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The development of long-term symptoms of coronavirus disease 2019 (COVID-19) more than four weeks after primary infection, termed “long COVID” or post-acute sequela of COVID-19 (PASC), can implicate persistent neurological complications in up to one third of patients and present as fatigue, “brain fog”, headaches, cognitive impairment, dysautonomia, neuropsychiatric symptoms, anosmia, hypogeusia, and peripheral neuropathy. Pathogenic mechanisms of these symptoms of long COVID remain largely unclear; however, several hypotheses implicate both nervous system and systemic pathogenic mechanisms such as SARS-CoV2 viral persistence and neuroinvasion, abnormal immunological response, autoimmunity, coagulopathies, and endotheliopathy. Outside of the CNS, SARS-CoV-2 can invade the support and stem cells of the olfactory epithelium leading to persistent alterations to olfactory function. SARS-CoV-2 infection may induce abnormalities in innate and adaptive immunity including monocyte expansion, T-cell exhaustion, and prolonged cytokine release, which may cause neuroinflammatory responses and microglia activation, white matter abnormalities, and microvascular changes. Additionally, microvascular clot formation can occlude capillaries and endotheliopathy, due to SARS-CoV-2 protease activity and complement activation, can contribute to hypoxic neuronal injury and blood–brain barrier dysfunction, respectively. Current therapeutics target pathological mechanisms by employing antivirals, decreasing inflammation, and promoting olfactory epithelium regeneration. Thus, from laboratory evidence and clinical trials in the literature, we sought to synthesize the pathophysiological pathways underlying neurological symptoms of long COVID and potential therapeutics.

Expanding the liver donor pool includes reconsidering geographic characteristics. We evaluated demographics, trends, and outcomes of transplants from donors outside the contiguous US. Adult liver-only transplants from 2010 to 2022 were categorized by donor location (mainland US vs. non-mainland) using national registry data. Post-transplant survival was evaluated using time-to-event analysis, univariate and multivariable Cox regression. 1531 (1.5 ​%) liver transplants utilized non-mainland organs (991 performed in mainland US). Non-mainland to mainland donors were older, smoked less, had a lower BMI, and less steatosis (all p ​< ​0.05). Non-mainland organs traveled further (1241 vs. 84 miles,p ​< ​0.01) with longer ischemic times (8.6 vs. 5.9 ​h,p ​< ​0.01). Length of stay (p ​= ​0.80) and acute rejection (p ​= ​0.14) did not differ. Non-mainland recipients had similar survival at 1-(aHR 1.02, p ​= ​0.85), 5-(aHR 0.93, p ​= ​0.38), and 10-years (aHR 0.96, p ​= ​0.56). Non-mainland recipients had similar LOS and survival despite longer distance and cold ischemic time, emphasizing further consideration for non-mainland transplantation. •From 2010 to 2022, 1531 transplants utilized non-mainland donor organs, with 991 performed at centers in the mainland US.•Non-mainland donors had lower BMI, rates of cigarette smoking, and hepatic steatosis.•Outcomes were similar for non-mainland liver transplants despite longer ischemic time and travel distance.•Selected non-mainland liver donors may be increasingly considered for mainland transplantation.

Purpose Surgical video-based education (VBE) facilitates the understanding of surgical knowledge and technical skills and is an expanding field within surgical education. Medical students on their surgical clerkship may benefit from the use of resources focused on their needs to prepare for surgical cases. The primary objective of this study was to compare participants’ understanding of surgical content through multiple-choice (MC) and simulated intraoperative questions when using surgical video-based versus text-based education as preparation resources. Additional objectives included evaluating time spent on preparation and student perspectives on the use of surgical VBE. Methods Preclinical medical students were enrolled in a randomized controlled trial with cross-over. Each participant was randomly assigned a surgical video-based resource to prepare for a laparoscopic cholecystectomy or thyroidectomy surgical procedure, with a textbook resource allocated to the remaining procedure. After a 24-h preparation period, participants watched pre-recorded videos of both surgical procedures via proctored video conference. Multiple-choice assessments and simulated intraoperative questions assessed knowledge of surgical anatomy, complications, and clinical knowledge. Paired t tests were utilized to compare differences in study outcomes between arms. Results Forty-nine participants were enrolled, of which 37 completed the study. Participants who received VBE as preparation for the surgical gallbladder topic had significantly higher post-intervention MC scores than those who received text-based resources (78% vs. 65% correct, p  = 0.02). There was no significant difference in performance on the intraoperative questions between the VBE and text-based groups for either surgical procedure ( p  > 0.05). Surveys indicated a preference for VBE over text-based resources, including increased perceived helpfulness and preparedness, reduced anxiety, improved ability to follow surgical steps, and increased likelihood to recommend VBE to peers (all p  < 0.001). VBE was perceived to be significantly more efficient ( p  < 0.0001), and participants spent significantly less time on VBE versus text-based preparation (35.3 min vs. 44.7 min, p  = 0.004). Conclusion The surgical VBE resource used in this study improved medical student performance on assessments of surgical gallbladder disease compared to a text resource. The video-based resource required significantly less preparation time and was strongly preferred by student participants. Resources containing augmented videos appear more efficient and have promise to improve medical student preparation for the operating room.

