The Impact of Ipsilateral Implantable Cardioverter Defibrillator in Axillary Intra-Aortic Balloon Pump Support as Bridge to Heart Transplantation.

BACKGROUND: The axillary artery (AX) access for intra-aortic balloon pump (IABP) as a bridge to heart transplant (HT) allows mobility while awaiting a suitable donor. As end-stage heart failure patients often have an implantable cardioverter defibrillator (ICD) on the left side, the left AX approach may be avoided due to the perception of difficult access and proximity of two devices. We aimed to evaluate the outcomes of patients bridged to HT with a left-sided AX IABP with or without ipsilateral ICDs. METHODS: We retrospectively reviewed HT candidates at our institution supported by left-sided axillary IABP from November 2019 to February 2024, dividing them into two groups based on the presence (Group ICD, n = 48) or absence (Group No-ICD, N = 19) of an ipsilateral left-sided ICD. The exposure time was defined as the time from skin incision to the beginning of anastomoses of a Dacron graft. RESULTS: Technical success was achieved in 100% of the cohort, with median exposure times for AX access similar between groups (ICD, 12 [7.8, 18.2] vs. No ICD, 11 [7, 19] min; p = 0.75). The rate of procedural adverse events, such as significant access site bleeding and ipsilateral limb ischemia, did not significantly differ between both groups. Device malfunction rates were comparable (ICD, 29.2% vs. No ICD, 15.8%; p = 0.35). Posttransplant, in-hospital mortality, severe primary graft dysfunction, and stroke rates were comparable in both groups. CONCLUSION: The presence of an ipsilateral left-sided ICD does not adversely impact the procedural efficacy, complication rates, or posttransplant outcomes of left-sided AX IABP insertion in HT candidates.

Time to Operation and Mortality Risk in Elderly Patients with Intestinal Fistula: Not Too Early and Not Too Late.

INTRODUCTION: This study aimed to ascertain the risk factors contributing to in-patient mortality in elderly patients 65 years and older who were admitted emergently, diagnosed with intestinal fistula, and underwent surgery. MATERIALS AND METHODS: Data were extracted from the National Inpatient Sample (NIS) spanning the years 2005-2014. Multivariable logistic regression and a generalized additive model (GAM) were employed to investigate predictors of mortality. Continuous variables are presented as mean values with standard deviations (SD). RESULTS: The study encompassed 34,853 patients with a mean age of 77.7 years-56.5% were female and 79.4% were White. Patients were categorized into three groups based on the time elapsed between admission and surgery: less than two days (17,761), two to three days (8,407), and more than three days (4,233). Mortality rates were 2.7%, 6%, and 6.1% for patients who underwent surgery within two to three days, within two days, and after more than three days of admission, respectively. Notably, the group that operated more than three days from admission experienced nearly double the hospital length of stay (12 days, SD: 7.2) compared to the other two groups (6.3, SD: 6 and 6.1, SD: 4.8). Furthermore, the association between mortality and time to operation, as indicated by the GAM model, revealed a significant non-linear relationship after adjusting for age, gender, race, zip code, hospital location, and comorbidities (p<0.001). CONCLUSION: Elderly patients diagnosed with intestinal fistula should undergo operative treatment as soon as possible, once they are resuscitated. Delaying the operation more than three days after admission substantially increases the risk of mortality.

The Efficacy of Stem Cells in Wound Healing: A Systematic Review.

Wound healing is an intricate process involving coordinated interactions among inflammatory cells, skin fibroblasts, keratinocytes, and endothelial cells. Successful tissue repair hinges on controlled inflammation, angiogenesis, and remodeling facilitated by the exchange of cytokines and growth factors. Comorbid conditions can disrupt this process, leading to significant morbidity and mortality. Stem cell therapy has emerged as a promising strategy for enhancing wound healing, utilizing cells from diverse sources such as endothelial progenitor cells, bone marrow, adipose tissue, dermal, and inducible pluripotent stem cells. In this systematic review, we comprehensively investigated stem cell therapies in chronic wounds, summarizing the clinical, translational, and primary literature. A systematic search across PubMed, Embase, Web of Science, Google Scholar, and Cochrane Library yielded 22,454 articles, reduced to 44 studies after rigorous screening. Notably, adipose tissue-derived mesenchymal stem cells (AD-MSCs) emerged as an optimal choice due to their abundant supply, easy isolation, ex vivo proliferative capacities, and pro-angiogenic factor secretion. AD-MSCs have shown efficacy in various conditions, including peripheral arterial disease, diabetic wounds, hypertensive ulcers, bullous diabeticorum, venous ulcers, and post-Mohs micrographic surgery wounds. Delivery methods varied, encompassing topical application, scaffold incorporation, combination with plasma-rich proteins, and atelocollagen administration. Integration with local wound care practices resulted in reduced pain, shorter healing times, and improved cosmesis. Stem cell transplantation represents a potential therapeutic avenue, as transplanted stem cells not only differentiate into diverse skin cell types but also release essential cytokines and growth factors, fostering increased angiogenesis. This approach holds promise for intractable wounds, particularly chronic lower-leg wounds, and as a post-Mohs micrographic surgery intervention for healing defects through secondary intention. The potential reduction in healthcare costs and enhancement of patient quality of life further underscore the attractiveness of stem cell applications in wound care. This systematic review explores the clinical utilization of stem cells and stem cell products, providing valuable insights into their role as ancillary methods in treating chronic wounds.

