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We present observations of the intranight brightness variability of CR Boo, a member of the AM CVn stars group. The observational data are obtained with the 2m telescope of the Rozhen National Astronomical Observatory and the 60 cm telescope of the Belogradchik Observatory, Bulgaria, in BVR bands. We report the appearance of super-humps, with an amplitude from 0.08 to 0.25 mag, when the maximum brightness reaches the magnitude 14.08 in the V band, and 14.13 in the B band. A secondary maximum of each superhump is detected with the same periodicity as the superhumps: Psh = 24.76 - 24.92 min. In our results, the post maxima are shifted in time from = 7.62 min to = 16.35 min in different nights, with an amplitude of = 0.06 - 0.09 mag and an amplitude difference of = 0.035 mag towards the superhumps' maximum. We find a correlation of the post maxima with the accretion processes at the outer side of the disc. [ABSTRACT FROM AUTHOR]

Background: Authorship of surgical literature is important for the career advancement of surgeons, and gender disparities in authorship may hinder the representation and leadership of women within academic surgery. The aim of this systematic review and meta-analysis was to evaluate the gender distribution of first, senior, and overall authorship in peer-reviewed surgical journal studies across all surgical specialties to determine if disparities exist., Methods: PubMed, EMBASE, and Google Scholar databases were searched for studies investigating the gender distribution of authorship of surgical literature published before December 10th, 2021. Meta-analysis was performed and Cohen's Q test for heterogenous effects was used to determine whether random or fixed-effects models were appropriate., Results: Fifteen studies investigating gender distribution of authorship met inclusion, which included a total of 136,627 pooled studies. The meta-analysis demonstrated the meta-proportion of first authorship for women to be 20.6% (95% CI: 13.9, 28.2), the meta-proportion of senior authorship for women to be 11.9% (95% CI: 6.6, 18.5), and the meta-proportion of overall authorship for women to be 23% (95% CI: 16.2, 30.7). In addition, the proportion of senior authorship for women was found to be significantly lower than the proportion of overall authorship for women (11.9% versus 23.0%, P = .0106)., Conclusion: There is a significantly smaller proportion of women who are first, senior, and overall authors in surgical literature compared to their colleagues who are men. Sustainable and effective solutions aimed at improving the representation of women surgeons in surgical research and research leadership are necessary.

Introduction: Delayed splenic rupture is an often unpredictable event with high mortality. In this report, we discuss the successful management of delayed splenic rupture, presenting days after index injury, with no commonly associated injuries or blunt abdominal trauma., Case Presentation: A 50 year old male, not on anticoagulants, presented with blunt trauma after driving his motorcycle into a tree. The patient sustained right 3-5 rib fractures, displaced right midclavicular fracture, 25 % right pneumothorax, T5-9 posterior spinous process fractures, left 2nd-5th metatarsal fractures, and scattered abrasions to the left foot, knee and hand. Focused abdominal sonography for trauma (FAST) and admission abdominal multi-detector CT were negative for any intra-abdominal injuries. On hospital day 5, the patient acutely decompensated. FAST was grossly positive and emergent laparotomy revealed a splenic rupture. After a splenectomy, he recovered., Discussion: The spleen is the most commonly injured organ in blunt abdominal trauma. Although acute injury often presents with imaging findings or sequelae of hemorrhagic shock, complications of splenic trauma have the potential to result in delayed catastrophe. Bedside ultrasonography is a useful tool to assess acute decompensation in trauma patients along with CT imaging. Prompt identification and hemorrhage control are crucial to survival after trauma., Conclusion: Repeat CT scans are also important for the identification of delayed splenic rupture and timely intervention. Delayed hemorrhage after blunt trauma should never be ruled out regardless of the injury complexity or length of hospital admission., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: A devastating injury to the liver from a gunshot wound (GSW) challenges the most seasoned trauma surgeon. This challenge is intensified when patients develop severe shock with a high-grade injury. We present the case of a patient with a grade 5 liver injury after a GSW treated with operative and interventional radiology (IR) treatment simultaneously., Case Presentation: A 25-year-old male presented to our Trauma Center with hypotension, after an abdominal GSW. He was taken emergently to the operating room, which revealed a Grade 5 liver injury with massive hemorrhage. Operative intervention was initiated immediately and a non-anatomic left lobectomy with hepatorrhaphy was performed. IR was consulted intra-operatively and performed a left hepatic artery angioembolization. The patient received over 50 units of blood products during the combined procedures, with eventual bleeding control. On post-operative day 33, the patient became acutely hemodynamically unstable, and angiography revealed a splenic artery pseudoaneurysm, which was embolized but re-bled and resulted in splenectomy. The patient eventually recovered and follows up at 1-year revealed a patient doing well., Discussion: High-grade liver injuries carry significant mortality. Mortality worsens when severe shock is present. Operative intervention is the standard approach for patients who remain in shock. To help improve outcomes patients may benefit from a combined approach with the interventional radiology team., Conclusion: The acute management of severe liver injuries when presenting with ongoing shock is beneficial to include both trauma surgeons with interventional radiologists. Further studies are needed to determine the best approach for this devastating injury., Competing Interests: Declaration of competing interest None., (Copyright © 2022. Published by Elsevier Ltd.)

HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome is a rare but serious complication of pregnancy characterized by hemolytic anemia, elevated liver enzymes, and thrombocytopenia. It occurs in <1% of all pregnancies with 70% of cases developing before delivery, the majority occurring between the 27 th and 37 th weeks of gestation. Respiratory failure seen in HELLP syndrome clinically and radiographically appears similar to acute respiratory distress syndrome (ARDS), with presence of bilateral pulmonary opacities on imaging as well as persistent hypoxemia requiring elevated ventilator requirements. It is seen to complicate 3-10% of cases of HELLP syndrome. Pulmonary complications are theorized to occur as sequelae of the proinflammatory state induced by HELLP syndrome with endothelial dysfunction and subsequent microangiopathic hemolysis and thrombocytopenia. A robust cytokine inflammatory response similar to ARDS is seen, resulting in noncardiogenic pulmonary edema due to vasoplegia and capillary leak syndrome. We present a case of a 27-year-old uniparous female with a term pregnancy complicated by HELLP syndrome who developed respiratory failure requiring mechanical ventilation. Early CRRT and nitric oxide therapy were initiated, with the patient experiencing clinical and radiological improvement of respiratory function within 48 hours. We document the novel treatment of our patient's acute respiratory failure with CRRT and nitric oxide and delve into the literature regarding its use in acute respiratory failure and ARDS in association with HELLP syndrome., Competing Interests: The authors of this case report have no conflicts of interests or disclosures to report., (Copyright © 2021 Obteene Azimi-Ghomi et al.)

BACKGROUND Blunt renal injuries constitute a small proportion of solid organ trauma cases. Many American Association for the Surgery of Trauma grade IV and V lacerations are manageable with volume resuscitation and angioembolization. In select cases, emergent nephrectomy can be beneficial to patients, with little associated morbidity. CASE REPORT In 2 separate cases, an 18-year-old man and a 21-year-old woman were brought to our center after sustaining blunt trauma to the left flank. They were both found to have isolated grade V renal lacerations with vascular compromise. Both initially had normal vital signs but became unstable. Active extravasation was visible on contrast-enhanced computed tomography scans, and the patients ultimately underwent exploratory laparotomy and nephrectomy on hospital day 1. Both of them recovered quickly, had no acute complications, and were discharged in <1 week. Follow-up over the course of 1 year showed no untoward sequelae. CONCLUSIONS These cases highlight the role of nephrectomy to mitigate life-threatening hemorrhage in unstable patients. While observation or angioembolization is the preferred approach for many renal injuries, emergent nephrectomy remains important for patients who do not respond to blood products and have rapidly deteriorating shock. In these patients, results of an initial trauma evaluation can be unclear because of concomitant splenic injury, as well as renal injuries with hemoperitoneum that are visible on focused abdominal ultrasonography for trauma. When forgoing immediate laparotomy, surgeons can use continuous noninvasive hemoglobin monitoring along with serial hemoglobin measurements and abdominal examinations. Laparotomy with nephrectomy results in limited morbidity when it is done expeditiously with ongoing volume resuscitation.

