The Effect of Dialysis Shift on Depression and Sleep Disturbances in Patients on Chronic Hemodialysis.

Studies suggest that the hemodialysis (HD) shift on which a patient dialyzes impacts sleep disorders, depressive symptoms, quality of life, and mortality. However, study findings have been limited and inconsistent. The purpose of this project was to determine the relationship between HD shifts (morning, afternoon, and evening), and depression and sleep quality disturbance. Forty-one participants were recruited to participate in this project. Participants on the third shift had the highest levels of depression (M = 11.67) and poorest sleep quality (M = 14.5), compared to those who dialyzed on the first shift, who had the best sleep quality scores (M = 8.31; p = 0.013) and depression scores (M = 4.25). A significant positive correlation was observed between depression and sleep quality scores (r = 0.64; p < 0.001). Results indicate the HD shift can play a significant role in sleep disturbances and depression in patients on HD. Further studies need to be conducted to validate these findings.

Retrospective Review of Pediatric Blunt Renal Trauma: A Single Institution's Five Year Experience.

Children are at higher risk of renal injury from blunt trauma than adults due to a variety of anatomic factors such as decreased perirenal fat, weaker abdominal muscles, and a less ossified thoracic cage. Non-operative management is gaining in popularity for even major injuries, although there are no universally accepted guidelines. We present a retrospective review of pediatric major blunt renal injuries (grade 3 or higher) at a children's hospital in Hawai'i over a 5-year period. Medical records were examined between January 2009 and September 2014 from Kapi'olani Medical Center for Women and Children in Honolulu, Hawai'i. Inclusion criteria were a diagnosis of renal trauma, or the diagnosis of blunt abdominal trauma with hematuria. Exclusion criteria were grade I or II renal injury or death due to an additional traumatic injury. Mechanism of injury, clinical characteristics on admission, blood product requirements, surgical interventions performed, and hospital length of stay were retrospectively analyzed. Eleven total patient records were examined, nine of which fit inclusion criteria. Uniquely, 33% of patients sustained their renal injury while surfing. No patients required laparotomy or nephrectomy, though 22% of patients received a blood transfusion and 44% of patients underwent ureteral stent placement. Non-operative management of major renal injuries in children is feasible and allows for preservation of renal tissue. A novel mechanism of surfing as a cause of major renal trauma is seen in the state of Hawai'i.

An unusual presentation of a rare disease: posterior reversible encephalopathy syndrome following abdominal sepsis.

Posterior reversible encephalopathy syndrome (PRES) is an unusual disease of unknown incidence and cause. There are a wide range of associated, predisposing medical causes to include pregnancy, renal failure, immunosuppressive medication administration and hypertension. The diagnosis is made following the radiographic identification of characteristic vasogenic edema in the setting of neurologic impairment. A significant portion of patients will have long-term, if not permanent, sequelae of the disease. We present a patient who developed PRES following a hemicolectomy that was complicated by an anastomotic leak. She went on to a complete recovery following surgical treatment of the leak and supportive care.

Long-term epigenetic alterations in a rat model of Gulf War Illness.

Gulf War Illness (GWI) is a chronic, multisymptom illness that affects 25% of the 700,000 US veterans deployed to the Persian Gulf during the 1990-1991 Gulf War. Central nervous system impairments are among the most common symptoms reported, including memory dysfunction and depression. After 25 years, the diagnosis remains elusive, useful treatments are lacking, and the cause is poorly understood, although exposures to pyridostigmine bromide (PB) and pesticides are consistently identified to be among the strongest risk factors. Epigenetic changes including altered microRNA (miRNA) expression and DNA methylation play an important role in learning, memory, and emotion regulation and have been implicated in various neurological disorders. In this study, we used an established rat model of GWI to determine whether 1) chronic alterations in miRNA expression and global DNA methylation and DNA hydroxymethylation are mechanisms involved in the pathobiology of GWI, and 2) plasma exosome small RNAs may serve as potential noninvasive biomarkers of this debilitating disease. One year after a 28-day exposure regimen of PB, DEET (N,N-diethyl-3-methylbenzamide), permethrin, and mild stress, expression of 84 mature miRNAs and global 5-methylcytosine (5mC) and 5-hydroxymethylcytosine (5hmC) content were analyzed in the brains of GWI rats and vehicle controls by PCR array and enzyme-linked immunosorbent assay, respectively. Plasma exosome RNA next-generation sequencing analysis was performed in pooled samples to discover potential noninvasive biomarkers. We found that combined exposure to low doses of GW-related chemicals and mild stress caused epigenetic modifications in the brain that persisted one year after exposure, including increased expression of miR-124-3p and miR-29b-3p in the hippocampus and regional alterations in global 5mC and 5hmC content. GW-relevant exposures also induced the differential expression of two piwi-interacting RNAs (piRNAs) in circulation (piR-007899 and piR-019162). Results from this study implicate a role for epigenetic alterations in GWI. Evaluation of the diagnostic potential of plasma exosome RNAs in veterans with GWI is warranted.

