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Complications Beyond Borders: A Case Study on a Retained Surgical Towel Leading to an Intra-Abdominal Abscess Post-Hysterectomy
No full textBackground: The advancement of surgical techniques and procedures has dramatically improved healthcare outcomes globally. Despite these advancements, surgical interventions inherently carry the risk of complications, some of which can be severe and life-altering. Case Presentation: This report details a severe complication following a hysterectomy performed in Mexico on a 46-year-old woman, who developed an intra-abdominal abscess due to a retained surgical towel—a rare but grave surgical error. Initially, her post-surgical symptoms, including abdominal pain, fever, and malaise, were dismissed by her surgeon in Mexico as typical recovery effects. However, as her condition deteriorated, she sought emergency care in Arizona. A CT scan unveiled a significant abscess in her abdomen, marked by a radio dense ribbon indicative of the forgotten surgical towel. Emergency intervention was necessary to extract the towel and address the abscess, further complicated by the discovery of a multi-drug resistant organism. Conclusion: This incident highlights the paramount importance of adhering to surgical safety standards, the potential hazards of seeking medical procedures abroad, and the necessity for diligent postoperative monitoring and open communication between patients and their medical teams
Elevated Renal Oxidative Stress and Na+ Transporters are Associated with Hypertension in Postpartum Preeclamptic Rats
No full textApproximately 5-10% of US pregnancies result in preeclampsia (PE). PE is characterized by new onset hypertension (HTN) during pregnancy and is usually accompanied by end-organ damage, especially in the kidneys. Postpartum (PP) women and dams that had PE have an increased risk of developing HTN and chronic kidney disease (CKD) later in life. However, mechanisms linking PE to the long-term development of HTN and CKD are unknown. One aspect that may contribute to renal injury in PP PE women and dams is oxidative stress. Elevated concentrations of oxidative stress have been shown to augment the abundance and activity of renal transporters to increase sodium (Na+) reabsorption and blood volume. These alterations in renal transporters can consequently facilitate HTN. We hypothesize that at 6 weeks PP (~3 human years), PE dams will display oxidative stress, renal Na+ transporter abundance, and elevated blood pressure (BP).
Pregnant Sprague Dawley rats were assigned to two groups: normal (CON) and PE dams. On gestational day 14, the reduced uterine perfusion pressure surgery was performed to generate a model of PE. Dams gave birth naturally and weaned for 3 weeks. After 6 weeks PP, BP was measured via carotid catheterization, and kidneys were removed and sectioned. Western blots were used to quantify renal Na+ transporters: Na+ K+ 2Cl-transporter (NKCC2) in the kidney medulla (KM) and epithelial Na+ channel (ENaC) in both the kidney cortex (KC) and KM. Oxidative stress was evaluated by heat shock protein 1 (HSP-1), copper zinc superoxide dismutase (CuZnSOD), and manganese superoxide dismutase (MnSOD) via Western blots. Hydrogen peroxide (H2O2) and antioxidant capacity concentrations were assessed via colorimetric assays. PP PE dams had increased BP (126.3±6.18vs105.7±3.74 mmHg, p<0.05) at 6 weeks after birth. KC HSP- 1, H2O2, MnSOD, and antioxidant capacity were unchanged between groups. However, KC CuZnSOD protein abundance was decreased in PP PE dams (69.51±11.64vs100±5.73 IU/Protein/Control%, p<0.05). In the KM, HSP-1 abundance (113.7±3.3vs100±5.07 IU/Protein/Control%, p=0.06) and H2O2 concentrations (1.97±0.11vs1.31± 0.38 nM H2O2/mg Protein, p=0.08) were elevated in PP PE dams. MnSOD, CuZnSOD, and antioxidant capacity were unchanged between groups in the KM. No changes occurred in KC and KM ENaC protein abundance. However, NKCC2 protein abundance was elevated by ~50% in PP PE dams (151.71±22.17vs100±5.59 IU/Protein/Control%, p=0.06).
In summary, BP, oxidative stress, and NKCC2 were elevated in PP PE dams at 6 weeks. The presence of oxidative stress in the KM may lead to increased NKCC2 abundance. However, more studies are warranted to make this conclusion. NKCC2 elevation may result in increased Na+ and water reabsorption, leading to an increase in BP. Future studies will assess renal oxidative stress regulation of Na+ transporters in PP PE dams and determine the timeline PP in which changes in oxidative stress, Na+ transporters, and BP occur. This study is clinically relevant, because it indicates oxidative stress and NKCC2 in the KM, separately or together, may have a formative role in the pathogenesis of HTN and CKD in PP PE women later in life.Neurobiology of Aging and Alzheimer’s Disease Training Program (funded by NIH training grant T32 AG020494
Exploring Racial/Ethnic Disparities in Multimorbidity Among Cancer Patients at a Safety-Net Health System
