Lingual Raynaud\u27s Phenomenon after Surgical and Radiotherapeutic Intervention for Oral Squamous Cell Carcinoma

Raynaud\u27s phenomenon of the tongue after radiation therapy with or without chemotherapy is an exceedingly rare complication. Symptoms are similar to Raynaud\u27s disease of other sites and involve pallor and discomfort on exposure to cold temperatures that resolve with rewarming. Presentation occurs approximately 18-24 months after radiotherapy on average and can usually be managed effectively with lifestyle modification and pharmacotherapy. Here, we present a case of lingual Raynaud\u27s following surgery and adjuvant radiation therapy in a patient with squamous cell carcinoma of the oral cavity

Stronger but Not Faster : Flipped Classroom Teaching Significantly Improves Resident\u27s Skills but Not Speed

Objective: Flipped classroom teaching is a nontraditional education model where instructional content is delivered outside the classroom. This constructivist approach emphasizes self-direction, active inquiry; the instructor’s role is to foster critical reflection and facilitate the application and understanding of concepts. Our objective was to study the difference in time taken and quality of patch graft angioplasty performed by residents with and without flipped teaching. Methods: The study was set in a skills simulation teaching session overseen by attending surgeons. The intervention consisted of introducing a video outlining the technical aspects of patch graft angioplasty, watched before the session. The first group (2018 postgraduate year [PGY] 1 and 2 residents) was given instructions at the time of the class without a prior educational video or resources (Figs 1 and 2). The second group (2019, 2020 PGY 1 and 2 residents) was asked to watch a 20-minute video on the technical aspects of the procedure before the class. Participants then performed a standardized patch graft closure of a 1 cm arteriotomy using a polytetrafluoroethylene patch. The groups were timed. The quality of the closure was tested by assessing the number of leaks and the quantity of leak of the patch (Fig 3). Bivariate analysis sample t-tests were used for statistical analysis. P value \u3c.05 was considered significant. Pre- and post-session surveys were conducted to assess residents’ experience. Results: Forty-two residents (PGY 1 and 2) were enrolled in the study, 15 in nonintervention group 1 and 27 in intervention group 2, compared with 7 staff vascular surgeons. The mean completion time was 26 minutes (group 1) vs 27 minutes (group 2), P ¼ .6. The staff completion time was 12 minutes, P ¼ .001. The number of major leaks (not needle holes) was 2.0 (group 1) vs 1.6 (group 2), P ¼ .007, none for staff. The total quantity of leak was 42 mL (group 1) vs 15 mL (group 2), P ¼ .0001 (Table I). There was perceived improvement in skill on analyzing pre- and post-session surveys (Table II). Conclusions: A structured educational intervention, watching a video of a procedure before the skills session, did not change the time needed to complete the skill. There was improvement in the technical outcome of the procedure defined by a decrease in the total quantity of leak. Reversed classroom teaching significantly improves resident’s skill, not speed. There was also a perceived improvement in skill by participants. This is a pilot study and further instructional outcomes are being studied

Impact Of Preoperative Hemoglobina1c In Patients Undergoing Open Distal Vascular Procedures