Surgical Repair of Abdominal Aortic and Renal Artery Aneurysms in Takayasu's Arteritis.

Takayasu's arteritis is a large vessel vasculitis that can be a challenging diagnosis to make and has a varied clinical presentation. Management largely depends on affected vessel disease severity and individual patient considerations. The diagnosis must be considered in a young patient with large vessel aneurysms. We present a case of a 30 year-old woman of Pacific Islander descent who presented to the Tripler Army medical Center Vascular Surgery Department in Honolulu, Hawai'i seeking repair of her abdominal aortic and renal artery aneurysms prior to conception. A 30 year-old Pacific Islander woman with a history of a saccular abdominal aortic aneurysm and renal artery aneurysms presented to our clinic seeking vascular surgery consultation prior to a planned pregnancy. She had a renal artery stent placed at an outside institution for hypertension. She met the diagnosis of Takayasu's arteritis by Sharma's criteria. Physical exam was significant for a palpable, pulsatile, abdominal mass and CT angiography revealed a saccular irregular-appearing infra-renal abdominal aortic aneurysm, extending to the aortic bifurcation, with a maximum diameter of 3.3 cm. A right renal artery aneurysm was also identified proximally, contiguous with the aorta, with a maximal transverse diameter of 1.7 cm. The patient underwent a supraceliac bypass to the right renal artery with a 7 mm Dacron graft, as well as excision of the right renal artery aneurysm. The abdominal aortic aneurysm was replaced using a Hemashield Dacron bifurcated 14 mm x 7 mm bypass graft. Intraoperative measurements of the renal artery aneurysm were 1.5 x 1.5 cm and the saccular appearing distal abdominal aortic aneurysm measured 3.6 x 3.3 cm. The patient was discharged from the hospital 7 days post-operatively. At 1-year follow up, CT scan of the abdominal aorta revealed the repair was without any evidence of aneurysm formation, anastomotic pseudoaneurysm formation, or areas of stenosis. She has remained normotensive with a normal serum creatinine 18 months after her repair. She has since delivered her second child. It is rare for Takayasu's arteritis to present with aneurysmal disease. It is much more common to present with stenosis or occlusion. It has yet to be proven that Takayasu's truly has a higher incidence in those of Asian descent. Takayasu's can be a difficult diagnosis to make but can be aided with the use of Sharma's criteria. Our particular patient posed unique considerations on the effects of the physiology of pregnancy on her aneurysms and repair. Managing the active phases of disease is imperative, and though medical management is first line, surgical intervention may be necessary. Surgical intervention should be performed in a quiescent period of disease if possible given that biological inflammation at the time of intervention increases the complication rate. Repair of aneurysmal disease in a young female should also be considered prior to pregnancy.

Thoracoscopic pleural clipping for the management of congenital chylothorax.

PURPOSE: Medical management of congenital chylothoraces consists of total parental nutrition and tube thoracostomy. However, these infants are exposed to significant fluid shifts and the related leukopenia carries a high infection risk. The purpose of this review is to describe the technique of parietal pleural clipping as a surgical treatment of congenital chylothorax. METHODS: The medical records of all patients with a chylothorax diagnosis during the study period of January 2002 to April 2014 were retrospectively reviewed. RESULTS: Six of 14 infants identified underwent thoracoscopic parietal pleural clipping to disrupt the pleural lymphatic channel flow as visualization of the thoracic duct and lymphatics was not possible. Nearly all surgical patients had bilateral disease (5/6). Resolution of chylous leakage was dramatic following parietal clipping. In the surgical patients, chest tube output 2 days prior to surgery averaged 86.96 ml/kg/day. After parietal clipping, chest tube output dropped to an average of 6.5 ml/kg/day on post op day 2. Thereafter, chest tube output remained low to negligible and chest tubes were removed variably as enteral feeds were started. CONCLUSIONS: We describe a straightforward technique of thoracoscopic parietal pleural clipping as a safe and successful option for treatment of congenital chylothoraces.

The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012.

