Moving forward: Recommendations to overcome existing structural racism.

A critical need exists to address structural racism within academic and community medicine and surgery and determine methods that will serve to repair its long-standing effects and alleviate the associated negative consequences. Because of our broad skillset and the populations we serve, vascular surgeons are uniquely positioned to identify and address the effects of structural racism in our places of work and for the populations we treat. Our goal is to discuss the effects of racism on healthcare outcomes and provide recommendations on how to combat these through equitable practices such as the diversification of the vascular surgery workforce, inclusivity as partners and leaders, and the promotion of improved outcomes among our most vulnerable patients from racial and ethnic minority groups. It is imperative that we stand for antiracism within our field through our societies, journals, clinical trials, training programs, clinical practice groups, and leadership.

Early Results of Popliteal Vein External Banding for Treatment of Chronic Venous Insufficiency.

BACKGROUND: Chronic venous insufficiency (CVI) encompasses a myriad of clinical manifestations including lower extremity swelling and pain, ulcerations and chronic skin changes such as stasis dermatitis, and lipodermatosclerosis. CVI effects greater than 25 million Americans and has a significant socioeconomic and psychosocial impact. Treatment of CVI varies depending on the etiology. For those patients with deep venous reflux, restoration of the deep venous valvular system is critical. Popliteal vein external banding is a novel technique to treat deep venous reflux. Our study aims to retrospectively review the early outcomes for the largest U.S. series of patients undergoing popliteal vein external banding. METHODS: Patients with C4, C5, and C6 disease with underlying deep venous reflux were treated with external banding of the popliteal vein. Basic demographic, ultrasound, and procedural data were collected. Patients were seen in clinic and underwent post procedure duplex. Procedure-specific complications were also assessed. The primary outcome was improvement of symptoms or wound healing. RESULTS: Twelve patients were identified. Seventy-five percent of patients had a history of DVT on the ipsilateral extremity and 66.7% (n = 6) of those patients had previous common or external iliac vein stenting for post-phlebitic syndrome. 58.3% of patients had active ulcerations (C6) at the time of popliteal vein banding and the mean VCSS score was 12.7, consistent with advanced venous disease. Patients were followed for a mean 8.62 months. Of the 8 patients that had active ulcers (C6), 75% completely healed with a mean time to healing of 3.3 months. 91.6% of patients reported clinical improvement in their symptoms (i.e., reduction in edema/swelling, pain or improvement in size of ulcer). Three patients had post-operative wound complications and 1 required oral antibiotic for associated cellulitis. CONCLUSION: Popliteal vein external banding represents a viable treatment modality for patients with venous insufficiency secondary to deep venous reflux. It is technically easier than most deep venous reconstructive options and may have an important role in the multimodal treatment of patients with advanced CVI.

Four-extremity venous duplex ultrasound for suspected deep venous thrombosis is an anachronism.

BACKGROUND: Duplex ultrasound is the "gold standard" for diagnosis of acute deep venous thrombosis (DVT) because of its high specificity, sensitivity, safety, and portability. However, unnecessary testing epitomizes inefficient use of scarce health care resources. Here we hypothesize that the majority of simultaneous four-extremity duplex ultrasound (FED) examinations are unnecessary. By analyzing clinical factors of patients with acute DVT found on FED, we aimed to identify a subset of high-risk patients who may have a valid indication for four-extremity testing. METHODS: We retrospectively reviewed all venous duplex ultrasound examinations performed in our Intersocietal Accreditation Commission-accredited vascular laboratory from January 1, 2009, to December 31, 2016. Patients with duplex ultrasound scans of all four limbs were included. DVT risk factors and indication for duplex ultrasound examination were recorded. The primary outcome was finding of acute DVT. RESULTS: There were 188 patients who met our search criteria, of whom 31 patients (16.5%) had acute DVT (11 upper extremity, 16 lower extremity, and 4 upper and lower extremity). Fever of unknown origin (FUO) was the main indication for requesting FED (53.7%). Patients who underwent FED for FUO had a significantly lower likelihood of DVT (odds ratio, 0.21; P = .01). DVT was rarely the proximate cause (<1% of all cases) as follow-up culture results and clinical course most often revealed other sources of fever. Only patients with an upper extremity central venous catheter (CVC; n = 103) with at least two associated risk factors had an upper extremity DVT, which was usually line associated (93%). Only patients with at least two associated risk factors had a lower extremity DVT. CONCLUSIONS: FED for FUO is inefficient, given that DVT was rarely the proximate cause of fever. Acute upper extremity DVT was found only in patients with an upper extremity CVC, demonstrating that patients without upper extremity CVC do not benefit from upper extremity duplex ultrasound examination. Upper extremity DVT is usually line associated and dependent on the number of cumulative risk factors present, suggesting that only the extremity associated with the CVC in the right clinical context should be imaged. Lower extremity DVT is also dependent on the number of cumulative risk factors present, and testing should be reserved for patients according to the clinical context. Our results indicate that a restrictive strategy can reduce testing inefficiency and health care cost without compromising patients' safety.

