Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale.

BACKGROUND: Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. METHODS: A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. RESULTS: A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. CONCLUSION: Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.

Symptom phenotyping in people with cystic fibrosis during acute pulmonary exacerbations using machine-learning K-means clustering analysis.

INTRODUCTION: People with cystic fibrosis (PwCF) experience frequent symptoms associated with chronic lung disease. A complication of CF is a pulmonary exacerbation (PEx), which is often preceded by an increase in symptoms and a decline in lung function. A symptom cluster is when two or more symptoms co-occur and are related; symptom clusters have contributed meaningful knowledge in other diseases. The purpose of this study is to discover symptom clustering patterns in PwCF during a PEx to illuminate symptom phenotypes and assess differences in recovery from PExs. METHODS: This study was a secondary, longitudinal analysis (N = 72). Participants at least 10 years of age and being treated with intravenous antibiotics for a CF PEx were enrolled in the United States. Symptoms were collected on treatment days 1-21 using the CF Respiratory Symptom Diary (CFRSD)-Chronic Respiratory Symptom Score (CRISS). K-means clustering was computed on day 1 symptom data to detect clustering patterns. Linear regression and multi-level growth models were performed. RESULTS: Symptoms significantly clustered based on severity: low symptom (LS)-phenotype (n = 42), high symptom (HS)-phenotype (n = 30). HS-phenotype had worse symptoms and CRISS scores (p< 0.01) than LS-phenotype. HS-phenotype was associated with spending 5 more nights in the hospital annually (p< 0.01) than LS-phenotype. HS-phenotype had worse symptoms over 21 days than LS-phenotype (p< 0.0001). CONCLUSION: Symptoms significantly cluster on day 1 of a CF-PEx. PwCF with HS-phenotype spend more nights in the hospital and are less likely to experience the same resolution in symptoms by the end of PEx treatment than LS-phenotype.

Predicting return of lung function after a pulmonary exacerbation using the cystic fibrosis respiratory symptom diary-chronic respiratory infection symptom scale.

Background: Pulmonary exacerbations (PExs) in people with cystic fibrosis (PwCF) are associated with increased healthcare costs, decreased quality of life and the risk for permanent decline in lung function. Symptom burden, the continuous physiological and emotional symptoms on an individual related to their disease, may be a useful tool for monitoring PwCF during a PEx, and identifying individuals at high risk for permanent decline in lung function. The purpose of this study was to investigate if the degree of symptom burden severity, measured by the Cystic Fibrosis Respiratory Symptom Diary (CFRSD)- Chronic Respiratory Infection Symptom Scale (CRISS), at the onset of a PEx can predict failure to return to baseline lung function by the end of treatment. Methods: A secondary analysis of a longitudinal, observational study (N = 56) was conducted. Data was collected at four time points: year-prior-to-enrollment annual appointment, termed "baseline", day 1 of PEx diagnosis, termed "Visit 1", day 10-21 of PEx diagnosis, termed "Visit 2" and two-weeks post-hospitalization, termed "Visit 3". A linear regression model was performed to analyze the research question. Results: A regression model predicted that recovery of lung function decreased by 0.2 points for every increase in CRISS points, indicating that participants with a CRISS score greater than 48.3 were at 14% greater risk of not recovering to baseline lung function by Visit 2, than people with lower scores. Conclusion: Monitoring CRISS scores in PwCF is an efficient, reliable, non-invasive way to determine a person's status at the beginning of a PEx. The results presented in this paper support the usefulness of studying symptoms in the context of PEx in PwCF.

Cancer-related cognitive impairment in racial and ethnic minority groups: a scoping review.