Objective: The purpose of this study was to evaluate if preoperative hemoglobin (Hb) A1c levels was associated with worse outcomes in patients undergoing open lower extremity (LE) revascularization. Methods: A retrospective review of a statewide vascular surgery registry was queried for all patients who underwent open infrainguinal bypass or open LE thrombectomy procedures between January 2014 and June 2021. Patients were categorized into four groups depending on whether their plasma HbA1c was ≤6%, \u3e6% to ≤8%, \u3e8% to ≤10%, and \u3e10%. Regression models were used to evaluate the association between preoperative HbA1c and postoperative major adverse limb events (MALE), major adverse cardiac events (MACE), mortality, and length of stay (LOS). Results: A total of 5388 patients were included in the study. The average age was 66 years. Sixty-six percent of the cohort were male, and 78% were white. Demographics and comorbidities were associated with the HbA1c level. Mean LOS was 7 days for HbA1c \u3c6% and 10 days for HbA1c \u3e10% (P \u3c.001). No significant association was found when looking at perioperative MALE, MACE, 30-day mortality, or 1-year mortality. On multivariate analysis, only LOS remained significantly associated with the level of HbA1c (P \u3c.001) (Table). Conclusions: Suboptimal preoperative glycemic control in patients undergoing open LE vascular procedures for ischemia is associated with an increased risk of LOS. HbA1c level was not predictive of worse perioperative MACE, MALE, or mortality in this cohort. The increased in LOS could be explained by unmeasured complications, frailty, or increased hospitalization time needed to optimize glycemic control before discharge. [Formula presented

Incidence and prognosis of vascular complications after percutaneous placement of left ventricular assist device

OBJECTIVE: Mechanical assist devices have found an increasingly important role in high-risk interventional cardiac procedures. The Impella (Abiomed Inc, Danvers, Mass) is a percutaneous left ventricular assist device inserted through the femoral artery under fluoroscopic guidance and positioned in the left ventricular cavity. This study was undertaken to assess the incidence of vascular complications and associated morbidity and mortality that can occur with Impella placement. METHODS: We used a prospective database to review patients who underwent placement of an Impella left ventricular assist device in our tertiary referral center from July 2010 to December 2013. Patient demographics, comorbidities, interventional complications, and 30-day mortality were recorded. RESULTS: The study included 90 patients (60% male). Mean age was 66 years (range, 17-97 years). Hypertension was found in 69% of the patients, 37% were diabetic, 57% had a history of tobacco abuse, and 65% had chronic renal insufficiency. The median preprocedure cardiac ejection fraction was 30%. Most (87%) had undergone coronary artery intervention. Cardiogenic shock was documented in 67 patients (74%). The Impella was placed for an average of 1 day (range, 0-5 days). At least one vascular complication occurred in 15 patients (17%). Acute limb ischemia occurred in 12 patients; of whom four required an amputation and six required open or endovascular surgery. Other complications included groin hematomas and one pseudoaneurysm. All-patient 30-day mortality was 50%, which was not significantly associated with vascular complications. Female sex and cardiogenic shock at the time of insertion were associated with vascular complications (P = .043 and P = .018, respectfully). CONCLUSIONS: Vascular complications are common with placement of the Impella percutaneous left ventricular assist device (17%) and are related to emergency procedures. Vascular complications in this high-risk patient population frequently lead to withdrawal of care. These data provide quality improvement targets for left ventricular assist device programs

Impact of Preoperative Anemia in Patients Undergoing Peripheral Vascular Intervention

Objectives: Transcarotid artery revascularization (TCAR) is an emerging novel approach to carotid intervention, adopted and well-suited for high-risk patients. Our objective was to assess the outcomes of TCAR and determine its impact on the volume of carotid endarterectomy (CEA) and non-TCAR carotid artery stenting (CAS) in a single-state experience. Methods: A large statewide quality consortium registry was queried. The indications and outcomes of TCAR compared with CEA and non-TCAR CAS from January 2018 to October 2019 were reviewed. Non-TCAR CAS included transfemoral, transbrachial stenting and transcarotid stenting without the flow reversal technique. We also assessed the impact of TCAR on the trend of CEA and non-TCAR CAS performed, analyzing data from 2012 to 2019. Outcome comparisons were performed using the χ 2 and Mann-Whitney U tests, depending on the distribution of the outcomes. Results: A total of 438 TCARs were performed by 39 physicians in 16 hospitals; 60% of the patients were asymptomatic and 40% symptomatic. The TCAR indication was physiologic high risk for 369 patients (84%) and restenosis for 69 patients (16%), with most occurring after prior CEA (94%). Of the non-TCAR CAS cases, 94% were performed via transfemoral access. The patients undergoing non-TCAR CAS had the highest 30-day mortality ( P \u3c .001) and the highest incidence of 30-day new neurologic deficits ( P = .008) compared with the patients undergoing CEA and TCAR. CEA had the lowest myocardial infarction rate ( P = .015; Table). The number of TCAR procedures performed and the number of physicians and hospitals performing them increased during the 2-year period. Since the introduction of TCAR, no significant frequency decrease has occurred in the number of non-TCAR CAS or CEA cases by hospitals or physicians (Fig). However, a significant negative trend was found in the number of CEAs performed by physicians since 2012 ( P \u3c .001; Fig). Conclusions: TCAR is a safe method of carotid revascularization and is becoming an increasingly used method. TCAR has not affected the CEA hospital or physician volume since its introduction. CEA volumes and physician usage are declining, which could have future credentialing implications. In the present single-state experience, TCAR compared favorably with CEA and non-TCAR CAS might be less appealing because of its higher neurologic event rate

