Disparities in colon and rectal cancer queried individually between Hispanics and Whites

Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the second leading cause of cancer related deaths in the United States. Racial disparities between Hispanics and Whites exist for incidence of late-onset (LO) CRC. However, not much is known about potential disparities between colon cancer (CC) and rectal cancer (RC) incidence queried individually. Methods: Using the SEER database data from 2000 to 2010, we obtained the national estimates of CC and RC for Hispanics and Whites. We analyzed trends in incidence, mortality, gender and stage of disease for early-onset (EO) (50 years old) CC and RC. Results: In Hispanics, the overall incidence of CC and RC increased by 47% and 52%, respectively; while in Whites, the overall incidence of CC and RC decreased by 13% and 2% respectively. Incidence of EO CC increased in both Hispanics and Whites by 83% and 17%, respectively, and incidence of EO RC also increased for both groups with a 76% increase in Hispanics and a 34% increase in Whites. For LO CC, the incidence increased by 37% in Hispanics while it decreased by 17% in Whites and for LO RC, the trend in incidence increased in Hispanics by 41%, but decreased in Whites by 11%. Conclusions: This study established that the incidence of CC and RC are different and there is racial disparity in incidence between Whites and Hispanics. This study, hopefully, will help in crafting public policy that might help in addressing this disparity.Open Access JournalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Renal Artery Stenosis and Obstructive Uropathy: To Resect or to Stent?

INTRODUCTION: Atherosclerotic renal artery stenosis causes hypertension that is resistant to medical management and may eventually lead to loss of kidney function. The treatment options for uncontrolled hypertension include best medical therapy (BMT), renal artery stenting (RAS), or surgical intervention; however, the optimal modality remains uncertain. This is the case of a patient with renal artery stenosis complicated by concurrent obstructive uropathy. CASE DESCRIPTION: Our patient is a 66-year-old male with a long-standing history of hypertension uncontrolled with BMT (beta blocker, angiotensin II receptor blocker (ARB) and a thiazide diuretic) and progressive renal insufficiency which was presumed to be due to prostatic obstructive uropathy. Despite undergoing a transurethral prostatectomy, his renal function continued to decline. A pelvic magnetic resonance angiogram (MRA) was performed which showed bilateral renal artery stenosis with the left being worse than the right. Computed tomography angiogram (CTA) was then performed which confirmed significant bilateral renal artery stenosis of 80 percent and 60 percent of the left and right renal artery respectively. The patient then underwent balloon angioplasty followed by stenting of both vessels without complication. Post-stenting angiography showed less than 30 percent stenosis of either vessel. During hospitalization, he had some improvement in his blood pressure, and his renal function was improved from baseline. One month follow up showed no significant change in blood pressure from initial visit prior to stenting. DISCUSSION: In healthy subjects, reduced renal perfusion lowers the glomerular filtration rate (GFR), causing a response by the renin-angiotensin-aldosterone system (RAAS) which leads to a compensatory increase in blood pressure. Although the GFR is reduced, renal parenchyma is able to adapt to reduced blood flow if perfusion pressure is reduced by 40 percent. There are a number of ways to manage renal artery stenosis, including RAS versus BMT. Currently, the effects of stenting are controversial and not fully understood. Multiple randomized trails have shown confounding results. Some trails have shown benefit in RAS, while others have demonstrated increase adverse outcomes due to renal reperfusion. In this case, we decided to to proceed with RAS given the significant stenosis on imaging, the patient's clinical presentation of worsening renal function despite BMT, and having ruled out other causes of progressive renal failure. The decision to intervene in these patients is usually determined on a case-by-case basis after discussion between surgeon, nephrologist and patient and after educating the patient on the risks and benefits.N