Mixed adenoneuroendocrine carcinoma: A review of pathologic characteristics.

Mixed adenoneuroendocrine carcinoma (MANEC) is a rare pathologic entity defined as a tumor exhibiting both adenocarcinoma and neuroendocrine carcinoma components. Though uncommon, these tumors show aggressive behavior and generally portend a poor prognosis. This study seeks to further define clinicopathological characteristics of MANEC to aid in accurate diagnosis and properly direct clinical management. Thirty-four confirmed MANECs were identified in our 25-year retrospective review of cases arising in the gastrointestinal tract. Various gross and microscopic variables were compared to overall survival. Tumors diagnosed at advanced stage (pT4), had a prominent mucinous component and lacked goblet cell clusters, which were all significantly associated with worse overall survival. This study supports previous findings and further elucidates clinicopathologic characteristics of MANEC.

Risk Factors for Surgical Site Infection in Open and Laparoscopic Hartmann Closure: A Multivariate Analysis.

BACKGROUND: Hartmann reversal is a high-morbidity procedure. The aim of this study is to identify risk factors for surgical site infection (SSI) in the era of laparoscopy. MATERIALS AND METHODS: A query of the National Surgical Quality Improvement Program database was done. Patients undergoing open or laparoscopic Hartmann reversals were identified. Risk factors for and the incidence of SSI were assessed in both groups. RESULTS: A total of 7970 patients were identified and 1431 (18%) were done laparoscopically. The SSI rate in the overall population was 13.6%, with 14.9% in those undergoing open surgery and 8% with laparoscopic procedures. Obese patients and smokers had the highest incidences of SSI (18% and 17.5%, respectively). Open surgery (odds ratio=1.8, P<0.001) and obesity (odds ratio=1.6, P<0.001) significantly correlated with higher SSI rates. CONCLUSIONS: Patients undergoing Hartmann closure are at risk for SSI. Our findings indicate that laparoscopy can significantly reduce SSI, particularly in obese patients.

Appendiceal Mixed Adeno-Neuroendocrine Carcinoma: A Population-Based Study of the Surveillance, Epidemiology, and End Results Registry.

INTRODUCTION: Mixed adeno-neuroendocrine carcinoma (MANEC) is a rare pathological diagnosis recently defined by the World Health Organization (WHO) in 2010. Prior to the definition by the WHO, tumors with both adenocarcinoma and neuroendocrine components were given multiple pathological designations making it difficult to characterize the disease. The aim of our study is to better characterize MANEC to better understand its natural history to influence patient care and positively impact outcomes. MATERIALS AND METHODS: The surveillance, epidemiology, and end results program database was queried for all patients aged 18 years or older between 1973 and 2012 who had the diagnosis composite carcinoid (n = 249) of the appendix. Composite carcinoid tumors refer to tumors that have both adenocarcinoma and carcinoid tumor components present, consistent with that pathological diagnosis MANEC. For comparison, the database was also queried for carcinoid tumor of the appendix (n = 950), signet ring cell carcinoma of the appendix (n = 579), and goblet cell carcinoid (GCC) tumors of the appendix (n = 944). The data were retrospectively reviewed, and clinicopathological characteristics, treatment regimens, and survival data were obtained. RESULTS: The median age of diagnosis of MANEC tumors was 58 years of age. Eighty percent of patients were White, and 49% were female. Fifty-four percent of patients underwent hemicolectomy and 31% had partial/subtotal colectomy as their surgical management. Median overall survival for MANEC was 6.5 years (95% CI 4.5-9.7), which was statistically significantly shorter (p < 0.0001) in comparison to 13.8 years (95% CI 12.1-16.5) for GCC, 2.1 years (95% CI 1.8-2.3) for signet ring cell carcinoma, and 39.4 years (95% CI 37.1-NA) for carcinoid tumors. DISCUSSION: MANEC is a more aggressive clinical entity than both GCC of the appendix and carcinoid tumors of the appendix. Based on these findings, patients with MANEC tumors should undergo aggressive multidisciplinary cancer management.