Burnout is a significant and increasingly recognized issue. They aimed to investigate burn surgeons'(BSurg) perceptions regarding burnout, contributing factors, and implications to better identity possible targeted interventions. A 42-question anonymous online survey was distributed by the ABA to BSurg members. Respondents included BSurgs in university or nonuniversity hospital settings. Experience of burnout was reported among 89.8% of university and 84.6% of nonuniversity hospital-affiliated respondents. After adjusting for confounders, university BSurgs exhibited a higher risk of perceived burnout compared with nonuniversity settings (aOR: 1.081, 95% CI: 0.237, 4.937). Women BSurgs were at 5 times higher risk of reporting burnout compared with men (aOR: 5.048, 95% CI: 0.488, 52.255). BSurgs aged 40 to 44 had twice the risk of reporting burnout as ≥50 (aOR: 1.985, 95% CI:0.018, 216.308). Practicing for 21 to 30 years had 12 times higher risk of reporting burnout than practicing >30 (aOR: 12.264, 95% CI: 0.611, 246.041). Those working <50 hr/wk reported burnout more frequently than those who work ≥80 hr/wk (aOR: 2.469, 95% CI: 0.80, 76.662). Overall reports of burnout were high amongst burn surgeon respondents. Those with 21 to 30 years of clinical practice were at significantly higher risk of reporting burnout despite believing that their colleagues' burnout was more frequent than their own. Interventions addressing perceived burnout in younger burn surgeons may be limited by lack of participation due to fear of repercussions from administration or peers. Future administration-led burnout initiatives should acknowledge the differences between burn surgeon groups and offer resources unique to the individual physician's needs for burnout prevention to be successful., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Burn Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Twitter at conferences facilitates remote interaction and spread of ideas. Through the use of hashtags, conference information can be gathered, referenced, disseminated, and discussed in 1 electronic location by attendees and nonattendees from remote locations. The aim of this study is to analyze the American College of Surgeons Clinical Congress (ACSCC) Twitter hashtag activities and evaluate its impact on meeting participation and engagement for the last 5 annual meetings., Methods: Twitter hashtags #ACSCC15, #ACSCC16, #ACSCC17, #ACSCC18, and #ACSCC19 were studied to determine tweets, retweets, users, and impressions. Data regarding top influencers and the most tweeted links were analyzed. Symplur Signals, a software that specializes in hashtags, was utilized for the analyses., Results: Between 2015 and 2017, there was a consistent increase in tweets from 12 800 to 18 300 to 24 700, respectively. However, in 2018 and 2019, tweets dropped significantly to 19 700 and 19 300, respectively ( P < .05). Additionally, impressions dropped significantly by 24 million impressions from 2017 to 2019 (115.1M to 91.1M, P < .05) despite the growth of users from 2700 in 2015 to 4100 in 2016 and ~6500 in 2017-2019. This change occurred despite no change in meeting attendance rates, regardless of specialty ( P > .05). The most influential organizations in hashtag use were the American College of Surgeons (ACS) and Association of Women Surgeons (AWS)., Conclusion: Despite the significant reduction in views and online engagement activities in the past 2 years, the use of Twitter at the ACS CC has greatly increased the potential dissemination of information but not meeting attendance rates.