Management of Endoleak After Abdominal Aortic Aneurysm Repair

INTRODUCTION: Abdominal aortic aneurysm (AAA) represents a potentially life-threatening condition that requires proper surveillance and treatment. While AAA was historically treated by open surgical repair, technologic advances have resulted in Endovascular Aortic Aneurysm repair (EVAR) becoming the primary repair technique for AAA. Persistent endoleaks are a known complication of EVAR that often require additional intervention. We present a case highlighting the management of a Type 1B endoleak post-EVAR. CASE DESCRIPTION: Our patient is a 66-year-old male with history of EVAR at outside facility, and was evaluated in clinic with an enlarging iliac artery aneurysm. Computed tomography angiogram (CTA) demonstrated a 5cm aneurysmal degeneration of the right common iliac artery, most likely due to an endoleak in the distal portion of the stent (Type 1B). Due to the existing aortic endograft with a high flow divider, this required a combined axillary and femoral artery approach. The patient underwent placement of iliac branch endoprosthesis (IBE) at the right common iliac artery bifurcation with limb extension into both the external iliac and hypogastric arteries. Completion angiogram demonstrated successful extension of the endograft with exclusion of both the AAA and iliac aneurysm, preserved patency of the right hypogastric artery, and no endoleak. DISCUSSION: Endoleaks are a known complication of EVAR and frequently require intervention. There are multiple type of endoleak. Type 1 endoleaks denote leaks due to inadequate seal, and are divided further into 1A (proximal seal zone) and 1B (distal seal zone). Type II are due to branch vessel, type III endoleak are due to graft connection, and type IV due to graft porosity. The identification of location and type is frequently challenging and requires an angiogram. The management is based on the type of leak. Our patient had a type IB, due to leakage around the distal right common iliac limb. Relining the endograft with placement of an IBE device and extension of the stents into the external iliac and hypogastric arteries ensured development of adequate seal while preserving blood flow distally. With extensive pre-operative case planning and an intricate knowledge of the vascular anatomy, the modern vascular surgeon is equipped to provide advanced endovascular treatment options for complex vascular conditions.N

Thoracic Endovascular Repair of Descending Thoracic Aortic Thrombus

INTRODUCTION: Penetrating atherosclerotic ulcers (PAU) develop in the internal elastic lamina and indicate severe aortic atherosclerosis. PAU can have an associated intraluminal aortic thrombus, with associated risk of thromboembolism with subsequent mesenteric infarct and limb loss. We present a case of persistent descending thoracic aortic thrombus, with embolic renal infarcts, necessitating repair. CASE DESCRIPTION: A 80-year-old woman with history of bilateral renal infarcts on Eliquis and uncontrolled hypertension was referred to our department for extensive aortic atherosclerosis and 6mm ulceration proximal to the celiac artery, demonstrated on a CT. A follow up Computed Tomography Angiogram (CTA) demonstrated a persistent descending thoracic aortic thrombus and thoracic endovascular repair (TEVAR) was indicated. Preoperative imaging demonstrated >50% stenosis of the distal left common femoral artery (CFA). We accessed the proximal left CFA and subsequently placed stent grafts in the descending thoracic aorta, distally to proximally. Completion aortogram revealed complete occlusion in left external iliac artery. Doppler signals to the left foot were diminished on prompt exam. Current intraoperative imaging showed thromboembolism vs. flow-limiting dissection in the left CFA and external iliac arteries. Given these findings, an open endarterectomy of the iliac arteries was indicated, along with stent graft deployment in the left external iliac artery and bilateral stents in the common iliac arteries. A complete angiogram revealed a flow-limiting thromboembolism in the left superficial femoral artery (SFA). This was treated with covered stent placement, excluding the thrombus. Subsequent imaging demonstrated brisk flow into the left foot. On exam, pulses were palpable in the feet bilaterally and she moved all extremities. This patient had an uneventful hospital course and was discharge on postoperative day three. DISCUSSION: PAUs are a collective part of Acute Aortic Syndrome (AAS), seen in 2-8% of patients with AAS. PAUs develop from aortic mural thrombi, located most frequently in the abdominal aorta. A PAU > 4mm thick with ulceration is categorized as a complex plaque and warrants surgical repair. Anticoagulation is not sufficient for complex plaques. Endovascular repair (EVAR) is preferred to open since operating time is shorter, involves smaller incisions, and decreased hospital stay, with improved perioperative morbidity and all-cause mortality. Employing quality vascular access and wire manipulation can reduce endoleaks, access complications, and peripheral embolization. If complications arise, prompt imaging to access the stenotic vessels is necessary. This case demonstrates the potential morbidity of aortic thrombus embolization and the attention to detail required for successful treatment.N

Racial disparities in the incidence of colon cancer in patients with inflammatory bowel disease

