The Penobskan Porcupine Panic

This creative writing thesis takes its origins from a ten-page story written for a fiction class in the spring of 2015 and inspired by the song Penobska Oakwalk from the band Quilt

The Penobskan Porcupine Panic

This creative writing thesis takes its origins from a ten-page story written for a fiction class in the spring of 2015 and inspired by the song Penobska Oakwalk from the band Quilt

Gold Teeth: Making Meaning through Narrative

How do we create meaning in life through the telling of narratives? What do we have to gain by comparing stories from different cultures and times? By looking at two seemingly disparate stories - The Story of Kotikarna and Thomas Pynchon\u27s Inherent Vice - and asking ourselves how they impart similar meanings through varying narratological elements, we can better understand how humans order and establish value in the world, and how humans argue for these orders and values through narrative

Red blood cell transfusion within the first 24 hours of admission is associated with increased mortality in the pediatric trauma population: a retrospective cohort study

Abstract Background Allogeneic red blood cell transfusion is associated with increased morbidity and mortality in adult trauma patients. Although studies have suggested that the adoption of a more restrictive transfusion strategy may be safely applied to critically ill adult and all-cause critically ill pediatric patients, recent developments in our understanding of the negative consequences of red blood cell transfusion have focused almost entirely on adult populations, while the applicability of these findings to the pediatric population remains poorly defined. The object of this study was to evaluate the effect of red blood cell transfusion within the first 24 hours following admission on mortality in pediatric trauma patients treated at our institution. Results Age, race, and mechanism of injury did not differ between transfused and non-transfused groups, although there were significantly more female patients in the transfusion group (51 vs. 37%; p < 0.01). Shock index (pulse/systolic blood pressure), injury severity score, and new injury severity score were all significantly higher in the transfused group (1.21 vs. 0.96, 26 vs. 10, and 33 vs. 13 respectively; all p ≤ 0.01). Patients who received a red blood cell transfusion experienced a higher mortality compared to the non-transfused group (29% vs. 3%; p < 0.001). When attempting to control for injury severity, goodness-of-fit analysis revealed a poor fit for the statistical model preventing reliable conclusions about the contribution of red blood cell transfusion as an independent predictor of mortality. Conclusion Red blood cell transfusion within the first 24 hours following admission is associated with an increase in mortality in pediatric trauma patients. The potential contribution of red blood cell transfusion as an independent predictor of hospital mortality could not be assessed from our single-institution trauma registry. A review of state-wide or national trauma databases may be necessary to obtain adequate statistical confidence

Aortoesophageal fistula after thoracic endovascular aortic repair and transthoracic embolization

Endografts are more commonly being used to treat thoracic aortic aneurysms and other vascular lesions. Endoleaks are a potential complication of this treatment modality and can be associated with aneurysmal sac expansion and rupture. This case report presents a patient who developed a type IA endoleak after endograft repair of a descending thoracic aneurysm. The endoleak was successfully treated through computed tomographic-guided transthoracic embolization, although the patient experienced lower extremity paraparesis postprocedurally. The patient’s endovascular repair was complicated by the development of an aortoesophageal fistula and endograft infection necessitating operative débridement and endograft explantation

Management of a thoracic endograft infection through an ascending to descending extra-anatomic aortic bypass and endograft explantation

A 52-year-old man presented 33 months after thoracic aortic endovascular repair with hemoptysis and was found to have an aortobronchial fistula secondary to a mycotic aneurysm. The endograft infection was managed in a two-stage fashion. During the initial stage, the patient underwent an ascending-to-descending thoracic aortic bypass. Neither cardiopulmonary bypass, hypothermic circulatory arrest, nor aortic cross-clamping were used. During the same hospitalization, the patient underwent successful endograft explantation through a left thoracotomy. Imaging at 6 months demonstrated no anastomotic concerns and resolution of residual pulmonary inflammation. Thoracic aortic endograft infections necessitating endograft removal can potentially be successfully and safely managed without the need for cardiopulmonary bypass, hypothermic circulatory arrest, or interruption of aortic blood flow

Coverage of the left subclavian artery during thoracic endovascular aortic repair

BackgroundThoracic aortic stent grafts require proximal and distal landing zones of adequate length to effectively exclude thoracic aortic lesions. The origins of the left subclavian artery and other aortic arch branch vessels often impose limitations on the proximal landing zone, thereby disallowing endovascular repair of more proximal thoracic lesions.MethodsBetween October 2000 and November 2005, 112 patients received stent grafts to treat lesions involving the thoracic aorta. The proximal aspect of the stent graft partially or totally occluded the origin of at least one great vessel in 28 patients (25%). The proximal attachment site was in zone 0 in one patient (3.6%), zone 1 in three patients (10.7%), and zone 2 in 24 patients (85.7%). Patients with proximal implantation in zones 0 or 1 underwent debranching procedures of the supra-aortic vessels before stent graft repair. In one patient who underwent zone 1 deployment, the left subclavian artery was revascularized before stent graft deployment. Among patients who underwent zone 2 deployment with partial or complete occlusion of the left subclavian artery, none underwent prior revascularization. Patients were assessed postoperatively and at follow-up for development of neurologic symptoms as well as symptoms of left upper extremity claudication or ischemia.ResultsMean follow-up was 7.3 months. Among the 24 patients with zone 2 implantation, 10 (42%) had partial left subclavian artery coverage at the time of their primary procedure. A total of 19 patients experienced complete cessation of antegrade flow through the origin of the left subclavian artery without revascularization at the time of the initial endograft repair as a result of a secondary procedure or as a consequence of left subclavian artery thrombosis. Left upper extremity symptoms developed in three (15.8%) patients that did not warrant intervention, and rest pain developed in one (5.3%), which was treated with the deployment of a left subclavian artery stent. Two primary (type IA and type III) endoleaks (7.1%) and one secondary endoleak (type IA) (3.6%) were observed in patients who underwent zone 2 deployment. Three cerebrovascular accidents were observed. Thoracic aortic lesions were successfully excluded in all patients who underwent supra-aortic debranching procedures.ConclusionIntentional coverage of the origin of the left subclavian artery to obtain an adequate proximal landing zone during endovascular repair of thoracic aortic lesions is well tolerated and may be managed expectantly, with some exceptions