BACKGROUND: Component balanced resuscitation and avoidance of crystalloids in traumatically injured adults requiring massive transfusion are beneficial. Evidence for children is lacking. METHODS: After institutional review board approval was obtained, the Department of Defense Trauma Database identified 1,311 injured children 14 years or younger requiring transfusion after an injury and admitted to a deployed US military hospital from 2002 to 2012. Logistic regression determined risk factors for high-volume (≥40 mL/kg) or massive (≥70 mL/kg) transfusions. The effects of crystalloid and balanced component resuscitation in the first 24 hours were assessed. RESULTS: Nine hundred seven patients had recorded data sufficient for analysis. Two hundred twenty-four children received high-volume transfusion, and 77 received massive transfusions. Mortality was significantly higher for massive transfusions and high-volume transfusions than others (25% vs. 10% and 19% vs. 9%, respectively). Age of less than 4 years, penetrating injury, and Injury Severity Score (ISS) greater than 15 were associated with high-volume transfusions; an ISS greater than 15 and penetrating injury were associated with massive transfusions. Increased crystalloid administration showed a significant positive association with hospital days and intensive care unit days for both massive and high-volume transfusions, as well as a significant positive association with increased ventilator days in patients with high-volume transfusions. Balanced component resuscitation was not associated with improved measured outcomes and was independently associated with a higher mortality when all transfused patients were considered. CONCLUSION: In this cohort, heavy reliance on crystalloid for resuscitation had an adverse effect on outcomes. Balanced component resuscitation did not improve outcomes and was associated with higher mortality when all transfused patients were considered. Further study is needed regarding efficacy and clinical triggers for the implementation of massive transfusion in children. LEVEL OF EVIDENCE: Prognostic study, level IV.

Necrotizing soft tissue infection following a peripheral bypass.

BACKGROUND: Necrotizing soft tissue infection (NSTI), formerly referred to as necrotizing fasciitis, is a rare but serious postoperative complication. NSTI following arterial bypass is seen only once in the literature (for a coronary artery bypass) and is not mentioned following peripheral bypass. Although surgical site infections have been studied extensively, there are limited published data on postoperative NSTI and no data for NSTI following peripheral arterial bypass. CASE PRESENTATION: Here we present the first, to our knowledge, reported instance of an NSTI following a lower extremity peripheral bypass. Despite the continued function of the bypass, the patient became rapidly systemically ill with a focus at the surgical site. Because of prompt surgical debridement, the patient survived this severe infection, though did require an above the knee amputation to control the rapid spread of the disease. The patient, a native of American Samoa, was infected with organisms infrequently associated with NSTI, Morganella morganii and Aeromonas hydrophila. This article discusses the diagnosis and treatment of this rare postoperative complication, along with a brief review of the microbiology of the disease. CONCLUSIONS: NSTI is a rare but lethal postoperative complication. To our knowledge, this is the first reported case of an NSTI following an arterial peripheral bypass. This patient survived because of prompt and aggressive intervention.

Liver-directed therapies in metastatic colorectal cancer.

Colorectal cancer (CRC) is a major health concern in the United States (US) with over 140,000 new cases diagnosed in 2012. The most common site for CRC metastases is the liver. Hepatic resection is the treatment of choice for colorectal liver metastases (CLM), with a 5-year survival rate ranging from 35% to 58%. Unfortunately, only about 20% of patients are eligible for resection. There are a number of options for extending resection to more advanced patients including systemic chemotherapy, portal vein embolization (PVE), two stage hepatectomy, ablation and hepatic artery infusion (HAI). There are few phase III trials comparing these treatment modalities, and choosing the right treatment is patient dependent. Treating hepatic metastases requires a multidisciplinary approach and knowledge of all treatment options as there continues to be advances in management of CLM. If a patient can undergo a treatment modality in order to increase their potential for future resection this should be the primary goal. If the patient is still deemed unresectable then treatments that lengthen disease-free and overall-survival should be pursued. These include chemotherapy, ablation, HAI, chemoembolization, radioembolization (RE) and stereotactic radiotherapy.

Acute ischemic stroke and hyperglycemia.

To increase the comprehension about the profound effects of hyperglycemia within the first 48 hours poststroke on the outcomes of acute ischemic stroke, the authors reviewed multiple studies and literature reviews. Research supports the detrimental effects of hyperglycemia on the morbidity and mortality of patients diagnosed with acute ischemic stroke. The studies that were examined revealed that although further research is necessary, controlling hyperglycemia is overall beneficial to support superior clinical outcomes. The purpose of this article was to discuss the importance of not only glucose control but also the vital role of nurses in controlling glucose levels efficiently and immediately during the first 48 hours poststroke.

Management of Adenocarcinoma in the Setting of Recently Operated Perianal Paget's Disease.

Perianal Paget's disease only rarely presents with a synchronous invasive anal or rectal cancer. The purpose of this study is to present a case of an otherwise healthy patient who developed perianal Paget's disease. He was then found to have an invasive rectal adenocarcinoma, after having undergone an extensive resection and reconstruction with a bilateral V-to-Y reconstruction. This report describes an overview of perianal Paget's disease, the management of this disease in association with anal or rectal cancer, and our patient's outcome.