The use of fetal bovine collagen on chronic wounds increases limb salvage: a single-center retrospective analysis.

OBJECTIVE: As part of a quality assurance project at a large tertiary care surgical program in New York City, the effect of debridement, negative pressure wound therapy, and cellular- and tissue-based products (CTPs) on limb salvage was evaluated based on the following outcomes: freedom from amputation, wound closure, and freedom from readmission. Fetal bovine collagen was among the CTPs evaluated. MATERIALS AND METHODS: The data used in this study were derived from a database of all patients who had undergone procedures involving placement of a dermal matrix at the center over a 2.5-year period (January 2016-June 2018). This retrospective analysis included 256 patients who underwent debridement and/or placement of a CTP as part of the treatment course for chronic wounds. RESULTS: Of the 252 patients identified, 34 required either minor or major all-cause amputation from the initial wound intervention, whereas for 218 patients, there were no recorded amputations through the end of the study period after the initial wound intervention. When fetal bovine collagen was evaluated as an explanatory variable to the presence of future amputation, a statistically significant relationship between the variables was found. CONCLUSIONS: The results of the current data analysis indicate that a treatment algorithm that includes appropriate antibiotic therapy, tangential hydrosurgery, application of fetal bovine collagen, and a short course of negative pressure wound therapy may be a more favorable option to achieve limb salvage, freedom from readmission, and wound closure.

Different outcomes after kidney transplantation between African Americans and Whites: A matter of income? A single-center study.

BACKGROUND: Our center has one of the largest representations of African Americans in listed and transplanted patients. We investigated if and how racial differences affect outcomes in our patient population. METHODS: We performed a retrospective analysis of all kidney transplants in African American and (non-Hispanic) White patients in our center from 1/1/2005 to 12/31/2014. Cox regression was performed to evaluate the adjusted hazard ratios for graft loss. We investigated the influence of socioeconomic status on transplant outcomes. We stratified our patients into three groups based on income: lower (<$50 000 annual household income), medium ($50 000-100 000 annual household income), and higher (>$100 000 annual household income. RESULTS: There were 1333 patients in our study, 696 Whites and 637 African Americans. The 1-, 5-, and 10-year graft survival between the two groups was 96.5% vs 91.1%, 89% vs 80.7%, and 77% vs 66.3%, respectively (P < .001 by Log Rank, Breslow and Taron-Ware). When we compared the two groups separately in each income category, we found no statistical difference between African Americans and Whites in graft survival. In the regression model, income and not race was the significant factor influencing graft survival (P < .001 vs P = .61).

Early conversion to belatacept after renal transplantation.

Belatacept is a non-nephrotoxic immunosuppressive agent, which may make it the ideal agent for patients with delayed or slow graft function on calcineurin inhibitors. There are limited data on conversion of patients to belatacept within 6 months of transplantation. Between January 2012 and December 2015, 16 patients were converted to belatacept for delayed or poor graft function (eGFR<30 mL/min/1.73 m2 , MDRD); three were HIV positive. Conversion protocols were analyzed in patients ≤4 months and 4-6 months post-transplantation. Mean serum creatinine levels after belatacept conversion were compared with preconversion levels. Patient survival was 100%, and graft survival was 88%. The mean creatinine fell from 3.9±1.82 mg/dL prebelatacept conversion to 2.1±1.1 mg/dL at 6 months and 1.9±0.47 mg/dL (median 1.8 mg/dL) at 12 months postconversion. There was no significant increased risk of rejection, infection, or malignancy. HIV parameters remained largely stable. Early conversion to belatacept in patients with DGF or slow graft function is safe and efficacious, in a single-center nonrandomized retrospective analysis.

Intracardiac Extension of Intravenous Leiomyomatosis.

Intravenous leiomyomatosis with intracardiac extension is a rare condition characterized by extensive growth of a benign uterine mass that extends into the venous system through uterine channels and then into the cardiac chambers. A variety of presentations exist; cure relies on complete surgical resection. Extensive abdominal dissection, cardiopulmonary bypass (with or without circulatory arrest), and removal of the intracaval component are required. However, because of the rarity and variety of presentation, exact preferred management has not been well defined. A specific case, followed by a comprehensive literature review, helps delineate the specific decision making necessary for mass removal.

Hepatitis C and Human Immunodeficiency Virus Kidney Transplantation: The Mount Sinai Experience.

