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Obstetric fistula is a debilitating childbirth injury causing immense suffering for women and girls with the condition. The majority of fistulas can be successfully treated with a surgical repair, performed by a competent surgeon who has undergone specialist training and who works with a holistic fistula care team. As well as surgical repair, a critical component of fistula treatment is meticulous postoperative assessment to accurately determine surgical outcomes so that further treatment and support can be provided as required, and the risk substantially reduced of any patient being discharged with associated ongoing problems, such as urinary retention or residual/ongoing incontinence. Based on the opinions of experts in the field, these good practice recommendations provide a practical and standardized protocol for the correct assessment of surgical outcomes following vesicovaginal fistula surgery and appropriate subsequent management., (© 2024 The Author(s). International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Competing Interests: The authors have no financial conflicts of interest.

Introduction: Rectovaginal fistulas (RVFs) can arise from various etiologies, the most common cause especially in developing countries is obstetric injury. Uncommonly, rectal tuberculosis can present as RVF, posing a diagnostic and treatment challenge especially in a patient without established risk factors. The first case of rectal tuberculosis was reported by Davis et al., in 1957, and a 2022 systematic review identified only 28 cases reported since then., Presentation of Case: we report the case of a 25-year-old college woman who presented with a 3-month history of lower abdominal pain and fecal passage per vagina. She had undergone a failed RVF repair attempt at another hospital. Examination revealed a single rectovaginal fistula with surrounding granulation tissue, despite the absence of prior TB history. Investigations revealed chronic granulomatous inflammation and acid-fast bacilli on biopsy, confirming rectal tuberculosis as the cause of RVF. She received a 6-month course of anti-tuberculous medication after which she underwent a successful surgical repair of the RVF via a transverse transvaginal approach., Discussion: Rectal tuberculosis is a rare condition, typically occurring in the third and fourth decades of life. The ileocecal junction is the most common site for gastrointestinal TB Risk factors include impaired immunity. It is usually secondary to pulmonary TB, Diagnosis can be challenging due to the varied symptoms, which can overlap with other conditions like rectal cancer. Treatment involves a 6-month course of antituberculosis medication, and surgery may be needed for complications like rectovaginal fistula., Conclusion: this case highlights the atypical presentation of tuberculosis and emphasizes the importance of considering tuberculosis as a cause of RVF especially in young patients without apparent risk factors living in TB-endemic areas. It also highlights the challenges in differentiating TB-induced RVF from other causes of RVF., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

This case report presents the clinical journey of a 28-year-old nulliparous woman from Dar es Salaam, Tanzania, who sought medical attention due to lifelong urinary leakage since birth, profoundly impacting her emotional well-being and sexual encounters. Clinical examination revealed urinary leakage from the vagina, with unremarkable abdominal and genital findings. Laboratory investigations were normal. Computed tomography intravenous urography revealed a left duplex collecting system with significant hydroureteronephrosis in the left upper moiety, suggestive of an ectopic ureter. Intraoperative exploration confirmed a duplicated left ureter, with the upper moiety implanted into the vaginal canal. Surgical re-implantation of both left ureters into the bladder was successfully performed, correcting the anatomical anomaly. Postoperative follow-up demonstrated marked improvement in urinary symptoms, restoring the patient's confidence and alleviating emotional distress. This case underscores the complexity and rarity of congenital urinary tract anomalies, particularly in resource-constrained settings, and highlights the importance of a stepwise diagnostic and management approach., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Chorion trophoblasts (CTCs) and immune cell-enriched decidua (DECs) comprise the maternal-fetal membrane interface called the chorio-decidual interface (CDi) which constantly gets exposed to maternal stressors without leading to labor activation. This study explored how CTCs act as a barrier at CDi. The roles of human leukocyte antigen (HLA)-G and progesterone receptor membrane component 2 (PGRMC2) in mediating immune homeostasis were also investigated. The CDi was recreated in a two-chamber microfluidic device (CDi-on-chip) with an outer chamber of primary DECs and immune cell line-derived innate immune cells and an inner chamber of wild-type or PGRMC2 or HLA-G knockout immortalized CTCs. To mimic maternal insults, DECs were treated with lipopolysaccharide, poly(I:C), or oxidative stress inducer cigarette smoke extract. Expression levels of inflammation and immunity genes via targeted RNA sequencing, production of soluble mediators, and immune cell migration into CTCs were determined. In CDi-on-chip, decidua and immune cells became inflammatory in response to insults while CTCs were refractory, highlighting their barrier function. HLA-G and PGRMC2 are found to be vital to immune homeostasis at the CDi, with PGRMC2 serving as an upstream regulator of inflammation, HLA-G expression, and mesenchymal-epithelial transition, and HLA-G serving as a frontline immunomodulatory molecule, thus preventing fetal membrane compromise., (© 2024. The Author(s).)