Thoracic endovascular aortic repair of aortobronchial fistulas

BACKGROUND: Thoracic endovascular aortic repair of aortobronchial fistulas is an emerging treatment modality for this highly lethal condition. The feasibility and long-term durability of this form of intervention are largely unknown. METHODS: The records of five patients who received endografts to treat aortobronchial fistulas at our institution were reviewed. A literature review was also conducted using MEDLINE to identify reports detailing outcomes of patients undergoing thoracic endovascular aortic repair for this condition. Primary outcome end points included intraoperative mortality, 30-day mortality, and aortobronchial fistula recurrence. RESULTS: For the five patients treated at our institution, technical success was 100%. In follow-up, aortobronchial fistulas recurred in two patients, resulting in one patient death and one endograft explantation. We identified 32 reports that met inclusion for our final review. Inclusive of the five patients treated at out institution, 67 patients with reported outcomes comprised the overall analysis. Most patients (55%) had previously undergone thoracic aortic surgery. Commercially manufactured thoracic endografts were used in 75% of patients. No intraoperative mortality was reported, and the 30-day mortality was 1.5%. Aortobronchial fistula recurred after endovascular repair in six patients (9%) through a mean follow-up of 21.5 months. Three cases of recurrent aortobronchial fistula resulted in patient death. CONCLUSIONS: Thoracic endovascular aortic repair of aortobronchial fistulas appears to a viable alternative to conventional open repair with excellent short-term results. Recurrence of the aortobronchial fistula after endovascular repair is a potential complication necessitating long-term surveillance. Individual risk assessment is needed to determine if endovascular repair should be used as bridge therapy or as a definitive repair

Outcomes of surgical and endovascular treatment of acute traumatic thoracic aortic injury

Acute thoracic aortic injury resulting from blunt trauma is a life-threatening condition. Endovascular therapy is a less invasive treatment modality that may potentially improve patient outcomes. We reviewed our experience with patients who sustained blunt thoracic aortic injuries distal to the left subclavian artery and presented for open surgical or endovascular repair.Between August 1993 and August 2006, 62 patients sustained blunt thoracic aortic injuries distal to the origin of the left subclavian artery and proceeded to undergo open surgical (n = 48, 77%), or endovascular repair (n = 14, 23%). Revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS), individual associated traumatic injuries, as well as operative and postoperative outcomes were compared between open surgical and endovascular groups.Age, gender, race, and mechanism of injury did not differ between open surgical and endovascular groups. Additionally, RTS, ISS, and NISS values were not significantly different. The proportion of patients with sternal fractures (14% vs 0%), or unstable spinal fractures (36% vs 10%) was significantly greater in the endovascular group. Of the patients who received endografts, 93% (n = 13) were evaluated by a cardiothoracic surgeon and assessed to be prohibitive to operative intervention. Endografts utilized included commercially manufactured thoracic endografts (n = 6; 43%) and abdominal aortic endograft components (n = 8; 57%). Forty-one interposition grafts were placed in the open surgical group. Renal complications (32% vs 7%), and urinary tract infections (35% vs 7%) approached significance between surgical and endovascular groups ( = .082 and = .077, respectively). Intraoperative mortality for the surgical and endovascular groups was 23% and 0%, respectively ( = .056). Endovascular repair was associated with significant reductions in operative time (118 vs 209 minutes), estimated blood loss (77 vs 3180 ml), and intraoperative blood transfusions (0.9 vs 6.1 units). No endoleaks were detected during a mean follow-up of 9.4 months in the endovascular group.Endovascular repair of blunt descending thoracic aortic injuries utilizing thoracic or abdominal endographs is a technically feasible modality that is at least equivalent to open therapy in the short term and associated with a lower intraoperative mortality ( = .056). Endovascular therapy has advantages in operative time, operative blood loss, and intraoperative blood transfusions

Intestinal Ischemia-Reperfusion Injury Alters Purinergic Receptor Expression in Clinically Relevant Extraintestinal Organs

Intestinal ischemia-reperfusion (IIR) injury is known to initiate the systemic inflammatory response syndrome which often progresses to multiple organ failure. We investigated changes in purinoceptor expression in clinically relevant extra-intestinal organs following IIR injury