Mount Sinai Hospital in New York has a long history in the field of organ transplantation. The first kidney transplant at Mount Sinai was performed in 1967 by the late Dr. Lewis Burrows and the first laparoscopic donor nephrectomy in New York was performed at Mount Sinai in 1996. Over 3000 kidney transplantations have been performed at Mount Sinai. In the early 1990s, the first hepatitis C virus (HCV) positive patient at Mount Sinai underwent a kidney transplant and the first kidney transplant in a patient with human immunodeficiency virus (HIV) in New York was performed at Mount Sinai in 2001. In general, these patients have done well after renal transplantation, with outcomes similar to those seen in non-infected patients. This chapter will describe the evolution of immunosuppressive regimens in HCV positive and HIV positive patients, and will describe the outcomes of kidney transplantation in these patients. Given the favorable outcomes, it is reasonable to continue to offer renal transplantation as a treatment for end stage renal disease patients with HCV and/or HIV.

The evidence for nonoperative management of visceral artery dissections: a single-center experience.

BACKGROUND: Spontaneous isolated visceral artery dissection is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to acute intestinal ischemia, although a clear natural history has yet to be elucidated. No consensus exists on how best to manage these patients in the absence of true intestinal ischemia; however, much of the literature suggests that intervention is required. We present our institution's experience with 10 patients, both symptomatic and asymptomatic, all but 1 of whom was managed medically. METHODS: From September 2009 to August 2013, 10 patients presented to our institution with celiac or mesenteric artery dissection. We retrospectively reviewed these patients' clinical presentation, treatment, and follow-up. RESULTS: The mean age of the patients was 61.5 ± 10.3 (standard deviation [SD]) years (range, 41-77 years), and the mean follow-up period was 14.7 ± 11.6 (SD) months (range, 1-31 months). Four (40%) patients had abdominal pain and no ischemic changes of the bowel. There were 1 type I, 6 type II, 2 type III, and 1 type IV dissections according to Sakamoto classification. Treatments included observation without anticoagulation treatment in 8 patients (80%), anticoagulation treatment in 1 patient (10%), and endovascular stenting in 1 patient (10%) with unremitting abdominal pain. Anticoagulation was used in the 1 symptomatic patient with radiographic evidence of associated thrombus. The disease stabilized in all patients during follow-up. CONCLUSIONS: Most authors tend to advocate an endovascular or even operative repair for these processes. In our experience, most of these patients have a self-limited course of symptoms or their dissections are found incidentally. We believe that the results of conservative management in our cohort of patients support the conservative approach over the once recommended operative repair.

Outcomes of combined somatosensory evoked potential, motor evoked potential, and electroencephalography monitoring during carotid endarterectomy.

BACKGROUND: While much has been written about multiple methods of neuromonitoring during carotid endarterectomy (CEA), there has been relatively little discussion of the use of triple monitoring via somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) in conjunction with electroencephalography (EEG). Our objective was to evaluate the rate of detection and prevention of neurologic events by multinerve SEP, MEP, and EEG in patients undergoing CEA while under general anesthesia. METHODS: A prospective study of 181 consecutive patients undergoing CEA between June 2005 and September 2010 was reviewed. Intraoperative changes, including a 50% reduction in the amplitude of SEP waveforms, loss of MEP, and/or a 50% change in EEG frequency were noted as indications for shunting. This was correlated with the actual use of intraoperative shunting and postoperative neurologic sequelae at both 24 hours and 30 days. Median and tibial nerve SEPs and MEPs were also correlated. RESULTS: Eleven patients (6%) experienced intraoperative monitoring changes (SEP: 11/11; MEP: 6/11). Five of 11 patients with MEP/SEP changes underwent shunting, while the other 6 had normalization with the elevation of their blood pressure. Of the 11 patients that had neurophysiologic changes, 54% (6/11) were patients with symptomatic disease. No patients had significant EEG changes. The total shunt rate was 2.7% (5/181). No postoperative neurologic sequelae were noted. CONCLUSION: The ratio of shunting at 2.7% is equal to the lowest rates reported in the awake patient literature. Interestingly, the predicted synergy of multimodality monitoring cannot be directly attributed to an increased specificity resulting from the addition of SEP and MEP to EEG, because no patients had EEG changes. In addition, in today's cost-conscious world of health care, our results do not justify implementing this particular technique of neuromonitoring across the board-but it is apparent that the combination of these 3 modalities is both safe and effective with potential applications in symptomatic patients.

Statins reduce neurologic injury in asymptomatic carotid endarterectomy patients.