PURPOSE: Disparities in cognitive function among racial and ethnic groups have been reported in non-cancer conditions, but cancer-related cognitive impairment (CRCI) in racial and ethnic minority groups is poorly understood. We aimed to synthesize and characterize the available literature about CRCI in racial and ethnic minority populations. METHODS: We conducted a scoping review in the PubMed, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature databases. Articles were included if they were published in English or Spanish, reported cognitive functioning in adults diagnosed with cancer, and characterized the race or ethnicity of the participants. Literature reviews, commentaries, letters to the editor, and gray literature were excluded. RESULTS: Seventy-four articles met the inclusion criteria, but only 33.8% differentiated the CRCI findings by racial or ethnic subgroups. There were associations between cognitive outcomes and the participants' race or ethnicity. Additionally, some studies found that Black and non-white individuals with cancer were more likely to experience CRCI than their white counterparts. Biological, sociocultural, and instrumentation factors were associated with CRCI differences between racial and ethnic groups. CONCLUSIONS: Our findings indicate that racial and ethnic minoritized individuals  may be disparately affected by CRCI. Future research should use standardized guidelines for measuring and reporting the self-identified racial and ethnic composition of the sample; differentiate CRCI findings by racial and ethnic subgroups; consider the influence of structural racism in health outcomes; and develop strategies to promote the participation of members of racial and ethnic minority groups.

A telehealth intervention to increase patient preparedness for surgery: a randomized trial.

INTRODUCTION AND HYPOTHESIS: Methods to increase surgical preparedness in urogynecology are lacking. Our objective was to evaluate the impact of a preoperative provider-initiated telehealth call on surgical preparedness. METHODS: This was a multicenter randomized controlled trial. Women undergoing surgery for pelvic organ prolapse and/or stress urinary incontinence were randomized to either a telehealth call 3 (± 2) days before surgery plus usual preoperative counseling versus usual preoperative counseling alone. Our primary outcome was surgical preparedness, as measured by the Preoperative Prepardeness Questionnaire. The Modified Surgical Pain Scale, Pelvic Floor Distress Inventory-20, Patient Global Impressions of Improvement, Patient Global Impressions of Severity, Satisfaction with Decision Scale, Decision Regret Scale, and Clavien-Dindo scores were obtained at 4-8 weeks postoperatively and comparisons were made between groups. RESULTS: Mean telehealth call time was 11.1 ± 4.11 min. Women who received a preoperative telehealth call (n = 63) were significantly more prepared for surgery than those who received usual preoperative counseling alone (n = 69); 82.5 vs 59.4%, p < 0.01). A preoperative telehealth call was associated with greater understanding of surgical alternatives (77.8 vs 59.4%, p = 0.03), complications (69.8 vs 47.8%, p = 0.01), hospital-based catheter care (54 vs 34.8%, p = 0.04) and patient perception that nurses and doctors had spent enough time preparing them for their upcoming surgery (84.1 vs 60.9%, p < 0.01). At 4-8 weeks, no differences in postoperative and patient reported outcomes were observed between groups (all p > 0.05). CONCLUSIONS: A short preoperative telehealth call improves patient preparedness for urogynecological surgery.

Effects of meditation compared to music listening on biomarkers in breast cancer survivors with cognitive complaints: secondary outcomes of a pilot randomized control trial.

CONTEXT: We previously reported positive behavioral effects of both daily mantra meditation and classical music listening interventions in breast cancer survivors with cancer related cognitive complaints. OBJECTIVE: The objective of this pilot study was to compare the effects of the meditation intervention to a music listening intervention on biomarkers of inflammation and cellular aging (secondary outcomes) in breast cancer survivors. DESIGN: Randomized control trial, baseline data collection (time 1), post intervention data collection (time 2) SETTING: Community-based, Central Texas PARTICIPANTS: 25 breast cancer survivors (BCS) who were 3 months to 6 years post chemotherapy completion and reported cognitive changes. INTERVENTION(S): Kirtan Kriya meditation (KK) or classical music listening (ML), 8 weeks, 12 min a day MAIN OUTCOME: Telomerase activity [TA], c-reactive protein [CRP], soluble IL-2 receptor alpha [sIL-2Rα], soluble IL-4 receptor [sIL-4R], soluble IL-6 receptor [sIL-6R], soluble tumor necrosis factor receptor II [sTNF-RII], VEGF receptor 2 [sVEGF-R2], and VEGF receptor 3 [sVEGF-R3] RESULTS: Repeated measures analysis of variance models were analyzed from time 1 to time 2 by group for each biomarker. A pattern of greater telomerase activity across time in both groups (F (1,15) = 3.98, p = .06, ω2 = 0.04); significant decreases in sIL-4R across time for both groups (F (1,22) = 6.28, p = .02, ω2 = .003); group*time effect was nominally different but not statistically different for sIL-4R (F(1,22) = 3.82, p = .06, ω2 = .001); and a pattern for a group*time effect with ML group showing higher levels of sVEGF-R3 at time 2 (F (1,20) = 2.59, p = .12, ω2 = .009). No significant effects were found for CRP, sIL-2Rα, sIL-6R, sTNF-RII, or sVEGF-R2.