Follicular Skin Disorders, Inflammatory Bowel Disease, and the Microbiome: A Systematic Review.

Follicular skin disorders, including hidradenitis suppurativa (HS), frequently coexist with systemic autoinflammatory diseases, such as inflammatory bowel disease (IBD) and its subtypes, Crohn's disease and ulcerative colitis. Previous studies suggest that dysbiosis of the human gut microbiome may serve as a pathogenic link between HS and IBD. However, the role of the microbiome (gut, skin, and blood) in the context of IBD and various follicular disorders remains underexplored. Here, we performed a systematic review to investigate the relationship between follicular skin disorders, IBD, and the microbiome. Of the sixteen included studies, four evaluated the impact of diet on the microbiome in HS patients, highlighting a possible link between gut dysbiosis and yeast-exclusion diets. Ten studies explored bacterial colonization and HS severity with specific gut and skin microbiota, including Enterococcus and Veillonella. Two studies reported on immunological or serological biomarkers in HS patients with autoinflammatory disease, including IBD, and identified common markers including elevated cytokines and T-lymphocytes. Six studies investigated HS and IBD patients concurrently. Our systematic literature review highlights the complex interplay between the human microbiome, IBD, and follicular disorders with a particular focus on HS. The results indicate that dietary modifications hold promise as a therapeutic intervention to mitigate the burden of HS and IBD. Microbiota analyses and the identification of key serological biomarkers are crucial for a deeper understanding of the impact of dysbiosis in these conditions. Future research is needed to more thoroughly delineate the causal versus associative roles of dysbiosis in patients with both follicular disorders and IBD.

Impact of postoperative morbidity on outcomes in patients with advanced epithelial ovarian cancer undergoing intestinal surgery at the time of primary or interval cytoreductive surgery: A Memorial Sloan Kettering Cancer Center Team Ovary study.

OBJECTIVE: To assess the impact of short-term postoperative complications on oncologic outcomes for patients with epithelial ovarian cancer undergoing primary cytoreductive surgery (PCS) or interval cytoreductive surgery (ICS) with intestinal resection. METHODS: A retrospective chart review was performed for patients with ovarian cancer who underwent PCS or ICS with at least one intestinal resection at our institution from 1/1/2015 to 12/31/2020. Progression-free survival (PFS) and overall survival (OS) were analyzed for the PCS and ICS cohorts separately. Short-term complications within 30 days of surgery (surgical secondary events [SSEs]) were graded by a validated institutional SSE system. RESULTS: Among 437 patients who underwent intestinal resections during PCS (n = 289) or ICS (n = 148), 183 (42%) had one, 180 (41%) had two, and 74 (17%) had three intestinal resections. Six (1.4%) of 437 patients experienced an anastomotic leak postoperatively. There were no perioperative deaths. There was no difference in PFS and OS for patients who underwent PCS with any SSE vs. no SSE within 30 days of surgery (HR, 1.05; 95% CI: 0.76-1.47; p = 0.75 and HR, 0.79; 95% CI: 0.49-1.26; p = 0.32, respectively). There was no difference in PFS and OS for patients who underwent ICS with any SSE vs. no SSE within 30 days of surgery (HR, 1.43; 95% CI: 0.99-2.07; p = 0.055 and HR. 1.18; 95% CI: 0.72-1.93; p = 0.52, respectively. CONCLUSION: Short-term postoperative morbidity for patients who underwent intestinal surgery during primary surgical management for advanced ovarian cancer did not impact oncologic outcomes.

Utilization of hepatitis C virus infected donors in heart transplant recipients with elevated MELD-XI score.

BACKGROUND: The advent of direct-acting antivirals has helped to increase the safe utilization of organs from hepatitis C virus positive (HCV+) donors. However, the outcomes of heart transplantation (HT) using an HCV+ donor are unclear in recipients with underlying liver disease represented by an elevated model for end-stage liver disease excluding international normalized ratio (MELD-XI). METHODS: The United Network of Organ Sharing database was queried from Jan 2016 to Dec 2021. Post-transplant outcomes stratified by recipient MELD-XI score (low <10.37, medium, 10.38-13.39, and high >13.4) was compared between patients with HT from HCV+ (N = 792) and patients with HT from HCV-negative donors (N = 15,266). RESULTS: The median MELD-XI score was comparable (HCV+, 12.1, vs. HCV-negative, 11.8, p = .37). In the HCV+ group, donors were older (33 vs. 31 years, p < .001). Ischemic time of donor hearts (3.48 vs. 3.28 h, p < .001) and travel distance (250 vs. 157 miles, p < .001) were longer in HCV+ group. In the Kaplan Meier analysis with a median follow-up of 750 days, survival was comparable between the two groups (2-year survival, MELD-XI Low: HCV+, 92.4 ± 3.6% vs. HCV-negative, 91.1 ±.8%, p = .83, Medium: HCV+ 89.2 ± 4.3% vs. HCV-negative, 88.2 ± 1.0%, p = .68, and High: HCV+, 84.9 ± 4.5% vs. HCV-negative, 84.6 ± 1.1%, p = .75) In multivariate Cox hazard models, HCV donors were not associated with mortality in each MELD-XI subgroup (Low: adjusted hazard ratio (aHR), 1.02, p = .94; Medium: aHR, .95, p = .81; and High: aHR, .93, p = .68). CONCLUSION: Utilization of HCV+ hearts was not associated with an increased risk of adverse outcomes in recipients with an elevated MELD- XI score.