Introduction: Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy., Presentation of Case: A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent., Discussion: BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks., Conclusion: Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Antithrombin deficiency (ATD) was described in 1965 by Olav Egeberg as the first known inherited form of thrombophilia. Today, it is understood that ATDs can be congenital or acquired, leading to qualitative, quantitative, or mixed abnormalities in antithrombin (AT). All ATDs ultimately hinder AT's ability to serve as an endogenous anticoagulant and antiinflammatory agent. As a result, ATD patients possess higher risk for thromboembolism and can develop recurrent venous and arterial thromboses. Because heparin relies on AT to augment its physiologic function, patients with ATD often exhibit profound heparin resistance. Although rare as a genetic disorder, acquired forms of ATD are seen with surprising frequency in critically ill patients. This review discusses ATD in the context of surgical critical care with specific relevance to trauma, thermal burns, cardiothoracic surgery, and sepsis., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Acute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions., Methods: PubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes., Results: Eleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient., Conclusion: Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: There is a pressing need for COVID-19 transmission control and effective treatments. We aim to evaluate the safety and effectiveness of SARS-CoV-2 pharmacologic therapies as of August 2, 2020 according to study level of evidence., Methods: PubMed, ScienceDirect, Cochrane Library, JAMA Network and PNAS were searched. The following keywords were used: ((COVID-19) OR (SARS-CoV-2)) AND ((((((therapeutics) OR (treatment)) OR (vaccine)) OR (hydroxychloroquine)) OR (antiviral)) OR (prognosis)). Results included peer-reviewed studies published in English., Results: 15 peer-reviewed articles met study inclusion criteria, of which 14 were RCTs and one was a systematic review with meta-analysis. The following pharmacologic therapies were evaluated: chloroquine (CQ), hydroxychloroquine (HCQ), antivirals therapies, plasma therapy, anti-inflammatories, and a vaccine., Conclusion: According to level 1 evidence reviewed here, the most effective SARS-Co-V-2 pharmacologic treatments include remdesivir for mild to severe disease, and a triple regimen therapy consisting of lopinavir-ritonavir, ribavirin and interferon beta-1b for mild to moderate disease. Also, dexamethasone significantly reduced mortality in those requiring respiratory support. However, there is still a great need for detailed level 1 evidence on pharmacologic therapies., Competing Interests: Declaration of Competing interest Nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Traumatic thoracic aortic injuries (TAIs) carry a substantial mortality. Our study aim was to evaluate the impact of insurance status on outcomes in severely injured trauma patients after either thoracic endovascular aortic repair (TEVAR) or open repair using the National Trauma Data Bank Research Data Set (NTDB-RDS)., Methods: The NTDB-RDS was reviewed for outcomes in severely injured patients and TAI repair method (TEVAR vs open). Patients were divided into insured (Medicaid, Medicare, private insurance) and uninsured (self-pay) status groups. Patients were further divided by injury severity score (ISS) of 15-24 and ≥25 to adjust for injury burden. Demographic characteristics and outcome measures were compared. Chi-square, t -test, and analysis of variance were used with significance defined as P < .05., Results: Within the NTDB-RDS, a review of nearly 1 million patients led to 241 that underwent repair for TAI and had insurance status and repair type documented. 88.8% (214/241) of patients were insured, while 11.2% (27/241) of patients were uninsured. There were no significant differences in repair type based on insurance status. For open repair with an ISS ≥25, mortality was significantly higher in the uninsured group compared with insured (55.5% vs 21.9%, P = .001)., Conclusion: For open repair in patients with TAI and high injury burden, uninsured status was associated with a significant increase in mortality rate compared with insured patients. Future studies should investigate the effect of insurance type on TAI outcomes and causes of higher mortality in uninsured patients.

Background: Physician scientists who are also Editorial Board members or Associate Editors may prefer publishing in their own journal and therefore create an environment for conflicts of interest to arise., Objectives: To assess the relationship between the number of peer-reviewed publications in surgical journals in which authors serve as Editorial Board Members and Associate Editors and their total number of annual publications., Materials and Methods: A cross-sectional study utilizing PubMed was performed regarding the total annual number of peer-reviewed publications by Editorial Board Members/Associate Editors and the number published in their respective affiliated journals from 2016 to 2019. Significance defined as p < 0.05., Results: 80 Associate Editors and 721 Editorial Board Members (n = 801 total) were analyzed from 10 surgical journals. The mean number of total annual peer-reviewed publications varied from 5.19 to 17.18. The mean number of annual peer-reviewed publications in affiliated journals varied from 0.06 to 2.53. Multiple significant associations were discovered between the total number of annual peer-reviewed publications and number of peer-reviewed publications in affiliated journals for all authors/surgical journals evaluated, except for the International Journal of Surgery (p > 0.05)., Conclusions: We found significant associations between the total number of annual peer-reviewed publications by Editorial Board Members/Associate Editors and number of annual peer-reviewed publications by their affiliated surgical journals. The implementation and enforcement of a standardized double-blind review process and mandatory reporting of any potential conflicts of interest can reduce possible bias and promote a fair and high-quality peer-review process., Competing Interests: Authors declare no competing interests., (© 2020 The Author(s).)

