Gender, racial and ethnic disparities in index hospitalization operations for symptomatic carotid stenosis in Texas hospitals.

BACKGROUND: Recent literature and societal recommendations support early revascularization of symptomatic carotid patients over the traditional six-week period. Nonetheless, the timing of these interventions can vary widely among populations. The goal of this study is to identify any factors influencing carotid revascularization during the index hospitalization for patients with symptomatic disease. METHODS: The Texas Department of State Health Services database was queried to identify all patients > 45 years old admitted to nonfederal Texas Hospitals between 2009 to 2013 with an admission diagnosis of carotid artery stenosis and either transient ischemic attack (TIA), cerebrovascular accident (CVA), or amaurosis fugax. Diagnoses codes and demographic data were also used to adjust for clinical, social, and demographic factors (including area of residence and treatment). Descriptive statistics and multivariable logistic regression were used to identify significant factors for index admission revascularization. RESULTS: A total of 29,046 symptomatic patients were identified among the 153,484 patients who had an eligible admission diagnosis. This included 16,244 (55.9%) males and 12,802 (44.1%) females. Only 4,594 (15.8%) patients were revascularized during the index hospitalization. The majority of these patients presented with amaurosis (OR 5.58; 95% CI 4.84-6.44) instead of CVAs (OR 0.48; 95% CI 0.45-0.51) or TIAs . Adjusting for hospital volume, insurance coverage, residence, and other clinical factors, rates of index admission carotid intervention remained significantly lower for women (OR 0.85; 95% CI 0.79-0.91), persons categorized as black (OR 0.60; 95% CI 0.53-0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70-0.86). CONCLUSIONS: Gender, race and ethnicity appear to correlate with rates of carotid intervention at index hospitalization despite thorough risk adjustment for clinical, social and demographic factors. Efforts should be directed towards reducing these disparities.

Resuscitative endovascular balloon occlusion of the aorta for non-traumatic intra-abdominal hemorrhage.

BACKGROUND: Hemorrhagic shock is the second leading cause of death in blunt trauma and a significant cause of mortality in non-trauma patients. The increased use of resuscitative endovascular balloon occlusion of the aorta (REBOA) as a bridge to definitive control for massive hemorrhage has provided promising results in the trauma population. We describe an extension of this procedure to our hemodynamically unstable non-trauma patients. METHODS: This is a retrospective review of patients requiring REBOA for end stage non-traumatic abdominal hemorrhage from our tertiary care facility. After excluding patients with trauma, supradiaphragmatic bleed and thoracic/abdominal aortic aneurysms, demographics, etiology of bleed, REBOA placement specifics, complications and outcomes were reviewed. RESULTS: From August 2013 to August 2016, 11 patients were identified requiring REBOA placement for hemodynamic instability from non-traumatic abdominal hemorrhage. Average patient age was 54.9 (SD 15.2). Sixty-four percent suffered cardiac arrest prior to REBOA, with mean shock index of 1.29. Average time from diagnosis of shock (MAP ≤ 65) or signs of bleeding to placement of REBOA was 177 min. The leading etiologies of hemorrhage were ruptured visceral aneurysm and massive upper gastrointestinal bleed. REBOA was placed by both acute care and vascular surgeons. The procedure was mainly completed in the operating room in 82% of the patients and at the bedside in 18%. One patient expired before operative repair. Definitive surgical control of the source of bleeding was obtained by open surgical approach (n = 6) and combined surgical and endovascular approach (n = 4). In-hospital survival was 64%. There were no local complications related to REBOA placement. CONCLUSION: Similar to the trauma population, REBOA is an adjunctive technique for proximal control of bleeding as well as resuscitation in end stage non-traumatic intra-abdominal hemorrhage. We propose an algorithmic approach to REBOA use in this population and a larger prospective review is necessary to determine both the timing of REBOA placement and which non-traumatic patients may benefit from this technique. LEVEL OF EVIDENCE: V. STUDY TYPE: Brief report.

"Second-look" laparotomy: warranted, or contributor to excessive open abdomens?