The Use of Ancillary Services Under a Bundled Care Versus a Fee-For-Service Payment Model.

OBJECTIVES: Colocated services in a team-based integrated practice unit (IPU) optimize care of pelvic floor disorders. Our goal was to compare ancillary service utilization in a multidisciplinary IPU between patients covered by a bundled payment model (BPM) versus a traditional fee-for-service model (FFSM). METHODS: Medical records of women attending an IPU for pelvic floor disorders with colocated services, including nutrition, social work, psychiatry, physical therapy, and subspecialty care between October 2017 and December 2018, were included in this retrospective chart review. All patients were offered treatment with ancillary services according to standardized care pathways. Data extracted included patient demographics, pelvic floor disorder diagnoses, baseline severity measures, payment model, and ancillary services used. Univariate and multivariate logistic regression identified variables predicting higher uptake of ancillary services. RESULTS: A total of 575 women with pelvic floor disorders presented for care during the study period, of which 35.14% attended at least 1 appointment with any ancillary services provider. Ancillary service utilization did not differ between patients in the BPM group and those in the FFSM group (36.22 vs 33.47%; P = 0.489). Social work services were more likely to be used by the BPM compared with the FFSM group (15.95 vs 6.28%; P < 0.001). The diagnosis of fecal incontinence was associated with a higher chance of using any ancillary service (odds ratio, 4.91; 95% confidence interval, 1.81-13.33; P = 0.002). CONCLUSIONS: One third of patients with pelvic floor disorders receiving care in an IPU used colocated ancillary services. Utilization does not differ between payment models.

A Cross-Sectional Exploration of Cytokine-Symptom Networks in Breast Cancer Survivors Using Network Analysis.

PURPOSE: The purpose of this study is to (a) visualize the symptom-cytokine networks (perceived stress, fatigue, loneliness, perceived cognitive impairment, daytime sleepiness, sleep quality, and 13 cytokines) and (b) explore centrality metrics of symptom-cytokine networks in breast cancer survivors who completed chemotherapy treatment. METHODS: Cross-sectional analysis of data collected from 66 breast cancer survivors who were on average three years post chemotherapy completion. Perceived stress, fatigue, loneliness, perceived cognitive impairment, daytime sleepiness, and sleep quality were measured with self-report instruments, and a panel of 13 cytokines was measured from serum using multiplex assays. Symptoms and cytokines were simultaneously evaluated with correlations, network analysis, and community analysis. RESULTS: Network analysis revealed the nodes with the greatest degree and closeness were interleukin-2, granulocyte-macrophage colony-stimulating factor, interleukin-13, and perceived cognitive impairment. Node betweenness was highest for perceived cognitive impairment and interleukin-2. Community analysis revealed two separate communities of nodes within the network (symptoms and the cytokines). Several edges connected the two communities including perceived cognitive impairment, stress, fatigue, depression, interleukin-2, granulocyte-macrophage colony-stimulating factor, interleukin-8, interleukin-13, and interleukin-10. Partial correlation analyses revealed significant negative relationships between interleukin-2 and fatigue, loneliness, stress, and perceived cognitive impairment (rs = -.27 to -.37, ps < .05) and a significant negative relationship between perceived cognitive impairment and granulocyte-macrophage colony-stimulating factor (r = -.34, p < .01). CONCLUSIONS: Our analyses support that perceived cognitive impairment, stress, loneliness, depressive symptoms, and fatigue co-occur and extend the literature by suggesting that interleukin-2 may contribute to the underlying mechanistic pathway of these co-occurring symptoms. Our findings add to a growing body of literature that is shifting to study symptoms as they co-occur, or cluster, rather than individual symptoms.