Monocyte-lymphocyte cross-communication via soluble CD163 directly links innate immune system activation and adaptive immune system suppression following ischemic stroke

CD163 is a scavenger receptor expressed on innate immune cell populations which can be shed from the plasma membrane via the metalloprotease ADAM17 to generate a soluble peptide with lympho-inhibitory properties. The purpose of this study was to investigate CD163 as a possible effector of stroke-induced adaptive immune system suppression. Liquid biopsies were collected from ischemic stroke patients (n = 39), neurologically asymptomatic controls (n = 20), and stroke mimics (n = 20) within 24 hours of symptom onset. Peripheral blood ADAM17 activity and soluble CD163 levels were elevated in stroke patients relative to non-stroke control groups, and negatively associated with post-stroke lymphocyte counts. Subsequent in vitro experiments suggested that this stroke-induced elevation in circulating soluble CD163 likely originates from activated monocytic cells, as serum from stroke patients stimulated ADAM17-dependant CD163 shedding from healthy donor-derived monocytes. Additional in vitro experiments demonstrated that stroke-induced elevations in circulating soluble CD163 can elicit direct suppressive effects on the adaptive immune system, as serum from stroke patients inhibited the proliferation of healthy donor-derived lymphocytes, an effect which was attenuated following serum CD163 depletion. Collectively, these observations provide novel evidence that the innate immune system employs protective mechanisms aimed at mitigating the risk of post-stroke autoimmune complications driven by adaptive immune system overactivation, and that CD163 is key mediator of this phenomenon

Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion

OBJECTIVE: The occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. METHODS: We performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. RESULTS: A total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived \u3e24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P \u3c .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). CONCLUSIONS: Proximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended

Success Rate of Embolization for Type II Endoleaks at a Major Tertiary Referral Center

