomography (CT) scans of the chest and/or abdomen/pelvis were performed. 246 patients were noted to have adrenal incidentalomas and met inclusion criteria. The CT report recommended follow-up in 63/246 cases (25.6%). 38/246 (15.4%) patients were referred for evaluation. Age, adrenal nodule size, and type of evaluating provider did not affect referral. A radiology report recommending follow-up was associated with increased referral rate (OR 5.441, 95% CI: 2.491–11.887). Conclusion There was low outpatient referral for adrenal incidentalomas. Language in the radiology report significantly influenced referral rates and may be an important resource for improving guideline adherence.

Educational efforts related to viral hepatitis have the potential to increase awareness and identify chronically infected individuals and can lead to successful vaccination strategies. However, in underserved semirural communities, such as the Korean American community in Killeen, Texas, these outreach activities are lacking. The GanYum (“hepatitis” in Korean) Prevention Project aimed to evaluate thoughts/behaviors, assess vulnerability, and educate Korean Americans on hepatitis B and C. Two outreach events were held at a Korean church and a Korean market (O'Mart) to provide education, screening, and outreach about viral hepatitis. Ninety-six patients were screened at two events. Five patients were found to be positive for hepatitis B surface antigen and were referred to their primary care physicians and the liver clinic at Scott & White Healthcare in Temple, Texas. Fifty-one patients (53%) were found to be immune to hepatitis B, and 40 patients (42%) were hepatitis B vulnerable. We demonstrated that the prevalence of chronic hepatitis B in Koreans in our study is similar to the previously documented prevalence (5%). Our educational efforts were successful in changing perceptions regarding the modes of transmission and exacerbating factors of chronic viral hepatitis and encouraged participants to seek care for their liver diseases, if needed. We found that both venues (the church and Korean market) were appropriate to screen and educate participants; churches seemed to have a more engaged audience.

Background: The mu opioid receptor (MOR) has previously been found to regulate ethanol-stimulated dopamine release under some, but not all, conditions. A difference in ethanol-evoked dopamine release between male and female mixed background C57BL/6J-129SvEv mice led to questions about its ubiquitous role in these effects of ethanol. Using congenic C57BL/6J MOR knockout (KO) mice and C57BL/6J mice pretreated with an irreversible MOR antagonist, we investigated the function of this receptor in ethanol-stimulated dopamine release. Methods: Microdialysis was used to monitor dopamine release and ethanol clearance in MOR -/-, +/+, and +/− . male and female mice after intraperitoneal (i.p.) injections of 1.0, 2.0, and 3.0 g/kg ethanol (or saline). We also measured the increase in dopamine release after 5 mg/kg morphine (i.p.) in male and female MOR+/+ and −/− mice. In a separate experiment, male C57BL/6J mice were pretreated with either the irreversible MOR antagonist beta funaltrexamine (BFNA) or vehicle, and dopamine levels were monitored after administration of 2 g/kg ethanol or 5 mg/kg morphine. Results: Although ethanol-stimulated dopamine release at all the 3 doses of alcohol tested, there were no differences between MOR+/+, −/−, and +/− mice in these effects. Female mice had a more prolonged effect compared to males at the 1 g/kg dose. Administration of 2 g/kg ethanol also caused a similar increase in dopamine levels in both saline-pretreated and BFNA-pretreated mice. Five mg/kg morphine caused a significant increase in dopamine levels in MOR+/+ mice but not in MOR−/− mice and in saline-pretreated mice but not in BFNA-pretreated mice. Intraperitoneal saline injections had a significant, albeit small and transient, effect on dopamine release when given in a volume equivalent to the ethanol doses, but not in a volume equivalent to the 5 mg/kg morphine dose. Ethanol pharmacokinetics were similar in all genotypes and both sexes at each dose and in both pretreatment groups. Conclusions: MOR is not involved in ethanol-stimulated dopamine release in the ventral striatum of C57BL/6J mice.