BACKGROUND AND PURPOSE: Statins are neuroprotective in a variety of experimental models of cerebral injury. We sought to determine whether patients taking statins before asymptomatic carotid endarterectomy exhibit a lower incidence of neurological injury (clinical stroke and cognitive dysfunction). METHODS: A total of 328 patients with asymptomatic carotid stenosis scheduled for elective carotid endarterectomy consented to participate in this observational study of perioperative neurological injury. RESULTS: Patients taking statins had a lower incidence of clinical stroke (0.0% vs 3.1%; P=0.02) and cognitive dysfunction (11.0% vs 20.2%; P=0.03). In a multivariate regression model, statin use was significantly associated with decreased odds of cognitive dysfunction (odds ratio, 0.51 [95% CI, 0.27-0.96]; P=0.04). CONCLUSIONS: Preoperative statin use was associated with less neurological injury after asymptomatic carotid endarterectomy. These observations suggest that it may be possible to further reduce the perioperative morbidity of carotid endarterectomy. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597883.

Potential adverse effects of norepinephrine on cortical somatosensory-evoked potentials during carotid endarterectomy: a case report.

The cerebral metabolic and vascular effects of intravenous norepinephrine have been shown in an animal model using somatosensory-evoked potentials (SSEPs). A case of intravenous norepinephrine resulting in a decrease in SSEP amplitude (of greater than 50%) despite no significant change in blood pressure, prior to cross-clamping during a carotid endarterectomy is presented. This finding may have implications for the use of norepinephrine in the critical care unit as well as the operating room.

The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease.

BACKGROUND: Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat. Patients with an ankle-brachial index (ABI) of 0.5-0.8 have been shown to heal poorly. Because adequate compression therapy is contraindicated in patients with an ABI of <0.7, we decided to undertake an aggressive approach of percutaneous revascularization for these patients. METHODS: A total of 27 patients with clinical and duplex scan evidence of chronic venous insufficiency, active leg ulcers, and impaired arterial perfusion (ABI: <0.7) were treated using a protocol that required performing percutaneous revascularization before ambulatory compression therapy. The patients were followed at 2-week intervals (average) before and after revascularization. Wound measurements and time to complete closure were also recorded. RESULTS: The results of the patients were compared with their own previous wound healing trajectories. Additionally, their healing rate was compared with previously published rates of impaired arterial perfusion venous wound closure; 25% closure at 10 weeks, 50% at 19 weeks. At enrollment, the average ABI and wound sizes were 0.56 and 12 cm(2), respectively. On average, the wounds had remained open for 17 weeks. After the intervention, the average ABI was 0.97, average time taken to complete closure was 10 weeks, closure rate at 10 weeks was 75%, and absolute closure rate was 100%. CONCLUSION: Although previous studies have shown that closure of mixed arterial venous ulcers occur without arterial intervention, attaining a near normal ABI allows for timelier wound closure. Therefore, we advocate an aggressive approach of percutaneous revascularization in this population.

Neuropsychological dysfunction in the absence of structural evidence for cerebral ischemia after uncomplicated carotid endarterectomy.

OBJECTIVE: Neurocognitive dysfunction has been shown to occur in roughly 25% of patients undergoing carotid endarterectomy (CEA). Despite this, little is known about the mechanism of this injury. Recently, several groups have shown that new diffusion weighted imaging (DWI)-positive lesions are seen in 20% of patients undergoing CEA. We investigated to what degree neurocognitive dysfunction was associated with new DWI lesions. METHODS: Thirty-four consecutive patients undergoing CEA were subjected to pre- and postoperative cognitive evaluation with a battery of neuropsychological tests. Postoperative magnetic resonance imaging was performed in all patients within 24 hours of surgery. Lesions that showed high signal on DWI and restricted diffusion on apparent diffusion coefficient maps but no abnormal high signal on the fluid-attenuated inversion recovery images were considered hyperacute. RESULTS: Cognitive dysfunction was seen in eight (24%) patients. New hyperacute DWI lesions were seen in three (9%). Only one (13%) of the patients with cognitive dysfunction had a new DWI lesion. Two thirds of the new DWI lesions occurred in the absence of cognitive deterioration. Patients with cognitive dysfunction had significantly longer carotid cross-clamp times. CONCLUSION: Neurocognitive dysfunction after CEA does not seem to be associated with new DWI positive lesions.

A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation.