Association of Obesity with DNA Methylation Age Acceleration in African American Mothers from the InterGEN Study.

African American women are affected by earlier onset of age-associated health deteriorations and obesity disproportionally, but little is known about the mechanism linking body mass index (BMI) and biological aging among this population. DNA methylation age acceleration (DNAm AA), measuring the difference between DNA methylation age and chronological age, is a novel biomarker of the biological aging process, and predicts aging-related disease outcomes. The present study estimated cross-tissue DNA methylation age acceleration using saliva samples from 232 African American mothers. Cross-sectional regression analyses were performed to assess the association of BMI with DNAm AA. The average chronological age and DNA methylation age were 31.67 years, and 28.79 years, respectively. After adjusting for smoking, hypertension diagnosis history, and socioeconomic factors (education, marital status, household income), a 1 kg/m2 increase in BMI is associated with 0.14 years increment of DNAm AA (95% CI: (0.08, 0.21)). The conclusion: in African American women, high BMI is independently associated with saliva-based DNA methylation age acceleration, after adjusting for smoking, hypertension, and socioeconomic status. This finding supports that high BMI accelerates biological aging, and plays a key role in age-related disease outcomes among African American women.

Significance of Microbiota in Obesity and Metabolic Diseases and the Modulatory Potential by Medicinal Plant and Food Ingredients.

Metabolic syndrome is a cluster of three or more metabolic disorders including insulin resistance, obesity, and hyperlipidemia. Obesity has become the epidemic of the twenty-first century with more than 1.6 billion overweight adults. Due to the strong connection between obesity and type 2 diabetes, obesity has received wide attention with subsequent coining of the term "diabesity." Recent studies have identified unique contributions of the immensely diverse gut microbiota in the pathogenesis of obesity and diabetes. Several mechanisms have been proposed including altered glucose and fatty acid metabolism, hepatic fatty acid storage, and modulation of glucagon-like peptide (GLP)-1. Importantly, the relationship between unhealthy diet and a modified gut microbiota composition observed in diabetic or obese subjects has been recognized. Similarly, the role of diet rich in polyphenols and plant polysaccharides in modulating gut bacteria and its impact on diabetes and obesity have been the subject of investigation by several research groups. Gut microbiota are also responsible for the extensive metabolism of polyphenols thus modulating their biological activities. The aim of this review is to shed light on the composition of gut microbes, their health importance and how they can contribute to diseases as well as their modulation by polyphenols and polysaccharides to control obesity and diabetes. In addition, the role of microbiota in improving the oral bioavailability of polyphenols and hence in shaping their antidiabetic and antiobesity activities will be discussed.

Relationships among psychoneurological symptoms and levels of C-reactive protein over 2 years in women with early-stage breast cancer.

PURPOSE: The aim of the present study was to explore clusters of psychoneurological symptoms and inflammation (levels of C-reactive protein) over time in a cohort of women with early-stage breast cancer. Specifically, we examined the relationships among affective symptoms (depression, anxiety, fatigue, sleep disturbances, pain, and perceived stress), domains of cognitive performance, and levels of peripheral C-reactive over a period of 2 years. METHODS: This was a prospective, longitudinal study of 77 women diagnosed with early-stage breast cancer. Data collection, including symptom questionnaires, performance-based cognitive testing, and blood draws, took place at 5 time points: prior to initiating adjuvant chemotherapy, prior to the fourth chemotherapy treatment, and at 6, 12, and 24 months after the initiation of chemotherapy. RESULTS: Exploratory factor analysis with varimax orthogonal rotation was used to examine the covariance among symptoms at each visit. Using the factor scores and weighted sums, three clusters were identified: global cognition, affective symptoms, and cognitive efficiency. Peripheral levels of C-reactive protein were inversely correlated with the cognitive efficiency factor across time. CONCLUSIONS: The findings suggest that objectively measured domains of cognitive function occur independently of other affective symptoms that are commonly reported by women with breast cancer in long-term survivorship. The cognitive efficiency symptom cluster may be amenable to interventions targeted to biological influences that reduce levels of C-reactive protein.