We report the case of a 53-year-old male who developed polycompartment syndrome (PCS) secondary to cardiogenic shock. After suffering a cardiac arrest, a self-perpetuating cycle of intra-abdominal hypertension (IAH) and vital organ damage led to abdominal compartment syndrome (AbCS), which then contributed to the precipitation of extremity compartment syndrome (CS) in bilateral thighs, legs, forearms, and hands. This report is followed by a review of the literature regarding the pathophysiology of this rare sequela of cardiogenic shock. While the progression from cardiogenic shock to AbCS and ultimately to PCS has been hypothesized, no prior case reports demonstrate this. Furthermore, this case suggests more generally that IAH may be a risk factor for extremity CS. Future studies should examine the potential interplay between IAH and extremity CS in patients at risk, such as polytrauma patients with tibial fractures.

Introduction The standard of care for gastric cancer in the United States involves perioperative chemotherapy. While most post-therapy pathologic staging results are concordant (i.e. ypT + N + or ypT0N0), patients occasionally display discordant results, such as ypT0N1. Herein, we characterized the survival of patients with ypT0N1 staging to better determine their categorization within the American Joint committee on Cancer (AJCC) staging system. Methods Using the National Cancer Database (NCDB), we queried all patients diagnosed with gastric adenocarcinoma from 2004 to 2021 who received neoadjuvant chemotherapy. Patients were stratified by their ypTNM stage: (1) ypT0N0; (2) ypT+N0; (3) ypT+N1; and (4) ypT0N1. Multivariable Cox proportional hazard regression was used to assess 5- and 10-year survival between ypTNM stages. Results A total of 28,985 patients received neoadjuvant chemotherapy, of whom 2378 (8.2%) had ypT0N0, 9402 (32.4%) had ypT+N0, 5339 (18.4%) had ypT+N1, and 318 (1.1%) had ypT0N1 staging. Overall, patients had a median age of 64 years, with the majority being male (74.9%) or White (82.2%). Additionally, 50.2% received care from an academic center, and 53.3% received neoadjuvant chemotherapy and radiotherapy. On multivariable analysis, patients with ypT0N1 had a 105% higher risk for mortality within 5 years (adjusted hazards ratio [aHR] 2.05, 95% confidence interval [CI] 1.69–2.50) and 86% increased risk within 10 years (aHR 1.86, 95% CI 1.54–2.23) when compared with ypT0N0. Conclusion Patients with stage ypT0N1 disease have worse 5- and 10-year outcomes than those with node-negative disease. Thus, their survival pattern most closely matches patients with ypstage IIB and III disease.

Myasthenia gravis (MG) is an antibody-mediated disorder that disrupts postsynaptic acetylcholine receptors with consequent fatigable weakness, bulbar symptoms, and respiratory fragility. MG patients can be challenging to manage during open abdominal surgery given the unpredictable efficacy of neuromuscular and reversal agents and the risk of precipitating an MG crisis. Regional neuraxial anesthesia eliminates the need for these agents and endotracheal intubation. Here, we report the case of a 66-year-old male with a history of advanced MG, vasovagal episodes with bradycardia and asystolic arrest, and complicated diverticulitis who underwent an uncomplicated open sigmoid colectomy achieved with epidural anesthesia-analgesia. Neuraxial anesthesia can be considered and further investigated as an effective approach in optimizing high-risk patients undergoing open laparotomy for colorectal surgical care.

Emphysematous pancreatitis (EP) is a rare and potentially fatal condition of the pancreas. It is associated with gas-forming bacteria and is characterized by the presence of gas in or around the pancreas. It is identified by a computed tomography scan of the abdomen. Although predisposing factors are not precisely known, diabetes mellitus, which predisposes to gas gangrene, is seen to be commonly associated with patients of EP. EP being potentially fatal requires immediate management. Surgery is generally indicated in EP. However, EP can also managed conservatively. In our case, the patient developed recurrent pancreatitis, the cause being idiopathic, and the second episode of acute pancreatitis was complicated by EP and gastroduodenal artery pseudoaneurysm.