Increased platelet mitochondrial function correlates with clot strength in a rodent fracture model.

BACKGROUND: Thromboelastographic measures of clot strength increase early after injury, portending higher risks for thromboembolic complications during recovery. Understanding the specific role of platelets is challenging because of a lack of clinically relevant measures of platelet function. Platelet mitochondrial respirometry may provide insight to global platelet function but has not yet been correlated with functional coagulation studies. METHODS: Wistar rats underwent anesthesia and either immediate sacrifice for baseline values (n = 6) or (1) bilateral hindlimb orthopedic injury (n = 12), versus (2) sham anesthesia (n = 12) with terminal phlebotomy/hepatectomy after 24 hours. High-resolution respirometry was used to measure basal respiration, mitochondrial leak, maximal oxidative phosphorylation, and Complex IV activity in intact platelets; Complex I- and Complex II-driven respiration was measured in isolated liver mitochondria. Results were normalized to platelet number and protein mass, respectively. Citrated native thromboelastography (TEG) was performed in triplicate. RESULTS: Citrated native TEG maximal amplitude was significantly higher (81.0 ± 3.0 vs. 73.3 ± 3.5 mm, p < 0.001) in trauma compared with sham rats 24 hours after injury. Intact platelets from injured rats had higher basal oxygen consumption (17.7 ± 2.5 vs. 15.1 ± 3.2 pmol O 2 /[s × 10 8 cells], p = 0.045), with similar trends in mitochondrial leak rate ( p = 0.19) when compared with sham animals. Overall, platelet basal respiration significantly correlated with TEG maximal amplitude ( r = 0.44, p = 0.034). As a control for sex-dependent systemic mitochondrial differences, females displayed higher liver mitochondria Complex I-driven respiration (895.6 ± 123.7 vs. 622.1 ± 48.7 mmol e - /min/mg protein, p = 0.02); as a control for systemic mitochondrial effects of injury, no liver mitochondrial respiration differences were seen. CONCLUSION: Platelet mitochondrial basal respiration is increased after injury and correlates with clot strength in this rodent hindlimb fracture model. Several mitochondrial-targeted therapeutics exist in common use that are underexplored but hold promise as potential antithrombotic adjuncts that can be sensitively evaluated in this preclinical model.

Adiposity and Coagulation: Predicting Postinjury Coagulation With Advanced Imaging Analysis.

INTRODUCTION: Anatomic distribution of adipose tissue has demonstrated variable associations with hypercoagulability. Utilizing a retrospective analysis of a previously enrolled prospective cohort, we assessed computed tomography (CT) scan-based anthropometric and volumetric measures of adiposity as predictors of postinjury hypercoagulability. METHODS: Segmentation analysis of arrival CT scans in significantly injured patients at a single level-I trauma center enrolled from December 2017 to August 2021 were analyzed for anthropometric indices of waist circumference (WC) and sagittal abdominal diameter (SAD), and volumetric parameters of visceral adipose tissue, superficial/deep subcutaneous adipose tissue, psoas/paravertebral muscle volume, and abdominal wall muscle volume. Associations with thromboelastography (TEG) were explored. RESULTS: Data from 91 patients showed strong correlations between body mass index and standard anthropometric measures of WC and SAD (P < 0.001); calculated volumes of subcutaneous adipose tissue and visceral adipose tissue (P < 0.001); and ratios of subcutaneous adipose:psoas muscle (SP ratio) and visceral adipose:psoas muscle ratio (both with P < 0.001, respectively). Correlation between TEG maximal amplitude (MA) and body mass index and SAD were not significant, with only weak correlation between TEG-MA and WC (r = 0.238, P = 0.041). Moderate but significant correlations existed between SP ratio and TEG-MA (r = 0.340, P = 0.005), but not visceral adipose:psoas muscle ratio (r = 0.159, P = 0.198). The relationship between TEG-MA and SP ratio remained significant when adjusted for injury severity score and lactate level (b = 0.302, P = 0.001). CONCLUSIONS: SP ratio is more strongly correlated with TEG-MA than standard obesity measures, and independently predicts increasing clot strength/stability after injury. Coagulation-relevant measures of sarcopenic obesity can be measured on CT scan, and may be used to optimize thromboprophylaxis strategies for obese injured patients.

Acute Liver Failure Triggered by Therapeutic Dose of Acetaminophen in a Patient with Cystic Fibrosis.

