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Arizona City, AZ, United States

Janvier A.L.,Johns Hopkins Bayview Medical Center | Hamdan H.,Arizona Health science Center | Malas M.,Johns Hopkins Bayview Medical Center
Clinical Nephrology

A 53-year-old man developed a deep venous thrombus (DVT) and pulmonary embolism (PE) shortly after an open Rouxen-Y gastric bypass was performed. He later suffered a life-threatening gastrointestinal bleed while on anticoagulation for the DVT. Thus, anticoagulation was held and an inferior vena cava (IVC) filter (G2, Bard Inc., Tempe, AZ, USA) was placed for PE prophylaxis. About 10 days after filter placement, he presented with severe low back pain and syncope. He also presented with hypotension and anuria unresponsive to intravenous fluids. A STAT non-contrast CT scan of the abdomen revealed that his IVC filter had migrated from an infrarenal to a suprarenal position. Given the high clinical suspicion for renal vein thrombosis, an attempt at IVC filter retrieval was made. The filter could not be retrieved because it was embedded in a large IVC thrombus that extended from the hepatic veins down to the common iliac veins. The patient received nearly 4 days of tPA that was administered at the site of the thrombus with a long thrombolytic catheter (UNIFUSE, Angiodynamics, Queensbury, NY, USA). While his creatinine peaked at 7.6 on hospital Day 4, he eventually began to produce urine and his creatinine had declined to his baseline of 1.0 on follow-up 1 month later. About 18 months after admission, his creatinine had further declined to 0.8. We report the first published case of acute renal failure due to bilateral renal vein thrombosis in the setting of IVC filter migration and thrombosis. This report highlights an important, but rare complication of IVC filter placement as well as the non-operative management of acute bilateral renal vein thrombosis. ©2010 Dustri-Verlag Dr. K. Feistle. Source

Ransom E.R.,University of Pennsylvania | Doghramji L.,University of Pennsylvania | Palmer J.N.,University of Pennsylvania | Chiu A.G.,University of Pennsylvania | And 2 more authors.
American Journal of Rhinology and Allergy

Background: Minimally invasive surgery for neoplasms of the anterior skull base has revolutionized the treatment of these diseases. The relative effect of endoscopic procedures, however, has not been described in terms of disease-specific and global health-related quality of life (QoL). Methods: A single-center longitudinal study was performed of patients undergoing complete endoscopic resection of anterior skull base neoplasms. Patients presenting between October 2009 and September 2010 were enrolled. QoL assessments were based on the 22-question Sinonasal Outcomes Test (SNOT-22), Health Utilities Index Mark II (HUI-2), and Short-Form 12 (SF-12) and were completed preoperatively and at 3, 6, and 12 months postoperatively. Comparisons over time were made within subjects. Results: Fourteen patients were enrolled; 11 completed preoperative and postoperative assessments (79%). Our cohort consisted of five men and six women; mean age was 55 years. Six patients had malignant tumors; four required adjuvant therapy. SNOT-22 scores were stable or improved in 10 cases (91%), with a significant difference for the cohort (mean, -33 points; p < 0.01). Ten (91%) patients had stable or improved HUI-2 scores (mean utility change, +0.13). SF-12 scores were stable for both mental (p = 0.17) and physical (p = 0.26) components. Mean quality-adjusted life year gain over the study period was 0.07. Conclusion: Complete endoscopic resection of anterior skull base neoplasms is oncologically sound with anecdotal QoL improvements relative to open craniofacial resection. We show positive, quantifiable QoL results with validated global and disease-specific instruments. Additional work will help to improve outcomes in this population and will be used in formal cost-effectiveness analysis. Copyright © 2012, OceanSide Publications, Inc. Source

Majeed B.,University of Arizona | Tawinwung S.,University of Arizona | Eberson L.S.,University of Arizona | Secomb T.W.,University of Arizona | And 3 more authors.
International Journal of Hypertension

Adaptive immune function is implicated in the pathogenesis of vascular disease. Inhibition of T-lymphocyte function has been shown to reduce hypertension, target-organ damage, and vascular stiffness. To study the role of immune inhibitory cells, CD4+CD25+Foxp3+ regulatory T cells (Tregs), on vascular stiffness, we stimulated the proliferation of Treg lymphocytes in vivo using a novel cytokine immune complex of Interleukin-2 (IL-2) and anti-IL-2 monoclonal antibody clone JES6-1 (mAb CD25). Three-month-old male C57BL/6J mice were treated with IL-2/mAb CD25 concomitantly with continuous infusion of angiotensin type 1 receptor agonist, [Val5]angiotensin II. Our results indicate that the IL-2/mAb CD25 complex effectively induced Treg phenotype expansion by 5-fold in the spleens with minimal effects on total CD4+ and CD8+ T-lymphocyte numbers. The IL-2/mAb CD25 complex inhibited angiotensin II-mediated aortic collagen remodeling and the resulting stiffening, analyzed with in vivo pulse wave velocity and effective Young's modulus. Furthermore, the IL-2/mAb CD25 complex suppressed angiotensin II-mediated Th17 responses in the lymphoid organs and reduced gene expression of IL-17 as well as T cell and macrophage infiltrates in the aortic tissue. This study provides data that support the protective roles of Tregs in vascular stiffening and highlights the use of the IL-2/mAb CD25 complex as a new potential therapy in angiotensin II-related vascular diseases. © 2014 Beenish Majeed et al. Source