Autologous bone marrow mononuclear cell implantation therapy is an effective limb salvage strategy for patients with severe peripheral arterial disease.

OBJECTIVE: This study was conducted to determine if intramuscular and intra-arterial stem cell injections delay or prevent major limb amputations, improve ankle-brachial index measurements, relieve rest pain, and improve ulcer healing. METHODS: A prospective case series with interventions occurring between December 2007 and September 2012 and a 3-month minimum follow-up was conducted at an urban tertiary care referral hospital. Patients with severe limb-threatening peripheral arterial disease, without other options for revascularization, were eligible for enrollment. Dual intramuscular and intra-arterial injection of bone marrow mononuclear cells harvested from the iliac crest was performed. Major limb amputation at 3 months was the primary outcome measure. Secondary outcome measures included ankle-brachial index measurements, rest pain, and ulceration healing. Kaplan-Meier survivorship was performed to ascertain overall survivorship of the procedure. RESULTS: No complications related to the procedure were reported. Of 49 patients (56 limbs) enrolled, two patients (two limbs) died, but had not undergone major amputation, and five limbs (8.9%) underwent major amputation within the first 3 months. Three-month follow-up evaluations were conducted on the remaining 49 limbs (42 patients). Median postprocedure revised Rutherford and Fontaine classifications were significantly lower compared with median baseline classifications. After 3 months, seven patients (nine limbs) died but had not undergone major amputation, and seven limbs (14.3%) underwent major amputation. At a mean follow-up of 18.2 months, the remaining 33 limbs (29 patients) had not undergone a major amputation. Freedom from major adverse limb events (MALE) was 91.1% (95% confidence interval, 79.9-96.2) at 3 months and 75.6% (95% confidence interval, 59.4-86.1) at 12 months. CONCLUSIONS: This procedure was designed to improve limb perfusion in an effort to salvage limbs in patients for whom amputation was the only viable treatment option. The results of this analysis indicate that it is an effective strategy for limb salvage for patients with severe peripheral arterial disease.

A five-year review of management of upper-extremity arterial injuries at an urban level I trauma center.

BACKGROUND: Upper-extremity arterial injuries are relatively uncommon, but they may significantly impact patient outcome. Management of these injuries was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS: Upper-extremity trauma patients presenting with arterial injury between January 2005 and July 2010 were included in this retrospective review. Descriptive statistics were used to describe demographic, injury, treatment, and outcome data. These variables also were compared between blunt and penetrating arterial injuries and between proximal and distal arterial injuries. RESULTS: During a 5.6-year period, 135 patients with 159 upper-extremity arterial injuries were admitted, yielding an incidence of 0.74% among trauma admissions. The majority of patients (78.5%) suffered concomitant upper-extremity injuries. The most common injury mechanism was laceration by glass (26.4%). Arterial injuries were categorized into 116 penetrating (73.0%) and 43 blunt (27.0%) mechanisms. Arterial distribution involved was as follows: 13 axillary (8.2%), 40 brachial (25.2%), 52 radial (32.7%), 51 ulnar (32.1%), and 3 other (1.9%). The types of arterial injuries were as follows: 69 transection (43.4%), 68 laceration (42.8%), 16 occlusion (10.1%), 3 avulsion (1.9%), and 3 entrapment (1.9%). One patient (0.7%) required a primary above-elbow amputation. The majority of injuries (96.8%) receiving vascular management underwent surgical intervention--76 primary repair (49.7%), 41 ligation (26.8%), 31 bypass (20.3%), and 5 endovascular (3.3%). Conservative treatment was the primary strategy for five arterial injuries (3.3%). Of the patients receiving vascular intervention, three (2.2%) required major and three (2.2%) required minor amputations during hospitalization and no patients expired. CONCLUSION: The current multidisciplinary team management approach with prompt surgical management resulted in successful outcomes after upper-extremity arterial injuries. No outcome differences between penetrating and blunt or between proximal and distal arterial injuries were calculated. This management approach will continue to be used.