Here we present the case of a cystic fibrosis (CF) patient with preserved pulmonary function who developed acute liver failure requiring liver transplant following an episode of binge drinking and ingestion of a modest amount of acetaminophen. Cystic Fibrosis Liver Disease (CFLD) is the third most common cause of death among CF patients. The pathogenesis of CFLD is complex and still not fully understood. It is important that patients suffering from CF know about the possible dangers associated with acetaminophen and ethanol ingestion. Our case report highlights the need for more research that needs to be done to truly understand the underlying pathogenesis of CFLD and the significant risk factors that play a part in the development of acute liver failure in patients with CF.

Racial, Gender, and Neighborhood-Level Disparities in Pediatric Trauma Care.

BACKGROUND: Disparities in trauma outcomes and care are well established for adults, but the extent to which similar disparities are observed in pediatric trauma patients requires further investigation. The objective of this study was to evaluate the unique contributions of social determinants (race, gender, insurance status, community distress, rurality/urbanicity) on trauma outcomes after controlling for specific injury-related risk factors. STUDY DESIGN: All pediatric (age < 18) trauma patients admitted to a single level 1 trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed (n = 14,398). Primary outcomes were receipt of opioids in the emergency department, post-discharge rehabilitation referrals, and mortality. Multivariate logistic regressions evaluated demographic, socioeconomic, and injury characteristics. Multilevel logistic regressions evaluated area-level indicators, which were derived from abstracted home addresses. RESULTS: Analyses adjusting for demographic and injury characteristics revealed that Black children (n = 6255) had significantly lower odds (OR = 0.87) of being prescribed opioid medications in the emergency department compared to White children (n = 5883). Children living in more distressed and rural communities had greater odds of receiving opioid medications. Girls had significantly lower odds (OR = 0.61) of being referred for rehabilitation services than boys. Post hoc analyses revealed that Black girls had the lowest odds of receiving rehabilitation referrals compared to Black boys and White children. CONCLUSION: Results highlight the need to examine both main and interactive effects of social determinants on trauma care and outcomes. Findings reinforce and expand into the pediatric population the growing notion that traumatic injury care is not immune to disparities.

Rosai-Dorfman Disease of the Chest Wall Following Mastectomy for Breast Cancer.

Rosai-Dorfman disease (RDD) is a rare benign proliferative histiocytic disorder generally affecting the cervical lymph nodes as sinus histiocytosis with massive lymphadenopathy. We present a unique case of multifocal soft tissue RDD originating from previous mastectomy site and retroperitoneum. The patient is a 62-year-old African American female with a prior history of bilateral breast invasive ductal adenocarcinoma. 2 years following completion of therapy, our patient re-presented with an abdominal wall mass. The core biopsy was discordant, and the mass had rapid growth prompting excision. After the excision of the abdominal wall mass pathology confirmed RDD. A PET confirmed a solitary mass behind the left kidney this mass was biopsied and confirmed that it was RDD in the retroperitoneum. Due to the slow growth of this mass observation was deemed reasonable. We present this case to highlight the need for further research to improve treatment guidelines and expectations.

Late Diagnosis of Metastatic Leiomyosarcoma Originating in the Ureter.

This case report highlights a patient with a leiomyosarcoma originating in the ureter. A chart review was performed on a single patient who presented with a malignant retroperitoneal mass measuring 11.5 × 8.2 × 6.5 cm with subsequent metastasis sites to the breast, pancreas, liver, and lungs. The diagnosis of a leiomyosarcoma is uncommon, accounting for 0.1-0.4% of all cancer diagnoses in the United States. The diagnosis of a leiomyosarcoma originating from the ureter is extremely rare with fewer than 20 reported cases to date. Lack of typical urinary tract cancer signs and symptoms prevented an early presentation, allowing for considerable tumor growth and making complete surgical resection unlikely. We present this case as an example of a rare presentation of a very rare disease and to emphasize the necessity for further research of leiomyosarcoma and early diagnosis.

Multiple Intraabdominal and Pelvic Cystadenomas From Ovarian Remnant Syndrome.

Serous cystadenomas are benign epithelial neoplasms of the ovary, and they typically have an average size of around 10 cm. Our patient is a 68-year-old female who originally presented with abdominal page. Our patient's prior surgical history includes a bilateral salpingo-oophorectomy. Computed tomography scans showed five abdominal and pelvic masses of significant size. Our patient elected to undergo exploratory laparotomy and mass excision, and all five masses were able to be removed successfully. Final pathology confirmed the diagnosis of serous cystadenomas consistent with ovarian origin despite our patient undergoing a previous bilateral salpingo-oophorectomy. Our patient presented with a rare syndrome known as ovarian remnant syndrome that is thought to be caused by difficult hysterectomy procedures and prior abdominal surgeries that can unknowingly leave ovarian remnants. Second, the patient was found to have 5 abdominal and pelvic masses, and most of the masses were a very large size.