Kalish J.A.,Boston Medical Center | Farber A.,Boston Medical Center | Homa K.,Society for Vascular Surgery | Trinidad M.,Arizona Health science Center | And 4 more authors.
Journal of Vascular Surgery

Background: Surgical site infection (SSI) is a major source of morbidity after infrainguinal lower extremity bypass (LEB). This study examines processes of care associated with in-hospital SSI after LEB and identifies factors that could potentially be modified to improve outcomes. Methods: The Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry (2003 to 2012) was queried to identify in-hospital SSI after 7908 consecutive LEB procedures performed by 365 surgeons at 91 academic and community hospitals in 45 states. Variables associated with SSI were identified using multivariable logistic regression and hierarchical clustering. Expected and observed SSI rates were calculated for each hospital. Results: The overall in-hospital SSI rate after LEB was 4.8%. Univariate analysis showed that obesity, dialysis, tissue loss, preoperative ankle-brachial index <0.35, distal target, vein graft conduit, continuous incision for vein harvest, transfusion >2 units of packed red blood cells, procedure time >220 minutes, and estimated blood loss >100 mL were associated with higher SSI rates, whereas chlorhexidine (compared with iodine) skin preparation was protective. Multivariable analysis showed independent predictors of SSI included ankle-brachial index <0.35 (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.03-2.30, P < .04), transfusion >2 units (OR, 3.30; 95% CI, 2.17-5.02; P < .001), and procedure time >220 minutes (OR, 2.11; 95% CI, 1.05-4.23; P < .04). Chlorhexidine was protective against SSI (OR, 0.53; 95% CI, 0.35-0.79; P = .002). Stratified analyses based on the presence of tissue loss yielded similar results. Across VQI hospitals, observed SSI rates ranged from 0% to 30%, whereas expected SSI rates adjusted by the four independent predictors ranged from 0% to 7.2%. Conclusions: In-hospital SSI after LEB varies substantially across VQI hospitals. Three modifiable processes of care (transfusion rate, procedure time, and type of skin preparation) were identified and may be used by hospitals to reduce SSI rates. This study demonstrates the value of the SVS VQI detailed shared clinical registry to identify improvement opportunities directly pertinent to providers that are not available in typical administrative data sets. © 2014 by the Society for Vascular Surgery. Source

Dalsing M.C.,Indiana University | Makaroun M.S.,University of Pittsburgh | Harris L.M.,State University of New York at Buffalo | Mills J.L.,Arizona Health science Center | And 2 more authors.
Journal of Vascular Surgery

Methods of learning may differ between generations and even the level of training or the training paradigm, or both. To optimize education, it is important to optimize training designs, and the perspective of those being trained can aid in this quest. The Association of Program Directors in Vascular Surgery leadership sent a survey to all vascular surgical trainees (integrated [0/5], independent current and new graduates [5 + 2]) addressing various aspects of the educational experience. Of 412 surveys sent, 163 (∼40%) responded: 46 integrated, 96 fellows, and 21 graduates. The survey was completed by 52% of the integrated residents, 59% of the independent residents, and 20% of the graduates. When choosing a program for training, the integrated residents are most concerned with program atmosphere and the independent residents with total clinical volume. Concerns after training were thoracic and thoracoabdominal aneurysm procedures and business aspects: 40% to 50% integrated, and 60% fellows/graduates. Integrated trainees found periprocedural discussion the best feedback (79%), with 9% favoring written test review. Surgical training and vascular laboratory and venous training were judged "just right" by 87% and ∼71%, whereas business aspects needed more emphasis (65%-70%). Regarding the 80-hour workweek, 82% felt it prevented fatigue, and 24% thought it was detrimental to patient care. Independent program trainees also found periprocedural discussion the best feedback (71%), with 12% favoring written test review. Surgical training and vascular laboratory/venous training were "just right" by 87% and 60% to 70%, respectively, whereas business aspects needed more emphasis (∼65%-70%). Regarding the 80-hour workweek, 62% felt it was detrimental to patient care, and 42% felt it prevented fatigue. A supportive environment and adequate clinical volume will attract trainees to a program. For "an urgent need to know," the integrated trainees are especially turning to online texts rather than traditional textbooks, which suggests an opportunity for a shift in educational focus. Point-of-care is the best time for education and feedback, suggesting a continued need for dedicated faculty. The business side of training is underserved and should be addressed. Copyright © 2012 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery. Source

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