This SIIM-sponsored 2023 report highlights an industry view on artificial intelligence adoption barriers and success related to diagnostic imaging, life sciences, and contrasts. In general, our 2023 survey indicates that there has been progress in adopting AI across multiple uses, and there continues to be an optimistic forecast for the impact on workflow and clinical outcomes. This report, as in prior years, should be seen as a snapshot of the use of AI in imaging. Compared to our 2021 survey, the 2023 respondents expressed wider AI adoption but felt this was behind the potential. Specifically, the adoption has increased as sources of return on investment with AI in radiology are better understood as documented by vendor/client use case studies. Generally, the discussions of AI solutions centered on workflow triage, visualization, detection, and characterization. Generative AI was also mentioned for improving productivity in reporting. As payor reimbursement remains elusive, the ROI discussions expanded to look at other factors, including increased hospital procedures and admissions, enhanced radiologist productivity for practices, and improved patient outcomes for integrated health networks. When looking at the longer-term horizon for AI adoption, respondents frequently mentioned that the opportunity for AI to achieve greater adoption with more complex AI and a more manageable/visible ROI is outside the USA. Respondents focused on the barriers to trust in AI and the FDA processes., (© 2024. The Author(s).)

Background: Oncocytic carcinoma (OCA) was recently reclassified as a distinct differentiated thyroid carcinoma (DTC). Given its rarity, OCA studies are limited. This study describes the characteristics of OCA in a 20-year cohort., Methods: Retrospective analysis of patients with OCA at a single tertiary care hospital from 2000 to 2021., Results: Fifty-one OCA patients (22M:29F) were identified. The mean age at diagnosis was 60.3 years; 90% presented as palpable mass; 24% had a family history of thyroid cancer. None had vocal fold paresis. On ultrasound, most tumors were solid and hypoechoic. FNA (n = 14) showed Bethesda-4 lesions in 93%. All were treated surgically. Histologically, 63% demonstrated angioinvasion, 35% had lymphovascular invasion, and 15% had extrathyroidal extension. Radioactive iodine was used as adjunct therapy in 77%., Conclusion: OCA has distinct features that distinguish it from other DTCs, and additional focused studies will help clarify the aggressive nature, treatment options, and prognosis of the disease., (© 2024 Wiley Periodicals LLC.)

Competing Interests: The authors have no financial conflicts of interest.

Background: The bony facial trauma score (BFTS) is a rubric used to assess the severity of facial trauma. Objectives: To compare the BFTS with relevant clinical outcomes while controlling for medical comorbidities and polytrauma. Methods: A retrospective review of facial trauma patients evaluated between 2017 and 2022 was conducted. While controlling for medical comorbidities and polytrauma, multivariate regression models were used to assess the relationship between BFTS and outcome variables such as length of stay (LOS) and malocclusion. Results: In total, 176 patients were included in the analysis. The average age was 36.5 years (standard deviation [SD] of 16.8), and 68.8% were male. The most common mechanism of injury was blunt force (92.6%) and the mean BFTS was 10.73 (SD of 11.05). BFTS was found to correlate with the following ( p  < 0.05): total LOS and ICU LOS, malocclusion, likelihood of requiring multiple surgeries, and diplopia. Conclusion: The BFTS is significantly correlated with multiple outcome variables while controlling for medical comorbidities and polytrauma.