Background: The use of Twitter hashtags at medical conferences has revolutionized the way healthcare professionals interact and advance their education. We aim to investigate the scope of the Academic Surgical Congress's online reach and engagement through the use of Twitter hashtags #ASC from 2015 to 2019, by analyzing the number of impressions and tweets and retweets., Methods: A cross sectional study of Twitter data through Symplur with the following conference hashtags for the Academic Surgical Congress annual meetings for years 2015-2019: #ASC2015, #ASC2016, #ASC2017, #ASC2018, and #ASC2019. Data on tweets, retweets, users, and impressions was reviewed along with information on the top 10 influencers and the most frequently tweeted links. Symplur Signals software was utilized to extract and assimilate data. Statistical Significance was defined as p < 0.05., Results: Twitter engagement metrics significantly increased from 11,400 to 32,100 from 2015 to 2017 (p < 0.05). However, from 2017 to 2019, there was a significant decline in engagement metrics from 32,100 to 26,100 (p < 0.05). Impressions increased significantly from 13,100 in 2015 to 71,800 impressions in 2019 (p < 0.05). Users grew significantly from 1500 in 2015 to peak at 4600 in 2017 before dropping back to 3300 in 2019 (p < 0.05). The most influential organizations during these years were the organizers of the conference: Association for Academic Surgery and the Society of University Surgeons. Conference attendance progressively increased from approximately 1700 in 2016 to about 2100 in 2019 (p < 0.05)., Conclusions: Twitter engagement metrics at the Academic Surgical Congress 2015-2019 has fluctuated, while impressions significantly increased through the years indicating the consistent dissemination of conference content., Competing Interests: Authors declare no competing interests., (© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd.)

Background: Our main objective was to review the literature to answer the following questions regarding paediatric massive transfusion (PMT) protocols: (a) How is PMT defined?; (b) Which blood product ratios have been investigated, and what is their effect on outcomes?; and (c) What evidence exists regarding PMT outcomes?, Methods: The PRISMA guidelines were used. We searched PubMed, Google Scholar, Cochrane Library, EMBASE, Wiley Online Library and Ovid. Articles were screened for inclusion based on relevance to PMT. Articles were assessed for study design, presence of established/tested PMT, PMT definition, PMT activation criteria and Transfusion Ratios for the final determination of article inclusion., Results: Our search produced 3213 articles, with 33 included for final review. Existing definitions of PMT are based on volume administered/kg but vary in timeframe criteria (over 4 hours vs 24 hours). Some studies have investigated "high" balanced transfusion ratios as seen in adults (1:1 FFP:pRBC), with a few showing statistically significant improvement in paediatric mortality vs lower ratios. PMT protocol implementation has not been shown to consistently reduce paediatric trauma mortality across multiple centres. However, other operational aspects, such as reduced time to first transfusion, are apparent benefits., Conclusions: There is poor consensus over the definition of PMT. Definitions that involve early recognition have the most promise for practice and future studies. Evidence supporting an optimal blood product ratio in PMT is also lacking but trends towards supporting balanced approaches. Implementation of PMT protocols has been limited in showing significant improvement of overall paediatric trauma mortality but may reduce associated morbidity., (© 2020 British Blood Transfusion Society.)

Background: Social media amplifies the accessibility, reach and impact of medical education and conferences alike. The use of hashtags at medical conferences allows material to be discussed and improved on by the experts via online conversation on Twitter. We aim to investigate the utilization of hashtags at the American Association for the Surgery of Trauma (AAST) meetings from 2016 to 2019 and its potential role in knowledge dissemination and meeting participations., Methods: Symplur Signals software was used to analyze hashtags for the AAST meetings by year: #AAST2016, #AAST2017, #AAST2018, #AAST2019., Results: Number of tweets decreased significantly from 2016 to 2019 (4500 to 4400 to 3600 to 2600, respectively, p<0.05). Retweets also decreased significantly from 2016 to 2019 (3600 to 3300 to 2600 to 1900, respectively, p<0.05). Users decreased from 2016 to 2019 (1600 to 1400 to 937 to 743, respectively, p<0.05). Despite this decrease, impressions were 5.8 million in 2016, increasing to 8.6 million in 2017, then 9.6 million in 2018 and finally peaking in 2019 where impressions reached 10 million (p<0.05). The top influencer for 2016-2019 was the AAST Twitter account., Conclusion: Twitter #AAST 2016-2019 online engagement and interactions have declined during the last 4 years while impressions have grown steadily indicating potential widespread dissemination of trauma-related knowledge and evidence-based practices, and increased online utilization of conference material to trauma surgeons, residents and fellows, trauma scientists, other physicians and the lay public. #AAST online engagement and impressions did not have influence on meeting attendance rates., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