Mixed Adeno-neuroendocrine Carcinoma: An Aggressive Clinical Entity.

BACKGROUND: Mixed adeno-neuroendocrine carcinoma (MANEC) is a rare pathologic diagnosis recently defined by the World Health Organization in 2010. Due to poor understanding of MANEC as a clinical entity, there is significant variation in the management of these patients. The purpose of our study was to characterize MANEC to develop evidence-based treatment strategies. METHODS: The Ohio State University patient database was queried for the diagnosis of MANEC and 46 patients were identified. For comparison, the database also was queried for goblet cell carcinoid (GCC) of the appendix, signet ring cell carcinoma, and carcinoid/neuroendocrine tumor of the appendix. Charts were then retrospectively reviewed for clinicopathologic characteristics, patient treatment, and survival data. RESULTS: The mean age of diagnosis of MANEC was 54 years. Eighty-seven percent of MANEC arose from the appendix, with 28 % of patients undergoing appendectomy and 35 % undergoing right hemicolectomy as their index operation. Immunohistochemical staining was positive for chromogranin (82 %), synaptophysin (97 %), and CD56 (67 %). Sixty-seven percent of patients presented with stage IV disease and 41 % had nodal metastases. Overall survival was 4.1 years, which was statistically significantly different (p ≤ 0.05) compared with carcinoid tumors (13.4 years), GCC (15.4 years), and signet ring carcinoma (2.2 years). CONCLUSIONS: MANEC is a more aggressive clinical entity than both GCC of the appendix and carcinoid/neuroendocrine tumors of the appendix. Based on these findings, we recommend patients with MANEC tumors undergo aggressive multidisciplinary cancer management and close surveillance.

Retrospective Evaluation of Laparoscopic Versus Open Hartmann's Reversal: A Single-Institution Experience.

PURPOSE: Restoration of intestinal continuity after Hartmann's procedure has significant associated morbidity. There has been a trend toward increasing utilization of laparoscopy in colorectal surgery, with improvements in short-term outcomes. This study evaluates our experience with laparoscopic Hartmann's procedure reversal. METHODS: All patients who underwent laparoscopic and open reversal of Hartmann's procedure between 2007 and 2010 were reviewed. Demographics, length of stay, postoperative morbidity, and mortality were compared between the 2 groups. RESULTS: Nineteen patients underwent laparoscopic Hartmann's reversal and 62 underwent open reversal. There were no statistically significant differences in demographics, comorbidities, mean operative times, blood loss, reoperation, and readmission rates between the groups. The laparoscopic group had a shorter length of hospitalization (5.7 vs. 7.9 d, P<0.01). CONCLUSIONS: Laparoscopic reversal of Hartmann's pouch is a safe and feasible alternative to the open reversal technique. Patients who undergo the laparoscopic technique have a shorter length of hospital stay.

Plekhg4 is a novel Dbl family guanine nucleotide exchange factor protein for rho family GTPases.

Mutations in the PLEKHG4 (puratrophin-1) gene are associated with the heritable neurological disorder autosomal dominant spinocerebellar ataxia. However, the biochemical functions of this gene product have not been described. We report here that expression of Plekhg4 in the murine brain is developmentally regulated, with pronounced expression in the newborn midbrain and brainstem that wanes with age and maximal expression in the cerebellar Purkinje neurons in adulthood. We show that Plekhg4 is subject to ubiquitination and proteasomal degradation, and its steady-state expression levels are regulated by the chaperones Hsc70 and Hsp90 and by the ubiquitin ligase CHIP. On the functional level, we demonstrate that Plekhg4 functions as a bona fide guanine nucleotide exchange factor (GEF) that facilitates activation of the small GTPases Rac1, Cdc42, and RhoA. Overexpression of Plekhg4 in NIH3T3 cells induces rearrangements of the actin cytoskeleton, specifically enhanced formation of lamellopodia and fillopodia. These findings indicate that Plekhg4 is an aggregation-prone member of the Dbl family GEFs and that regulation of GTPase signaling is critical for proper cerebellar function.