Treatment of varicose veins by transilluminated powered phlebectomy surgery: a 9-year experience.

Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique for varicose vein removal that addresses some limitations of traditional procedures. The study objective was to analyze perioperative and follow-up outcomes after TIPP and present modifications gleaned over 9 years of performing the technique. Four hundred and thirty-one patients who underwent TIPP performed between June 2002 and April 2011 were included in this retrospective review. Descriptive statistics were used to describe demographic, treatment, and outcome data. The mean procedure time was 20.2 minutes. The majority (50.5%) of cases involved 10 to 20 incisions. No significant varicosities were reported at a follow-up of 12 weeks. Postoperative complications included 2 (0.5%) deep vein thromboses, 8 (1.9%) cellulitis episodes, 16 (3.7%) hemosiderin staining cases, 2 (0.5%) abscesses, and 2 (0.5%) cases of excessive or hypertrophic scarring. All but one patient reported good outcomes and were satisfied with the procedure. With proper training and experience, TIPP with a lower oscillation frequency and secondary tumescence results in good outcome and high patient satisfaction.

Short- to mid-term results using autologous bone-marrow mononuclear cell implantation therapy as a limb salvage procedure in patients with severe peripheral arterial disease.

Short- to mid-term results of a prospective study evaluating dual intramuscular and intra-arterial autologous bone-marrow mononuclear cell (BM-MNC) implantation for the treatment of patients with severe peripheral arterial occlusive disease (PAD) in whom amputation was considered the only viable treatment option are presented. Ankle-brachial indices (ABIs), rest pain, and ulcer healing were assessed at 3 months. Success was defined as improvement in ABI measurements; absence of rest pain; absence of ulcers; and absence of major limb amputations. Twenty patients (21 limbs) have been enrolled. Three-month follow-up evaluation accounting included 18 patients (19 limbs). Four (22.2%) major and 2 (11.1%) minor amputations were performed within 3 months postoperatively. With 17 (94.4%) of 18 limbs demonstrating at least one criterion for success and major amputation avoided in 14 (77.8%) of 18 limbs at the 3-month evaluation, this specific BM-MNC implantation technique is an effective limb salvage strategy for patients with severe PAD.

A 5-year review of management of lower extremity arterial injuries at an urban level I trauma center.

BACKGROUND: The purpose of this study was to review the management of lower extremity arterial injuries to determine incidence, assess the current management strategy, and evaluate hospital outcome. METHODS: This was a retrospective review, including trauma database query, and medical records review set in an urban level I trauma center. Sixty-five patients with 75 lower extremity arterial injuries were admitted between April 2005 and April 2010. The interventions were primary amputation, medical management, vascular surgical intervention, and subsequent amputation. The main outcome measures were age, gender, race, mechanism of injury, type of injury, associated lower extremity injuries, concomitant injuries, Injury Severity Score, Abbreviated Injury Scale, surgical procedures and interventions, limb salvage rate, mortality, length of stay, and discharge disposition. RESULTS: During a 5-year period, 65 patients with 75 lower extremity arterial injuries were admitted to the hospital, yielding an incidence of 0.39% among trauma admissions. The study population was comprised primarily of young men, with a mean Injury Severity Score of 15.2 and a mean Abbreviated Injury Scale of 2.7 (moderate to severe injuries). The majority of patients (78.4%) suffered concomitant lower extremity injuries, most frequently bony or venous injuries, whereas 35.4% experienced associated injuries to other body regions. The most common injury mechanism was a gunshot wound (46.7%). Arterial injuries were categorized into 42 penetrating (56.0%) and 33 blunt mechanisms (44.0%). Involved arterial distribution was as follows: 4 common femoral (5.3%), 4 profunda femoris (5.3%), 24 superficial femoral (32.0%), 16 popliteal (21.3%), and 27 tibial (36.0%) arteries. The types of arterial injuries were as follows: 28 occlusion (37.3%), 23 transection (30.7%), 16 laceration (21.3%), and 8 dissection (10.7%). Orthopedic surgeons performed amputations as primary procedures in 3 patients (4.6%). The majority (76.8%) of injuries receiving vascular management underwent surgical intervention, with procedure distribution as follows: 26 bypass (49.1%); 13 primary repair (24.5%); 7 ligation (13.2%); 4 endovascular (7.5%); and 3 isolated thrombectomy (5.7%) procedures. Concomitant venous repair and fasciotomy were performed in 22.4% and 38.2% of cases, respectively. Medication was the primary strategy for 16 arterial injuries (23.2%). Subsequent major amputation was required for 3 patients (4.8%) who initially received vascular management. Three patients (4.6%) died during hospitalization. CONCLUSION: The current multidisciplinary team management approach, including use of computed tomographic or conventional angiography and prompt surgical management, resulted in successful outcomes after lower extremity arterial injuries and will continue to be utilized.