The inflammatory process leading to human labor is mostly facilitated by immune cells, which can be studied by isolating and characterizing primary immune cells from the feto-maternal interface. However, difficulty and inconsistency in sampling approaches of immune cells and short lifespan in vitro prevent their usage in mechanistic studies to understand the maternal-fetal immunobiology. To address these limitations, existing cell line models can be differentiated into immune-like cells for use in reproductive biology experiments. In this chapter, we discussed cell culture methods of maintaining and differentiating HL-60, THP-1, and NK-92 cells to obtain neutrophil-like, macrophage-like, and decidual natural killer-like cells, respectively, which can then be used together with intrauterine cells to elucidate and investigate immune mechanisms that contribute to parturition., (© 2024. The Author(s), under exclusive license to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Hospice and palliative care (PC) are important components of lung cancer care and independently provide benefits to patients and their families. Objective: To better understand the relationship between hospice and PC and factors that influence this relationship. Methods: A retrospective cohort study of patients diagnosed with advanced lung cancer (stage IIIB/IV) within the U.S. Veterans Health Administration (VA) from 2007 to 2013 with follow-up through 2017 ( n  = 22,907). Mixed logistic regression models with a random effect for site, adjustment for patient variables, and propensity score weighting were used to examine whether the association between PC and hospice use varied by U.S. region and PC team characteristics. Results: Overall, 57% of patients with lung cancer received PC, 69% received hospice, and 16% received neither. Of those who received hospice, 60% were already enrolled in PC. Patients who received PC had higher odds of hospice enrollment than patients who did not receive PC (adjusted odds ratio = 3.25, 95% confidence interval: 2.43-4.36). There were regional differences among patients who received PC; the predicted probability of hospice enrollment was 85% and 73% in the Southeast and Northeast, respectively. PC team and facility characteristics influenced hospice use in addition to PC; teams with the shortest duration of existence, with formal team training, and at lower hospital complexity were more likely to use hospice (all p  < 0.05). Conclusions: Among patients with advanced lung cancer, PC was associated with hospice enrollment. However, this relationship varied by geographic region, and PC team and facility characteristics. Our findings suggest that regional PC resource availability may contribute to substitution effects between PC and hospice for end-of-life care.

Introduction: Prolonged inflammation and infection in burns may cause inadequate healing. Platelet granules contain anti-inflammatory mediators that impact wound healing. Synthetic platelets (SPs) avoid portability and storage difficulties of natural platelets and can be loaded with bioactive agents. We evaluated wound healing outcomes in deep partial-thickness (DPT) burns treated topically with SP loaded with antibiotics., Materials and Methods: Thirty DPT burns were created on the dorsum of two Red Duroc hybrid pigs. Six wounds were randomized into five groups: SP alone, SP loaded with gentamicin vesicles, SP with gentamicin mixture, vehicle control (saline), or dry gauze. Wounds were assessed from postburn days 3-90. Primary outcome was re-epithelialization percentage at postburn day 28. Secondary outcomes included wound contraction percentage, superficial blood flow relative to normal skin controls, and bacterial load score., Results: Results showed that re-epithelialization with the standard of care (SOC) was 98%, SP alone measured 100%, SP loaded with gentamicin vesicles was 100%, and SP with gentamicin mixture was 100%. Wound contraction was 5.7% in the SOC and was ∼10% in both the SP loaded with gentamicin vesicles and SP with gentamicin mixture groups. Superficial blood flow in the SOC was 102.5%, SP alone was 170%, the SP loaded was 155%, and gentamicin mixture 162.5%. Bacterial load score in the SOC was 2.2/5.0 and was significantly less at 0.8/5.0 in SP loaded with gentamicin vesicles (P > 0.05). SP and gentamicin mixture scored 2.7 and 2.3/5.0., Conclusions: Topical SP treatment did not significantly improve outcomes. However, SP loaded with gentamicin-infused vesicles decreased bacterial load., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

The current standard of care for the coverage of large wounds often involves split thickness skin grafts (STSGs) which have numerous limitations. One promising technique that has gained traction is fractional autologous skin grafting using full-thickness skin columns (FTSC). Harvesting occurs orthogonally by taking numerous individual skin columns containing the epidermis down through the dermis and transferring them to the wound bed. The purpose of this porcine study was to investigate the efficacy of implanting FTSCs directly into deep partial-thickness burn wounds, as well as examining donor site healing at the maximal harvest density. It was hypothesised that by utilising FTSCs, the rate of healing in deep partial thickness burns can be improved without incurring the donor morbidity seen in other methods of skin grafting. Deep partial-thickness burns were created on the dorsum of female red duroc swine, debrided 3 days later and FTSCs were implanted at varying expansion ratios directly into the burn wounds. At day 14, 1:50 expansion ratio showed significantly faster re-epithelialisation compared to the debrided burn control and 1:200. Donor sites (at 7%-10% harvest density) were 100% re-epithelialised by day 7. Additionally, the maximal harvest density was determined to be 28% in an ex vivo model, which then five donor sites were harvested at 28% density on a red duroc swine and compared to five STSG donor sites. At maximal harvest density, FTSC donor sites were significantly less hypopigmented compared to STSGs, but no significant differences were observed in re-epithelialisation, contraction, blood flow or dermal thickness. In conclusion, implantation directly into deep partial-thickness burns is a viable option for the application of FTSCs, favouring lower expansion ratios like 1:50 or lower. Little difference in donor site morbidity was observed between FTSC at a maximal harvest density of 28% and STSGs, exceeding the optimal harvest density., (© 2023 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