INTRODUCTION: The overuse of temporary abdominal closure and second look (SL) laparotomy in emergency general surgery (EGS) cases has been questioned in the recent literature. In an effort to hopefully decrease the number of open abdomen (OA) patients, we hypothesize that reviewing our cases, many of these SL patients could be managed with single-stage operative therapy and thus decrease the number of OA patients. METHODS: This is a retrospective review of prospectively collected data from Jun 2013-Jun 2014, evaluating EGS patients managed with an OA who required bowel resection in either index or SL laparotomy. Demographics, clinical variables, complications and mortality were collected. Fisher's exact t test was used for statistical analysis. RESULTS: During this time frame, 96 patients were managed with OA and 59 patients required a bowel resection. 55 (57%) of those required one bowel resection at the index operation with 4 (4.2%) only requiring one bowel resection at the second operation. In the patients requiring bowel resections, 18 (30%) required a resection at SL. At SL laparotomy, resection was required for questionably viable bowel at the index operation 60% (11), whereas 39% (7) had normal appearing bowel. Indications for resection at SL laparotomy included evolution of existing ischemia, new onset ischemia, staple line revision, and "other". 23 patients (39%) were hemodynamically unstable, contributing to the need for temporary abdominal closure. In the multivariate analysis, preoperative shock was the only predictor of need for further resection. Complications and mortality were similar in both groups. CONCLUSION: Almost one-fifth of the patients undergoing SL laparotomy for open abdomen required bowel resections, with 6.8% of those having normal appearing bowel at index operation, therefore in select EGS patients, SL laparotomy is a reasonable strategy.

Surgical Scarring after Arterial Bypass, an Etiology of Venous Hypertension.

Venous ulcers can be a chronic debilitating condition with a high rate of recurrence. Herein, we describe a case of a patient who successfully underwent an arterial bypass for rest pain but returned with lower extremity swelling and venous ulcers. Venography demonstrated a focal common femoral vein stenosis due to scarring from the surgical exposure. This was treated with endovenous stenting and resulted in resolution of the swelling and ulceration.

Open and Endovascular Management of Inferior Mesenteric Artery Aneurysms: A Report of Two Cases.

Inferior mesenteric artery (IMA) aneurysms are a rare entity, attributing to 1% of Splanchnic aneurysms (Edogawa S, Shibuya T, Kurose K et al. Inferior mesenteric artery aneurysm: case report and literature review. Ann Vasc Dis 2013;6:98-101), often found incidentally on evaluation for other intra-abdominal pathologies. Similar to other visceral arterial aneurysms, there is an estimated 20-50% risk of potentially fatal rupture and repair is generally recommended. We report 2 patients with IMA aneurysms, using them as cases to illustrate feasibility of both open and endovascular management options. Patient 1 is a 69-year-old male with bilateral claudication found to have an asymptomatic 20-mm IMA aneurysm. This patient underwent aortobifemoral bypass with branch polytetrafluoroethylene graft to distal IMA after excision of IMA aneurysm. Patient 2 is a 32-year-old male who underwent an ex vivo renal artery aneurysm repair and was noted on routine follow-up to have an incidental saccular 1.5-cm IMA aneurysm for which he underwent endovascular coil embolization. Both patients had an unremarkable postoperative course with a notable absence of stigmata of bowel ischemia.

The Use of Temporary Fecal Diversion in Colonic and Perianal Crohn's Disease Does Not Improve Outcomes.

AIMS: To determine whether temporary fecal diversion for refractory colonic and/or perianal Crohn's disease can lead to clinical remission and restoration of intestinal continuity after optimization of medical therapy. METHODS: We retrospectively reviewed our prospectively maintained database of patients treated at the University of Maryland for Crohn's disease between May 2004 and July 2014. Patients with colonic, perianal, or colonic and perianal Crohn's disease, who had fecal diversion for control of medically refractory and/or severe disease, were included. Outcomes, including disease activity and rate of ileostomy reversal, were evaluated up to 24 months from stoma formation. RESULTS: Thirty patients were identified. Fecal diversion was performed for perianal disease in 37%, colonic disease in 33%, and both in 30% of patients. Twelve (40%) patients underwent ileostomy reversal. Twenty-five percent of patients with perianal disease had their ostomies reversed compared to 70% of patients with colonic disease alone. More patients with complex compared to simple perianal disease remained diverted (p = 0.02). Six (20%) patients required colectomy. Of these, 50% had complex perianal disease, all had received two or more biologics, and two-thirds were on combination therapy pre-diversion. CONCLUSIONS: Our study found that nearly two-thirds of patients with medically refractory colonic and/or severe perianal Crohn's disease treated with fecal diversion and optimization of postoperative medical therapy remain diverted or require colectomy within two years after ileostomy formation. In patients with severe, refractory perianal disease and those treated with combination therapy and >1 biologic exposure pre-diversion, colectomy rather than temporary fecal diversion should be considered.