Background: Studies have explored the relationship between inflammatory bowel disease (IBD) [ulcerative colitis (UC) and Crohn's disease (CD)] and colon cancer (CC). Additionally, racial disparities in the incidence of CC is well known. However, the impact of racial disparity in IBD patients who develop CC remains unclear. The aim of this study is to address the knowledge gap in this particular group of patients. Methods: A retrospective analysis was done using the National Inpatient Sample (NIS) database from 2011. We included patients with IBD over age >= 18 years with a diagnosis of CC. Patients were stratified by race, gender, age, presence of IBD and CC. Statistical analysis was performed to compare the groups. Results: A total of 57,542 patients were included (CD: 36,357, UC: 21,001). Of all patients with and without IBD, advanced age, Black and Asian race conferred an increased risk of developing CC, whereas female gender, Hispanic and Native American race conferred a protective effect. In patients with IBD, advanced age conferred an increased risk for developing CC while female gender conferred a protective effect. In this subset of patients, black race conferred a protective effect. Conclusions: Racial disparity exists in the overall incidence of CC and among patients with IBD who develop CC. Interestingly, black race conferred a protective effect for patients with IBD, contrary to what is seen in the general population. These findings could be attributed to the environmental factors and genetic makeup between racial groups. Further studies are warranted to better understand these disparities.Open Access JournalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Challenging Endovascular Retrieval of Multiple Well Incorporated Inferior Vena Cava Filters

INTRODUCTION: Inferior Vena Cava (IVC) filters are placed in patients to prevent pulmonary embolism in patients with recurrent deep venous thromboembolism or in high risk patients who cannot tolerate anticoagulation at their initial event. IVC filters are designed as either optional (retrievable) or permanent, and filter selection is based on the indication for placement. We present a case of complex retrieval of two IVC filters from the same patient with a history of chronic venous thromboembolism and post thrombotic syndrome. CASE DESCRIPTION: Our patient is a 63 year-old male with a remote history of trauma that resulted in chronic venous thromboembolism and post thrombotic syndrome of left lower extremity. He presents a rare case where he had two separate IVC filters placed during his treatment; initially, a permanent filter was placed, with an additional retrievable filter placed due to recurrent pulmonary emboli. He eventually tolerated anticoagulation, and wanted these filters removed due to their possible contribution to his chronic leg swelling and pain. From a right internal jugular vein approach, the retrievable superior filter was removed with the conventional snaring technique. We were unable to remove the second filter using conventional snare technique, as well as a through and through “flossing” approach from both jugular and femoral vein access points. We then proceeded with using a 16Fr laser extractor sheath with multiple laser treatments, followed by large aortic balloon expansion from the femoral access site, in an attempt to loosen the filter from the IVC sidewall. This combination of approaches did free the filter from the IVC wall, but the filter remained outside the sheath. Under fluoroscopic visualization, we brought the dislodged filter into the internal jugular vein and, after surgically exposing the vein, successfully removed the filter. Completion venogram confirmed removal of both filters without venous extravasation. DISCUSSION: This case illustrates the complexity in removing permanent IVC filters in select patients wherein the legs of the filter have embedded into the IVC wall. In patients with higher complexity of IVC filter removal, various methods have been described. Two advanced modes of extraction which are popular are the Endobronchial Forceps Extractions and the Laser-Assist Snare Extraction. Different devices have their unique characteristics and different failure modes. In patients with filter legs embedded in the vessel wall, a more robust approach with laser-assist, balloon endotraction, and external traction to free it from the IVC sidewall may be required for successful retrieval, as in this patient.N