Introduction: Burns are common injuries on the battlefield. Given austere environments, surgical debridement of injured service members is often not feasible in these settings. Delays in surgical debridement create a risk of infection and deranged healing for burn patients. As such, this study attempts to identify the best commercially available off-the-shelf (OTS) therapies with field-deployable potential to improve prolonged field care (PFC) of burn-injured soldiers., Methods: Deep partial-thickness (DPT) burns (25 cm2) were created on the dorsum of 5 anesthetized pigs utilizing a thermocouple burn device at 100°C for 15 seconds. Nonsurgical debridement was done 1-hour after burn creation using sterile saline water and gauze to remove excess eschar tissue. Animals were then randomized into 5 experimental groups, and OTS therapies were applied to 6 of the 12 created DPT burns. The remaining 6 burns were treated with 1% silver sulfadiazine cream (Ascend Laboratories, LLC, Parsippany, NJ) as the PFC standard of care (SOC) controls. The 5 randomized OTS therapies were: irradiated sterile human skin allograft (IHS), biodegradable temporizing matrix (BTM), polylactic acid skin substitute, hyaluronic acid ester matrix (HAM), and decellularized fish skin graft (FSG). Wounds were serially assessed on post-burn days 3, 7, 14, 21, and 28. Assessments were conducted using a combination of photographs, histology, and quantitative bacteriology. Endpoints included burn wound progression, re-epithelialization, wound contraction, scar elevation index, and colony-forming units (CFU)., Results: The analysis demonstrated that by day 3, the FSG prevented burn wound progression the most efficiently. In terms of wound healing, the results showed re-epithelialization percentages close to 100% by day 28 for all treatment groups. No statically significant differences were observed. Quality of healing analyses demonstrated that the BTM-treated wounds had contracted less and the difference to the IHS-treated wounds was statistically significant (P < .05). As regards to antimicrobial properties, the CFU results showed no statistically significant differences between the OTS therapies and the SOC on days 3, 7, and 14., Conclusions: The impact of Food and Drug Administration-approved OTS therapies was compared to the current PFC SOC for the treatment of DPT burns in a porcine model. Several topical options exist for the management of burns prior to definitive treatment in the operating room and warrant further evaluation. These therapies are actively used on civilian burn counterparts and have far-forward, field-deployable potential for use at the point of injury so that injured service members may not need evacuation to higher roles of care and combat power may be preserved. Our results demonstrated that all the studied OTS therapies performed well when compared to the SOC in terms of burn wound progression, wound healing, quality of healing, and quantitative bacteriology., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Value-based care is the foundation of population health. The Health care Economic Efficiency Ratio (HEERO) scoring system is a promising new tool to measure the cost benefits of care in our Accountable Care Organization. HEERO score compares actual costs spent (utilizing insurance claims) and expected costs spent (estimated using the Centers for Medicare/Medicaid Services Risk score). Scores <1 suggest economic benefit. Sacubitril/valsartan has been shown to decrease readmissions for patients with heart failure (HF) and decrease health care costs. We explored the utility of sacubitril/valsartan in reducing HEERO scores and decreasing overall health care expenditure in patients with HF. Patients with HF in the population health cohort were enrolled. HEERO score was calculated for patients taking sacubitril/valsartan and other HF medications at 3-month intervals up to a year. We compared the average and total health care expenditure and inpatient days for patients on sacubitril/valsartan, spironolactone, β blocker (BB) along with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. For patients on sacubitril/valsartan, HEERO scores and inpatient days decreased (decreased health care expenditure) as the number of days of utilization increased (p <0.0001). In total, 270+ days of sacubitril/valsartan decreased health care costs by 22%. This cost reduction was mainly attributed to decreased inpatient days. Additionally, the combination of sacubitril/valsartan, spironolactone, and BB showed decreased HEERO score and inpatient days compared with spironolactone, BB and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in male patients. Sacubitril/valsartan use beyond 270 days resulted in decreased health care expenditure in a population health cohort compared with other HF medications. This economic benefit is achieved through the reduction in hospitalizations. Sacubitril/valsartan is an integral part of value-based care providing high-value, cost-effective care, and bolstering the economic wellbeing of patient care. Payor sources should consider this in subsidizing the cost of the medicine., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