Objective: The rise of endovascular aneurysm repair (EVAR) as the preferred treatment for abdominal aortic aneurysm (AAA) has introduced endoleaks as a major complication following AAA repair. The objective of this study is to assess the outcomes associated with endovascular embolization of type II endoleaks after EVAR. Methods: The institutional Radiology database at our tertiary referral hospital was queried for type II endoleak during the period 2006-2018. A retrospective chart review was then carried out. Only patients who underwent intervention for isolated type 2 endoleaks were analyzed. The primary outcome was success of the endoleak repair as determined by cessation of growth (i.e., ≤5mm change in diameter over follow-up period) of the native aneurysm sac. Patient outcomes for each failure of the above criterion were also collected. Other data pertaining to the location of endoleak, type of occlusion performed, type of embolic agent used, type of endograft used for EVAR, and incidence of aneurysm rupture were collected as secondary outcomes.Results:During this period 41 patients were treated for type II endoleaks. Demographics are shown in table 1. Cessation of growth was achieved in 28/41 (68.3%) of the patients after one embolization procedure. In 13/41 (31.7%) of patients, growth of the native aneurysm sac continued. Of the patients whose aneurysms continued to grow, 61.5% (8/13) did not undergo a second embolization. The remaining 38.5% (5/13) underwent a second embolization.Patient outcomes for both of these groups are presented in table II. None of the patients were found to have ruptured their aneurysm sac during follow-up after embolization. None of gender, race, the embolization site, or method of embolization were associated with embolization failure. Conclusions: Embolization of type II endoleaks is associated with a cessation of growth in the majority of cases and seems to be protective regarding the risk of aneurysm sac rupture. Future studies and additional follow-up will be important to elucidate the most significant risk factors for expansion and/or rupture of the endovascularly repaired abdominal aneurysm.Table I: Demographics for patients with type II endoleaks who underwent endovascular embolizationVariableValue Age (years +/- sd)75.66 +/- yearsAverage follow-up (months)62.65 monthsSex (%)71.7% male28.3% femaleRace (%)77.7% white17.8% black4.4% otherInflow vessel (%)43.2% lumbar only36.4% IMA only20.5% mixEmbolization site (%)40.5% vessel only14.3% cavity only20.5% mixEmbolization type (%)66.7% coil9.5% glue23.8% mixTable II: Outcomes for patients with continued growth after embolizationThose that did no undergo further embolizationThose that underwent a second embolization 3 were found to have type III endoleak and were successfully repaired with lining of the graft.2 whose aneurysm sac ceased growing. 2 who declined further treatment. 2 whose aneurysm sac continued to grow with persistent evidence of endoleak.1 who died from non-vascular complications. 1 who was lost to follow-up. 1 who is scheduled future surgical repair. 1 who was lost to follow-up.https://scholarlycommons.henryford.com/merf2019clinres/1026/thumbnail.jp

Association Between Increased Platelet P-Selectin Expression and Obesity in Patients With Type 2 Diabetes: A BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) substudy

OBJECTIVE- To determine whether obesity increases platelet reactivity and thrombin activity in patients with type 2 diabetes plus stable coronary artery disease. RESEARCH DESIGN AND METHODS- We assessed platelet reactivity and markers of thrombin generation and activity in 193 patients from nine clinical sites of the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D). Blood taken at the time of enrollment was used for assay of the concentration of prothrombin fragment 1.2 (PT1.2, released when prothrombin is activated) and fibrinopeptide A (FPA, released when fibrinogen is cleaved). Platelet activation was identified with the use of flow cytometry in response to 0, 0.2, and 1 mu mol/l adenosine diphosphate (ADP). RESULTS- Concentrations of FPA, PT1.2, and platelet activation in the absence of agonist were low. Greater BMI was associated with higher platelet reactivity in response to 1 mu m ADP as assessed by surface expression of P-selectin (r = 0.29, P < 0.0001) but not reflected by the binding of fibrinogen to activated glycoprotein IIb-IIIa. BMI was not associated with concentrations of FPA or PT1.2. Platelet reactivity correlated negatively with A1C (P < 0.04), was not related to the concentration Of triglycerides in blood, and did not correlate with the concentration of C-reactive peptide. CONCLUSIONS- Among patients enrolled in this substudy of BARI 2D, a greater BMI was associated with higher platelet reactivity at the time of enrollment. Our results suggest that obesity and insulin resistance that accompanies obesity may influence platelet reactivity in patients with type 2 diabetes.National Heart, Lung, and Blood Institute (NHLBI/NIH)[R01 HL69146]National Heart, Lung, and Blood Institute (NHLBI/NIH)[R01 HL71306]NHLBI[U01 HL061746]NHLBI[U01 HL06171748]NHLBI[U01 HL06384]National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK/NIH)[HL061744

Upper urinary tract urothelial carcinoma with loco‐regional nodal metastases: insights from the Upper Tract Urothelial Carcinoma Collaboration

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86906/1/j.1464-410X.2011.10075.x.pd