Postdischarge outcomes of blunt cerebrovascular injuries.

A retrospective review was conducted to assess outcomes of blunt cerebrovascular injuries (BCVIs) diagnosed in a 14-month period at a level-1 trauma center and evaluated postdischarge at a single vascular practice. Twenty-nine patients with 34 BCVIs (10 carotid; 24 vertebral) were admitted. Eleven (37.9%) patients were treated with combined anticoagulation and antiplatelet therapy, 9 (31.0%) with anticoagulation, and 4 (13.8%) with antiplatelets. Five (17.2%) patients underwent observation. Seventeen (58.6%) patients (19 injuries) returned for follow-up evaluation. At a mean follow-up of 9.2 weeks, all patients had normal neurological examinations with no complications. Sixteen (84.2%) BCVIs resolved. Anticoagulation and antiplatelet therapies were equally effective in preventing cerebral infarction. Although the majority of lesions resolve, BCVIs have the ability to progress and often require surgical intervention. Routine follow-up after discharge is warranted for all BCVIs and should include repeat computed tomography angiography (CTA) with bilateral carotid/vertebral duplex ultrasound (US) as a physiological test.

Use of autologous bone marrow mononuclear cell implantation therapy as a limb salvage procedure in patients with severe peripheral arterial disease.

BACKGROUND: Few options other than amputation exist for some patients with peripheral arterial occlusive disease (PAD) and severe anatomical limitations. METHODS: This prospective study presents short-term results of dual intramuscular and intra-arterial autologous bone marrow mononuclear cell (BM-MNC) implantation for the treatment of patients with severe PAD in whom amputation was considered the only viable treatment option. Baseline, two-week, and three-month evaluations were conducted. Ankle brachial indices (ABI) were calculated for both the dorsal pedis and the posterior tibial arteries. Rest pain and ulcer healing also were assessed. Success was defined as meeting the following four criteria: improvement in ABI measurements; relief of rest pain; ulcer healing, if applicable; and absence of major limb amputations. Patients not undergoing major limb amputations continued to be monitored for subsequent procedures. RESULTS: Nine patients for whom limb amputation was recommended underwent this procedure. The study population was comprised of five females and four males, with a mean age of 61.7 years. Eight (88.9%) patients had rest pain. Seven (77.8%) patients also had diabetes. Non-healing ulcers were present in eight (88.9%) cases. After the procedure, non-significant improvements of 0.12 and 0.08 in ABI were observed for the dorsalis pedis and posterior tibial ankle arteries, respectively. Three (33.3%) major amputations subsequently were performed, including a below-knee amputation 4.1 weeks after the BM-MNC implantation and two above-knee amputations at 5.4 and 11.0 weeks after the procedure. The six (66.7%) patients who did not have major amputations demonstrated improvement in symptom severity three months after the procedure, as evidenced by alleviation of rest pain and improvements by at least one level in Rutherford and Fontaine classifications, and have not required amputations at a mean follow-up of 7.8 months. Complete wound healing was achieved within three months in all patients who had ulcers prior to BM-MNC implantation and for whom amputation was not required. This specific BM-MNC implantation technique was fully successful in three (33.3%) patients, as major amputation was avoided and the other applicable criteria were met. Five (55.6%) additional patients demonstrated success in at least one of the four criteria. CONCLUSIONS: With eight (88.9%) of nine patients showing some level of improvement and amputation avoided in six (66.7%) patients, these short-term results indicate the use of BM-MNC implantation as a means of limb salvage therapy for patients with severe PAD shows promise in postponing or avoiding amputation in a patient population currently presented with few alternatives to amputation.