To: 1) characterize how COVID-19-related policies influence patient-clinician communication and relationships in the ICU, with attention to race and ethnicity as factors and 2) identify interventions that may facilitate patient-clinician communication., Design: We conducted a qualitative study between September 2020 and February 2021 that explored facilitators and barriers to patient-clinician communication and the formation of therapeutic relationships. We used thematic analysis to develop findings describing patient-communication and therapeutic relationships within the ICU early in the COVID-19 pandemic., Setting: We purposively selected hospital dyads from regions in the United States that experienced early and/or large surges of patients hospitalized with COVID-19., Subjects: We recruited a national sample of ICU physicians from Veteran Affairs (VA) Health Care Systems and their associated academic affiliate hospitals., Interventions: None., Measurements and Main Results: Twenty-four intensivists from seven VA hospitals and six academic-affiliate hospitals participated. Intensivists noted the disproportionate impact of the pandemic on among people holding minoritized racial and ethnic identities, describing how language barriers and restrictive visitation policies exacerbated institutional mistrust and compromised physicians' ability to develop therapeutic relationships. We also identified several perceived influences on patient-clinician communication and the establishment of therapeutic relationships. Barriers included physicians' fear of becoming infected with COVID-19 and use of personal protective equipment, which created obstacles to effective physical and verbal interactions. Facilitators included the presence of on-site interpreters, use of web-based technology to interact with family members outside the ICU, and designation of a care team member or specialist service to provide routine updates to families., Conclusions: The COVID-19 pandemic has threatened patient-clinician communication and the development of therapeutic relationships in the ICU, particularly among people holding minoritized racial and ethnic identities and their families. We identified several facilitators to improve patient-clinician communication as perceived by intensivists that may help improve trust and foster therapeutic alliances., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Objective: While Autoimmune Associated Vocal Fold Lesions (AaVFLs) have been described in many reports, there is no consensus on best practices in management. The purpose of this systematic review is to clarify the characteristics and treatment of dysphonia in the setting of AaVFLs., Study Design: Systematic review METHODS: Pubmed and OVIDMedline and Google Scholar were searched, including terms related to (1) Vocal fold/cord, rheumatoid node/nodule, bamboo nodes/nodules, laryngeal deposits/nodes/nodules and (2) Autoimmune diseases/syndromes, connective tissue disease., Results: Twenty-one studies with 83 patients diagnosed with AaVFLs were included. AaVFLs occurred predominantly in females in the 4th or 5th decade of life, with an overall mean age of 39.8 (SD = 12.8). Autoimmune or connective tissue disease was established prior to presentation to an otolaryngologist in 75.9% (44/58) of patients. Bilateral lesions were present in 83.8% (57/68) of patients. Treatment modalities included medical therapy alone (28.1%), voice therapy alone (17.5%), surgical treatment alone (7.0%), combination of medical and voice therapy (33.3%), and combination of surgical, medical and voice therapy (7.0%). All patients treated with voice therapy had voice improvement; lower rates were seen with solo medical (4/14 improved, 28.6%) or surgical therapy (3/6 improved, 50%)., Conclusion: AaVFLs occur predominantly in women in their 30's to 50's and are associated with a variety of autoimmune conditions. A significant number of patients (25%) present to the Otolaryngologist without an established autoimmune diagnosis. While treatment outcomes are not robustly reported, a significant number of patients with AAVFLs treated with voice therapy alone or voice therapy in combination with other treatment modalities (medical or surgical) experience subjective improvement in voice quality and function., Competing Interests: Conflict of Interest No potential conflicts of interest to report., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)