BACKGROUND Rib fractures (RFx) remain the most prevalent injury in an elderly population that will increase from 40 to 81 million for the next 30 years. We sought to create an accurate cost-effective algorithm to triage elderly patients with RFx that accounted for both frailty and trauma burden. METHODS Retrospective analysis evaluated 400 patients older than 55 years with RFx admitted to a level 1 trauma center from 2007 to 2012. Comorbidities included chronic obstructive pulmonary disease, congestive heart failure, tobacco use, obesity, and nutrition and functional status. Trauma burden included RFx, tube thoracostomy, pulmonary contusions, and spine and extremity fractures. Patients with Glasgow Coma Scale scores lower than 13, thoracoabdominal surgery, or deaths from other causes were excluded. Comparative analysis used bivariate and logistic regression. Variables contributing to intubation (INT) and pneumonia (PNA) were then used to create a scoring system to predict the need for intensive care unit (ICU) admission. RESULTS Six variables increased the risk for INT or PNA: chronic obstructive pulmonary disease, low albumin, assisted status, tube thoracostomy, Injury Severity Score, and RFx (p < 0.05). These six variables and congestive heart failure (odds ratio, 1.9; p = 0.06) were used to create a predictive model with the following scores assigned respectively: 1.4, 1.1, 1, 0.9, 0.1(n), 0.1(n), and 0.6. A score lower than 3.7 had a sensitivity and specificity of 78.5% and 78.9%. The negative predictive value was 94.5% for INT or PNA, suggesting a low risk for ICU requirement. Ninety-two ICU admissions had a score lower than 3.7. Forty had no other indication for ICU admission aside from RFx. These patients had an average ICU length of stay of 1.7 days, resulting in an increased cost of $2,200 per patient. CONCLUSION A scoring system combining frailty and trauma burden may provide more accurate and cost-effective triage of the elderly trauma patient with RFx. Further prospective studies are required to verify our scoring system. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Recently, diagnoses of small renal masses and renal cell carcinoma (RCC) have increased due to the widespread use of radiographic imaging studies (computerized tomography, magnetic resonance imaging). It appears that biological factors such as obesity and tobacco use increase the risk for RCC. In general, small malignant renal masses are low stage and low grade. The management of asymptomatic renal masses is a surgical challenge since overtreatment of benign masses is not desired, especially for patients with complex medical comorbidities, elderly patients, and those with impaired renal function. Partial nephrectomy has been considered the gold standard when treating small renal masses. However, technical challenges and possible irreversible ischemia-reperfusion injury should be considered when treating these lesions. Preservation of renal function without compromising oncological control is the foundation for nephron-sparing surgery. Laparoscopic renal cryoablation (LRC) emerges as an option to treat small renal masses due to the less invasive procedure with low intraoperative complications rates, with no renal ischemia-reperfusion injury and comparable medium term follow up. It is our objective to demonstrate our technique to perform an effective small renal tumor cryoablation using the laparoscopic approach.

Background Damage-control surgery frequently results in open abdomen. The objective of this study was to determine whether resuscitation with goal-directed fluid therapy (GDT) using “dynamic” hemodynamic indices via modern pulse contour analysis devices such as the FloTrac Vigileo monitor leads to lower fluid requirements, subsequent quicker abdominal closure, and overall improved outcomes in these patients. Methods Patients admitted to the surgical intensive care unit with open abdomen were retrospectively reviewed. Those resuscitated with Vigileo-guided GDT were matched to those resuscitated by static clinical parameters. Results Total fluid intake and vasopressor requirements were similar in both groups. GDT with the Vigileo allowed earlier lactate clearance and reduced the number of days until abdominal wall closure by an average of .99 days. Conclusions Vigileo-mediated GDT did not affect fluid volume or vasopressor use in open abdomen patients, but facilitated more effective resuscitation and decreased the number of days to fascial closure, leading to shorter hospital stays. Vigileo-mediated GDT, therefore, may improve overall outcomes in open abdomen patients.

The mu opioid receptor (MOR) has previously been found to regulate ethanol-stimulated dopamine release under some, but not all, conditions. A difference in ethanol-evoked dopamine release between male and female mixed background C57BL/6J-129SvEv mice led to questions about its ubiquitous role in these effects of ethanol. Using congenic C57BL/6J MOR knockout (KO) mice and C57BL/6J mice pretreated with an irreversible MOR antagonist, we investigated the function of this receptor in ethanol-stimulated dopamine release.Microdialysis was used to monitor dopamine release and ethanol clearance in MOR -/-, +/+, and +/- . male and female mice after intraperitoneal (i.p.) injections of 1.0, 2.0, and 3.0 g/kg ethanol (or saline). We also measured the increase in dopamine release after 5 mg/kg morphine (i.p.) in male and female MOR+/+ and -/- mice. In a separate experiment, male C57BL/6J mice were pretreated with either the irreversible MOR antagonist beta funaltrexamine (BFNA) or vehicle, and dopamine levels were monitored after administration of 2 g/kg ethanol or 5 mg/kg morphine.Although ethanol-stimulated dopamine release at all the 3 doses of alcohol tested, there were no differences between MOR+/+, -/-, and +/- mice in these effects. Female mice had a more prolonged effect compared to males at the 1 g/kg dose. Administration of 2 g/kg ethanol also caused a similar increase in dopamine levels in both saline-pretreated and BFNA-pretreated mice. Five mg/kg morphine caused a significant increase in dopamine levels in MOR+/+ mice but not in MOR-/- mice and in saline-pretreated mice but not in BFNA-pretreated mice. Intraperitoneal saline injections had a significant, albeit small and transient, effect on dopamine release when given in a volume equivalent to the ethanol doses, but not in a volume equivalent to the 5 mg/kg morphine dose. Ethanol pharmacokinetics were similar in all genotypes and both sexes at each dose and in both pretreatment groups.MOR is not involved in ethanol-stimulated dopamine release in the ventral striatum of C57BL/6J mice.