Nutcracker Syndrome: Case Report on the Management of Recurrent Stenosis After Stenting.

Nutcracker syndrome is a clinical entity leading to renal venous hypertension due to extrinsic compression of the left renal vein by the superior mesenteric artery. Current surgical therapy involves placement of an oversized renal vein stent with partial protrusion into the inferior vena cava (IVC) to relieve stenosis and prevent stent migration. Here, we present a patient with intractable pain and hematuria secondary to nutcracker syndrome who underwent left renal vein stent placement and developed recurrent symptoms due to flow-limiting kinking at the left renal hilum, with partial obstruction of the IVC from pseudointimal hyperplasia. This was treated with stent excision and construction of a left neorenal vein bypass. Thus, given these complications, we should perhaps revisit the recommendations for oversizing of the stent.

Anomalous mesenteric vessel-a rare etiology of intermittent partial small bowel obstruction.

We report a case of an 11-year with recurrent episodes of abdominal pain and vomiting. Diagnostic laparoscopy during a severe episode demonstrated an anomalous blood vessel incompletely encircling the bowel, leading to transient partial small bowel obstruction. This likely represents a remnant vessel from the omphalomesenteric duct. Recurrent abdominal pain and vomiting in the pediatric population requires careful history and physical exam, and a willingness to entertain unusual diagnoses.

Posttranscriptional regulation of 14-3-3ζ by RNA-binding protein HuR modulating intestinal epithelial restitution after wounding.

The 14-3-3ζ is a member of the family of 14-3-3 proteins and participates in many aspects of cellular processes, but its regulation and involvement in gut mucosal homeostasis remain unknown. Here, we report that 14-3-3ζ expression is tightly regulated at the posttranscription level by RNA-binding protein HuR and plays an important role in early intestinal epithelial restitution after wounding. The 14-3-3ζ was highly expressed in the mucosa of gastrointestinal tract and in cultured intestinal epithelial cells (IECs). The 3' untranslated region (UTR) of the 14-3-3ζ mRNA was bound to HuR, and this association enhanced 14-3-3ζ translation without effect on its mRNA content. Conditional target deletion of HuR in IECs decreased the level of 14-3-3ζ protein in the intestinal mucosa. Silencing 14-3-3ζ by transfection with specific siRNA targeting the 14-3-3ζ mRNA suppressed intestinal epithelial restitution as indicated by a decrease in IEC migration after wounding, whereas ectopic overexpression of the wild-type 14-3-3ζ promoted cell migration. These results indicate that HuR induces 14-3-3ζ translation via interaction with its 3' UTR and that 14-3-3ζ is necessary for stimulation of IEC migration after wounding.

miR-195 competes with HuR to modulate stim1 mRNA stability and regulate cell migration.

Stromal interaction molecule 1 (Stim1) functions as a sensor of Ca2+ within stores and plays an essential role in the activation of store-operated Ca2+ entry (SOCE). Although lowering Stim1 levels reduces store-operated Ca2+ entry and inhibits intestinal epithelial repair after wounding, the mechanisms that control Stim1 expression remain unknown. Here, we show that cellular Stim1 abundance is controlled posttranscriptionally via factors that associate with 3'-untranslated region (3'-UTR) of stim1 mRNA. MicroRNA-195 (miR-195) and the RNA-binding protein HuR competed for association with the stim1 3'-UTR and regulated stim1 mRNA decay in opposite directions. Interaction of miR-195 with the stim1 3'-UTR destabilized stim1 mRNA, whereas the stability of stim1 mRNA increased with HuR association. Interestingly, ectopic miR-195 overexpression enhanced stim1 mRNA association with argonaute-containing complexes and increased the colocalization of tagged stim1 RNA with processing bodies (P-bodies); the translocation of stim1 mRNA was abolished by HuR overexpression. Moreover, decreased levels of Stim1 by miR-195 overexpression inhibited cell migration over the denuded area after wounding but was rescued by increasing HuR levels. In sum, Stim1 expression is controlled by two factors competing for influence on stim1 mRNA stability: the mRNA-stabilizing protein HuR and the decay-promoting miR-195.