Normal saline (NS; 0.9% NaCl) is administered during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids. Recent evidence suggests that NS may be associated with adverse effects that are not seen with balanced-salt fluids, e.g., lactated Ringer's solution (LR). We hypothesized that NS is detrimental to renal function in kidney transplant recipients. Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy. The primary outcome measure was creatinine concentration on postoperative Day 3. The study was terminated for safety reasons after interim analysis of data from 51 patients. Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants. Twenty-six patients received NS, and 25 patients received LR. There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia (P = 0.05). Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis (P = 0.004). NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS. LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.

Decreased venous contamination on 3D gadolinium-enhanced bolus chase peripheral mr angiography using thigh compression.

OBJECTIVE: We evaluated the potential for improving bolus chase peripheral MR angiography in patients with fast arterial flow using thigh compression to prevent venous contamination. SUBJECTS AND METHODS: We performed bolus chase peripheral MR angiography in 32 consecutive patients in whom the travel time for a contrast agent to reach the popliteal artery trifurcation was less than 25 sec. Thigh compression was applied by a tourniquet (n = 13) or blood pressure cuff inflated to 60 mm Hg (n = 19). We compared the results with those of 36 consecutive patients who underwent angiography without thigh compression. The effect of thigh compression on arterial flow and tissue enhancement was assessed in patients with symmetric travel time in both legs by applying compression to one leg during the time-resolved 2D-projection MR angiography with 6 mL of gadolinium. On 3D bolus chase MR angiography, thigh compression was applied bilaterally. Venous contamination on the 3D images of the calf was graded as 0, none; 1, trace; 2, mild; 3, moderate; and 4, severe. Signal-to-noise ratio was measured in the popliteal artery. RESULTS: Thigh compression slowed the arterial travel time by a mean +/- SD of 4.7 +/- 2 sec (p < 0.001) with a blood pressure cuff and 3.1 +/- 1 sec (p < 0.001) with a tourniquet. Blood pressure cuffs reduced the score of venous contamination on the calf station from 1.9 to 0.4 (p < 0.05) for intermediate flow (contrast travel time, 20-25 sec) and from 2.5 to 0.9 (p < 0.05) for fast flow (< 20 sec). Thigh compression increased the popliteal artery signal-to-noise ratio (81 vs 52, p < 0.001). CONCLUSION: Thigh compression with blood pressure cuffs inflated to 60 mm Hg slows down arterial flow, increases arterial signal-to-noise ratio, and reduces venous contamination on 3D gadolinium-enhanced bolus chase peripheral MR angiography.

Failure of intraoperative jugular bulb S-100B and neuron-specific enolase sampling to predict cognitive injury after carotid endarterectomy.

OBJECTIVE: Cognitive decline occurs in 25% of patients after carotid endarterectomy (CEA). Elevated serum concentrations of S-100B and neuron-specific enolase (NSE) occur after stroke, and serum S-100B levels at 24 hours are associated with clinical outcome after both stroke and CEA. We hypothesized that we could detect acute elevations in serum levels of these markers obtained intraoperatively from the jugular bulb (JB) and that these elevations would predict cognitive dysfunction postoperatively as measured by neuropsychometric test performance. METHODS: Forty-three patients scheduled for elective CEA were assessed with a battery of neuropsychometric tests before and 1 day after surgery. Before the carotid artery was clamped, a 6-French Fogarty catheter was inserted into the facial vein and threaded 6 cm rostrally into the JB. Serum samples were withdrawn from this catheter and simultaneously from a radial arterial catheter (A-line) at three time points: before clamping, 15 minutes into clamping, and after unclamping the carotid artery. Concentrations between groups were compared by analysis of variance and paired t tests. RESULTS: Total deficit scores were significantly worse in 13 (30%) of the 43 patients 1 day after surgery. There was a trend toward elevations in JB concentrations of S-100B relative to A-line levels 15 minutes after cross-clamping (11% elevation, P = 0.079, paired t test). In addition, 15 minutes after clamping of the carotid artery, levels of S-100B from the JB were significantly elevated compared with levels at baseline (P = 0.040, one-way analysis of variance). No significant changes were found between any time point in levels of S-100B from the A-line blood or of NSE from either the JB or the A-line. Subtle cognitive decline after CEA was not correlated with intraoperative levels of S-100B or NSE, but there was a weak, statistically nonsignificant, association between a rise in 15-minute S-100B levels and cognitive injury that was not seen with JB samples. CONCLUSION: Although intraoperative levels of S-100B and NSE from the JB failed to predict cognitive injury, carotid cross-clamping, independent of injury, seems to be associated with early elevations in S-100B.