A 10-year review of blunt renal artery injuries at an urban level I trauma centre.

INTRODUCTION: Little consensus exists over the management of high-grade renal injuries, with continued debate over observation versus invasive surgery. Blunt renal artery injury (BRAI) is a high-grade injury that may result in renal dysfunction, hypertension, or failure. MATERIALS AND METHODS: Management of BRAI at a level I trauma centre during a decade was retrospectively reviewed to determine incidence, assess management strategy, and evaluate hospital outcomes. Data collected included demographics, injury details, standardised scoring, renal injury grade, haemodynamic stability, diagnostic modalities, medical interventions, mortality, and hospitalisation length. RESULTS: Thirty-eight BRAI patients (21 Grade IV and 17 Grade V injuries) were admitted, representing 0.16% of trauma admissions, and consisting primarily of young males. Ultrasonography and CT was performed in 92.1% and 76.3% of patients, respectively. Primary management included exploratory laparotomy in 42.9%, angiography and embolisation in 34.3%, and observation in 22.9%. Six nephrectomies and one revascularisation were performed. The incidence of BRAI and use of angiography are higher than those reported in previous studies. CONCLUSION: Over the past decade, increased use of CT as a diagnostic tool for confirming renal injury in haemodynamically stable patients at our institution may have contributed to the increase in BRAI detection. Higher utilisation of angiography has enabled a more conservative approach. In this series, angiography had a success rate of 94.4%. Angiography and embolisation or observation with careful monitoring are viable management options in haemodynamically stable patients with isolated BRAI.

Management of upper extremity arterial injuries at an urban level I trauma center.

Although relatively uncommon, upper extremity arterial injuries are serious and may significantly impact the outcome of the trauma patient. Management of upper extremity arterial injuries at an urban level I trauma center was reviewed to determine incidence, assess the current management strategy, and evaluate hospital outcome. Upper extremity trauma patients with arterial injury who presented between January 2005 and December 2006 were included in this retrospective review. Data collected included age, gender, race, mechanism of injury, type of injury, associated upper extremity injuries, concomitant injuries, injury severity score (ISS), diagnostic modalities employed, surgical procedures and interventions, mortality, length of stay, and discharge disposition. Statistical analysis between blunt and penetrating arterial injuries as well as between proximal and distal arterial injuries also was conducted. During a 2-year period, 28 patients with 30 upper extremity arterial injuries were admitted, yielding an incidence of 0.48%. The study population was comprised primarily of young Caucasian males, with a mean ISS of 9.0. The majority (89.3%) of patients suffered concomitant upper extremity injuries. Twenty-two nerve injuries were identified in 16 (57.1%) patients. The most common injury mechanism was cut by glass (39.3%). Arterial injuries were categorized into 18 (60.0%) penetrating and 12 (40.0%) blunt injuries. Involved artery distribution was as follows: 12 (40.0%) brachial, eight (26.7%) ulnar, seven (23.3%) radial, and three (10.0%) axillary. Over half (56.7%) of the injuries resulted from lacerations. Injuries were managed as follows: 14 (46.7%) primary repairs, eight (26.7%) ligations, six (20.0%) saphenous vein graft bypasses, and two (6.7%) endovascular procedures. Eleven (39.3%) patients required intensive care unit (ICU) admission. The overall mean length of hospitalization for these patients was 7.4 days compared to a mean length of hospitalization of 2.0 days for the 17 (44.7%) patients who did not require ICU admission. The overall limb salvage rate was 96.4% as arterial injuries were successfully repaired in 27 of 28 patients. No patients expired and all were discharged home. Equivalent demographics, mechanisms of injury, surgical management approaches, and successful hospital outcomes were demonstrated between penetrating and blunt injuries as well as between proximal and distal arterial injuries. The current management approach, including use of angiography and prompt surgical management, results in successful outcomes after upper extremity arterial injuries and will continue to be utilized.