An Interesting Case Highlighting Management of Pelvic Congestion Syndrome

INTRODUCTION: The development of valvular incompetence and/or obstruction in the pelvic and gonadal veins causing disabling symptoms comprises Pelvic Congestion Syndrome (PCS). It is a less known pathologic condition commonly occurring in women of child bearing age, and diagnosis can be challenging due to a variety of clinical presentations. Nutcracker syndrome (NCS) is a potential cause of PCS and involves compression of the left renal vein between the superior mesenteric artery and the aorta. We report one such case of a woman who presented with chronic pelvic pain. CASE DESCRIPTION: Our patient is a 31-year-old woman evaluated in our clinic with 6 years of unbearable back and suprapubic pain associated with dyspareunia and dysuria. She underwent evaluation by her gynecologist, and a transvaginal ultrasound demonstrated vaginal varicosities. Computed tomography angiogram (CTA) showed dilated left ovarian vein contiguous with left greater than right pelvic varicosities. We then performed a diagnostic venogram that demonstrated left pelvic venous plexus consistent with pelvic varicosities in the left ovarian vein and NCS anatomy. We decided to treat the PCS first. The patient underwent foam sclerotherapy of the pelvic venous plexus using 3cc of foam sclerosing agent (polidocanol) followed by coil embolization of the left ovarian vein. Post embolization venogram demonstrated radiographically successful treatment with no flow in the ovarian vein and preserved flow in the left renal vein. DISCUSSION: Chronic pelvic pain due to pelvic congestion is often associated with a constellation of symptoms including pelvic pain, dyspareunia, dysmenorrhea, and dysuria causing negative cognitive, behavioral, sexual and emotional consequences. There are three types of chronic pelvic pain, categorized by etiology. Type I is secondary to valvular incompetence of pelvic or ovarian veins, Type II is secondary to obstruction of outflow, and Type III is due to local compression. Venography is the gold standard for diagnosis. Treatment is directed at providing symptomatic relief with medical therapy, and treating the underlying cause by either endovascular (sclerotherapy and embolization, left renal venous stent placement) or open surgical techniques (including gonadal vein transposition, left renal vein transposition, or saphenous vein bypass).N

The BIG (brain injury guidelines) project: Defining the management of traumatic brain injury by acute care surgeons

BACKGROUND: It is becoming a standard practice that any ''positive'' identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelinesVbased on each patient's history, physical examination, and initial head CT findingsVregarding which patients require a period of observation, RHCT, or neurosurgical consultation. METHODS: In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. RESULTS: A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. J statistic is equal to 0.98. CONCLUSION: We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation. (J Trauma Acute Care Surg. 2014;76: 965Y969

Nano-Particle Removal from Surface of Materials Used in EUV Mask Fabrication

With device scaling, the current optical lithography technique is reaching its technological limit to print small features. Extreme Ultra-Violet (EUV) lithography has shown promise to print extremely thin lines reliably and cost-effectively. Many challenges remain before introducing EUV to large scale manufacturing. The main challenge addressed in this study is particle removal from EUV mask surfaces (CrON1, CrON2, and fused silica) and thermal oxide (SiO₂). Effective pre-clean procedures were developed for each surface. As chemical cleaning methods fail to meet SEMATECH criteria, addition of megasonic energy to EUV mask cleaning baths is seen as a promising cleaning methodology. As the requirement to print fine lines needs to be met, all materials used in EUV mask fabrication either absorb the incident EUV wavelength light or reflect it. Therefore, the masks used in the industry will be reflective instead of the conventional transmissive masks. Also, for the same reason, no protective pellicle can be used leading to all the surfaces unprotected from particle contamination. To avoid the detrimental effect of the particle contamination, a cleaning study for nano-particle removal was performed. A dark field microscope was utilized to study the removal of gold nano-particles from surfaces. The cleaning procedures utilized H₂SO₄ and NH₄OH chemistries with and without megasonic irradiation. The cleaning variables were bath concentration, temperature, and megasonic power. The contamination variables were the gold nanoparticles charge and size, from 40nm to 100nm. For 100 nm negatively charged gold nano-particles deposited on a CrON1 surface, a 1:10 H₂SO₄:DI bath at boiling temperature (101°C) without megasonics gave high particle removal efficiency (PRE) values as did a 1:10 H₂SO₄:DI bath at 35°C with 100W megasonics. Comparison of removal of poly diallyl-dimethyl ammonium chloride (PDAC) coated and uncoated gold nano-particles deposited on a CrON1 surface using dilute H₂SO₄ baths indicated that the coated, positively charged nano-particles were more difficult to remove. PRE trends for different baths indicate surface dissolution (shown to be thermodynamically favorable) as the particle removal mechanism. However, experimental etch rates indicated minimal surface etching in a 10 minute bath. Increased surface roughness indicated possible local galvanic corrosion at particle sites. Low surface etching results meet SEMATECH requirements. During the fused silica surface cleaning study, particle charge (negative) and size (100 nm) of the contamination source and cleaning bath chemistry (NH₄OH) were kept constant. Low PREs were obtained at room temperature for all NH₄OH bath concentrations; however, high PREs were obtained at an elevated temperature (78°C) without megasonics and at room temperature in more dilute chemistries with megasonic power applied. Similar PRE trends were demonstrated for thermal SiO₂ surfaces. The experimental etch rates of the thermal SiO₂ agree with published values