Poorly Differentiated Metastatic Carcinoma of Possible Eccrine Sweat Gland Origin.

Sweat gland carcinomas are a rare group of cancer, representing less than .01% of all diagnosed skin malignancies. We report the case of a 32-year-old male who presented with a fungating lesion on the posterolateral side of his left knee. Immunohistochemical results were positive for cytokeratin 5/6 and cytokeratin 7, consistent with possible eccrine gland origin. Our patient underwent wide local excision of the mass with lymph node dissection. Pathology confirmed the diagnosis of poorly differentiated carcinoma of possible adnexal, eccrine gland origin. He completed taxol/cisplatin-based chemotherapy and radiation. Surveillance imaging showed bilateral lung nodules, a right pleural effusion, and peritoneal carcinomatosis, which were diagnostic of metastatic carcinoma. He started carboplatin and epirubicin chemotherapy and has been doing well. Because standard of care treatment options for metastatic eccrine carcinoma have not been developed, it is imperative to report these cases to better understand these complex tumors and their treatment.

Robot-Assisted Right Colectomy with Sequential Wedge Resection of Segments 4 and 5 of The Liver and Cholecystectomy for Colon Cancer with Metastasis to The Liver.

The liver is the most common place for colon adenocarcinoma metastasis because of portal circulation. The surgical intervention for patients with colon adenocarcinoma with synchronous metastasis to the liver has been debated. Studies have shown that the simultaneous resection of a colorectal adenocarcinoma with a liver metastasis has similar outcomes compared to the traditional staged approach when looking at morbidity, mortality, and long-term oncologic effects. There has also been a shift to less invasive procedures when performing abdominal surgery. However, the laparoscopic method that has increasingly been used for the simultaneous procedure is technically challenging and therefore not widely adopted. The technical limitations hindering the simultaneous method could be overcome by utilizing a robotic approach. The aim of this report is to demonstrate the effectiveness of a robotic approach for colon adenocarcinoma with synchronous liver metastases.

Left-Sided Amyand Hernia.

An Amyand's hernia is defined by the presence of the vermiform appendix in the inguinal hernia sac. Most cases of Amyand's hernia are incidentally diagnosed intraoperatively while surgically reducing a right inguinal hernia. Right-sided Amyand's hernias are more common than left-sided Amyand's hernias for two reasons: the appendix is naturally located on the right side and right inguinal hernias are more common. The prevalence of an Amyand's hernia has been reported as 1%, but the true prevalence is much lower than that. We report a particularly rare case of a 5-month-old boy with a left-sided Amyand's hernia surgically repaired without appendectomy.

Social determinants of trauma care: Associations of race, insurance status, and place on opioid prescriptions, postdischarge referrals, and mortality.

BACKGROUND: Racial disparities in trauma care have been reported for a range of outcomes, but the extent to which these remain after accounting for socioeconomic and environmental factors remains unclear. The objective of this study was to evaluate the unique contributions of race, health insurance, community distress, and rurality/urbanicity on trauma outcomes after carefully controlling for specific injury-related risk factors. METHODS: All adult (age, ≥18 years) trauma patients admitted to a single Level I trauma center with a statewide, largely rural, catchment area from January 2010 to December 2020 were retrospectively reviewed. Primary outcomes were mortality, rehabilitation referral, and receipt of opioids in the emergency department. Demographic, socioeconomic, and injury characteristics as well as indicators of community distress and rurality based on home address were abstracted from a trauma registry database. RESULTS: Analyses revealed that Black patients (n = 13,073) were younger, more likely to be male, more likely to suffer penetrating injuries, and more likely to suffer assault-based injuries compared with White patients (n = 10,946; all p < 0.001). In adjusted analysis, insured patients had a 28% lower risk of mortality (odds ratio, 0.72; p = 0.005) and were 92% more likely to be referred for postdischarge rehabilitation than uninsured patients (odds ratio, 1.92; p = 0.005). Neither race- nor place-based factors were associated with mortality. However, post hoc analyses revealed a significant race by age interaction, with Black patients exhibiting more pronounced increases in mortality risk with increasing age. CONCLUSION: The present findings help disentangle the social determinants of trauma disparities by adjusting for place and person characteristics. Uninsured patients were more likely to die and those who survived were less likely to receive referrals for rehabilitation services. The expected racial disparity in mortality risk favoring White patients emerged in middle age and was more pronounced for older patients. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.