BACKGROUND Empyema of the gallbladder is a complication of cholecystitis that can develop into sepsis if not treated promptly. Signs and symptoms of gallstone disease are nausea/vomiting, right upper quadrant tenderness, and a history of gallstone disease. With persistence of the obstruction, inflammation and bacterial overgrowth within the gallbladder lumen and tissue may lead to eventual venous congestion, pressure necrosis and even empyema of the gallbladder. CASE REPORT A 60-year old male presented with complaints of mild mid-epigastric pain radiating to the back. He denied previous similar history. CT and ultrasound of the abdomen revealed acute cholecystitis. During surgery, it was clear that the imaging did not accurately represent the severity of the infection and he was diagnosed with gallbladder empyema. Surgery was difficult but was successfully finished. The patient's symptoms and laboratory results normalized by post-operative day 3 and he was discharged. He had no further complications during 2-week follow up. CONCLUSIONS Physicians should keep the abnormal presentations of gallbladder empyema in mind and prepare themselves for a presentation different from imaging during surgery. Several prognostic factors including gallbladder wall thickness, gender, white cell count and diabetes mellitus have been associated with severe complicated cholecystitis and empyema of the gallbladder.

Introduction: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that occur along the alimentary tract, and are most commonly found in the stomach. Rarely, these tumors can occur in the small bowel, and when located in the duodenum or proximal jejunum, they may require challenging reconstruction of the alimentary tract. Patients with GISTs often present with non-specific abdominal pain or symptoms of obstruction, hemorrhage, and less commonly perforation., Presentation of Case: A 46-year-old male presented to the hospital with a one-day history of left upper quadrant pain with fevers and chills. Physical examination was significant for signs of peritonitis, and laboratory results revealed leukocytosis and lactic acidosis. CT abdomen showed a large soft tissue mass in the proximal jejunum. In the operating theater he was found to have a perforated jejunal tumor. Pathology report revealed a 13cm GIST, pT4N0M0, Stage IIIa. He had an uneventful recovery and was discharged nine days after surgery., Discussion: Proximal jejunal GISTs are a rare entity and when present, perforation is unlikely. Pathological diagnosis of GISTs are relies on immunohistochemistry demonstrating c-KIT or CD34 positivity. The prognosis of GISTs are dependent on the size and the mitotic index. Definitive treatment of non-metastatic GISTs is R0 resection. When located in the duodenum or proximal jejunum, resection can be very challenging and may require clinical expertise in order to safely perform complex alimentary tract reconstruction., Conclusion: Further investigation is required in order to determine best practice management for patients who present with proximal GISTs., Competing Interests: No conflicts of interest., (© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd.)

Competing Interests: There are no conflicts of interest.

Background: Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications., Study Design and Methods: This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined as P < 0.05., Results: Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763], P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290], P < 0.0001)., Conclusion: Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Emergencies, Trauma, and Shock.)

Background: An invitation to speak at a national meeting represents the advancement of one's career and indicates acceptance and the attention of the scientific community. Studies have revealed gender disparities across medical and surgical society meetings. The purpose of our study was to assess the current trend of women surgeon speakers at major national trauma surgery conferences during the last 4 years (ie, 2016-2019)., Methods: A retrospective analysis of conference programs of major trauma surgery association annual meetings including the American Association for the Surgery of Trauma (AAST), the Eastern Association for the Surgery of Trauma (EAST), and the Western Trauma Association (WTA) was conducted. Our primary outcome was the number and proportion of women surgeon speakers at each conference each year., Results: Twelve conference programs from three national trauma surgery association annual meetings were reviewed. A total of 2029 speakers were included; 608 (30%) of which were female and 1421 (70%) of which were male. The proportion of women speakers ranged from 22.3% to 41.4%. The number of women speakers increased each year from 2016 to 2019: (EAST: 25.2%-39.8%, P = .049; AAST: 27.1%-41.4%, P < .00001, and WTA: 27.8%-33.3%, P = . 0.573)., Conclusion: The number of women surgeon speakers at national trauma surgery conferences significantly increased from 2016 to 2019. The increase in women trauma surgeon speakers is encouraging and should be celebrated, but organizational leadership should take this information into account while extending invitations to surgeons for speaking opportunities and continue to promote diversity and inclusivity.