Cannulation-related adverse events of peripheral veno-arterial extracorporeal membrane oxygenation support in heart transplantation: Axillary versus femoral artery cannulation.

BACKGROUND: In heart transplantation (HT), peripheral veno-arterial extracorporeal membranous oxygenation (VA-ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA-ECMO cannulation site which can be fatal. METHODS: From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA-ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). RESULTS: Patients in the AX group were older (AX: 59 years vs. 52 years, p = .006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p = .040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p = .460), incidence of stroke (10.2% vs. 6.5%, p = .863), VA-ECMO cannulation-related bleeding (6.1% vs. 12.9%, p = .522), and arm or limb ischemia (0% vs. 3.2%, p = .816) were comparable. ECMO cannulation-related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p < .001) including the wound infections (2.0% vs. 32.3%, p < .001). In FA group, all organisms were gram-negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation-related wound complications (Odds ratio, .23, p < .001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation-related complications. CONCLUSIONS: Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA-ECMO may be an excellent option in HT candidates or recipients when possible.

How Do We Physicians and Surgeons Deal With our Own Disease?

It is a "known secret" that physicians and surgeons do not make good patients and neglect their own health by ignoring early warning signs of physical and psychological problems. Moreover, often, they seek help late. What are the reasons for this self-neglect? Is it because we think we are "super humans," or we think that we will not get sick, cannot get sick, should not get sick, have no "right" to get sick, as we must care for others? Do we ignore ourselves because we must go to one more meeting, do one more thing, write or present one more paper, give one more lecture, or take the call even with a fever, cough, and chills? Why can't we call in sick? Is this the "macho" effect? Is this culture of denial pervasive everywhere, even though we should know better? Yes, it is! Don't we need to remember the advice given by airlines to put on an oxygen mask on yourself first before helping others? Unfortunately, many of us do not do it. In this article, we will present a personal reflection as an example and review how we physicians and surgeons neglect our own health, ignoring the early warning signs of physical and psychological problems, and how we often seek help late. We also discuss potential reasons for this becoming a "norm" for many of us. Lastly, we review measures taken by some healthcare systems to remedy this situation.

Odds of Mortality in Geriatric Patients with Appendicitis is 22 Times Higher than that in Non-Geriatrics: An Analysis of 336,880 Patients from NIS Database.

RESULTS: A total of 336,880 patients were included in the cohort. Mean age was 37.7 and 73.8 years in adult and elderly patients, respectively. 97.3% of adults and 94.2% of elderly patients underwent an operation. The mortality rate in the elderly patients (1.04%, n=402/38,509) was 22 times higher (p<0.0001) than that in adult patients (0.047%, n=144/301,408). Mean (SD) hospital length of stay (HLOS) was 2.6 (2.9) days in adults and 4.9 (5.2) days in elderly patients (p<0.0001). Ninety-nine percent of adult and elderly patients were discharged within 11 and 20 days after emergent hospitalization, respectively. In the final regression model, every one year older in age increased the odds of mortality by 5% (OR=1.05, 95%CI: 1.04-1.06, p<0.001), and for every one day longer, HLOS increased the odds of mortality by 1% (OR=1.01, 95%CI: 1.001-1.02, p<0.001). The multivariable logistic regression model was built on 82,006 patients whose HLOS was ≥4 days, the odds ratio for HLOS was 1.05 (95%CI: 1.04-1.06). This means that for every additional day in hospital after day 4, the odds of mortality increase by 5%.

Insertion of durable left ventricular assist device with repair of ischemic ventricular septal rupture.

BACKGROUND: A 63-year-old male who presented with acute anterior wall myocardial infarction with ischemic ventricular septal defect (VSD) required veno-arterial extracorporeal membrane oxygenation support due to a profoundly reduced left ventricular function. METHOD AND RESULS: The VSD was closed with a large bovine pericardial patches. Another Dacron patch was used to close the defect on the anterior wall. The inflow cannula of the left ventricular assist device (LVAD) was sewn to the Dacron patch to secure hemostasis and to maintain the cavity in the left ventricle. The Dacron patch beneath the inflow cuff was then incised, then the LVAD was connected. CONCLUSIONS: we described a case of concomitant insertion of durable LVAD and repair of ischemic VSD utilizing multiple patches.