No full textPurpose: Multimorbidity, defined as having two or more chronic health conditions, can substantially impact quality of life and mortality. Multimorbidity also increases the complexity of healthcare and treatment decision-making, particularly during cancer treatment. Racial/ethnic minorities may have higher risk for multimorbidity, potentially attributed to socioeconomic or other health-related factors. Therefore, we aimed to investigate racial/ethnic disparities in multimorbidity and potential explanatory factors among newly diagnosed cancer patients at a safety-net health system. Methods: We used electronic health record and cancer registry data from JPS Health Network, an urban safety-net health system in North Texas. Our eligible population included patients ≥18 years of age diagnosed with a first primary cancer in 2016–2020 (excluding in situ cases), whose initial diagnosis or at least part of the first course cancer treatment was received at JPS. Our outcomes were prevalence of multimorbidity (≥2 chronic conditions) and severe multimorbidity (≥3 chronic conditions). We included 30 chronic conditions defined by the Centers for Medicare & Medicaid Services and used up to a 2-year lookback period before cancer diagnosis. We used descriptive statistics to summarize sociodemographic characteristics and assess the proportions of multimorbidity by race/ethnicity. We used logistic regression to assess unadjusted and adjusted associations between race/ethnicity and multimorbidity and severe multimorbidity. Results: Our study included5,019 patients newly diagnosed with cancer. The most common cancer types were breast (13%), lung (12%), and colorectal (11%). The median age was 58 years (interquartile range: 50 – 64) and the majority were females (51%), racial/ethnic minority (59%), and uninsured (51%).Overall, 79% had multimorbidity and 62% had severe multimorbidity. Non-Hispanic Black (NHB) patients had the highest proportion of multimorbidity (86%) and severe multimorbidity (73%),whereas Hispanic patients had the lowest proportions (74% and 54%, respectively). In our unadjusted logistic regression model for multimorbidity, NHB patients had 1.75[95% CI: 1.44, 2.12]times higher odds and Hispanic patients had 0.80[95% CI: 0.69, 0.94]times the odds of multimorbidity compared with non-Hispanic White (NHW) patients. After adjusting for age, sex, body mass index, insurance status, and marital status, NHB patients maintained higher odds of multimorbidity (1.77 times [95% CI: 1.45, 2.17]), but Hispanic patients had no substantial difference (OR: 0.91[95% CI: 0.79, 1.07]) compared with NHW patients. In the unadjusted model for severe multimorbidity, NHB patients had 1.68 [95% CI: 1.44, 1.96]times higher odds and Hispanic patients had 0.71 [95% CI: 0.62, 0.81] times the odds of severe multimorbidity compared with NHW patients. In our adjusted model, NHB patientshad1.66 [95% CI: 1.41, 1.96] times higher odds and Hispanic patients had 0.77 [95% CI: 0.66, 0.89]times the odds of severe multimorbidity compared with NHW patients. Conclusions: We observed substantial racial/ethnic disparities in multimorbidity and severe multimorbidity among newly diagnosed cancer patients at a safety-net health system. Racial/ethnic disparities did not decrease after controlling for sociodemographic factors. Additional factors that are currently undocumented in electronic health records (e.g., social determinants of health) may help explain racial/ethnic disparities in multimorbidity and identify targetable points for interventions
Evaluating the Role of Arterial Stiffness on Amplitude of Cerebral Blood Flow Oscillations
No full textResearch Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 Medical Student Government Association Best in Second Year ClassBackground: Changing the pattern of cerebral blood flow by forcing oscillations in arterial pressure and blood flow at 0.1 Hz (10-second cycle) can limit reductions in cerebral tissue oxygenation during a condition of reduced cerebral perfusion. This method of inducing 0.1 Hz hemodynamic oscillations is called Pulsatile Perfusion Therapy (PPT). Sympathetic activation can increase the amplitude of 0.1 Hz hemodynamic oscillations, and acutely increase arterial stiffness. The impact of increasing carotid arterial stiffness on the magnitude of 0.1 Hz cerebral blood flow oscillations has not been examined. We hypothesize that the with application of 0.1 Hz PPT during a condition of cerebral hypoperfusion, 1) the subsequent increase in sympathetic activity will acutely increase carotid arterial stiffness, and; 2) greater carotid artery stiffness will result in a higher amplitude of oscillations in cerebral blood flow.
Methods: 10 healthy participants (8 males, 2 females) were exposed to 10-min of oscillatory lower body negative pressure (OLBNP) at 0.1 Hz, which induced both a state of cerebral hypoperfusion, and 0.1 Hz hemodynamic oscillations. Middle cerebral artery velocity (MCAv), internal carotid artery (ICA) diameter, and beat-to-beat arterial pressure were measured. ICA stiffness was determined using the beta-stiffness index, incorporating ICA diameter and arterial pressure measurements. The amplitude of 0.1 Hz MCAv oscillations was assessed via fast Fourier transformation.
Results: While OLBNP increased MCAv 0.1 Hz oscillations (36.1 ± 24.2 cm/s2 vs. 812.4 ± 668.0 cm/s2; P=0.01), ICA beta stiffness was not different between the baseline and OLBNP conditions (12.3 ± 4.9 au vs. 13.2 ± 5.7 au; P=0.56). There was no relationship between ICA stiffness and the amplitude of MCAv oscillations during OLBNP (r=0.17, P=0.68).
Conclusions: Contrary to our hypothesis, ICA stiffness did not increase during 0.1 Hz OLBNP, and there was no correlation between ICA stiffness and the magnitude of MCAv oscillations induced at 0.1 Hz. These data suggest that ICA stiffness may not determine the magnitude of induced oscillations in cerebral blood flow. Future studies will examine these effects in older adults to determine the potential beneficial application of PPT for the treatment of low cerebral perfusion conditions (e.g., Alzheimer’s disease, stroke).American Heart Association Transformational Project Award (19TPA34910743; CAR), American Heart Association Grant-in-Aid (17GRNT33671110; CAR), NIH Neurobiology of Aging & Alzheimer’s Disease Training Grant (T32AG020494; KAD; GKA), AHA Predoctoral Fellowship (GKA; 20PRE35210249
Assessing Barriers to Clinical Trial Enrollment Among African American Cancer Survivors in Louisville
No full textPurpose: Despite comprising approximately 22% of the population of Louisville, KY, African Americans comprise about 9% of cancer clinical trial (CCT) participants. Nationally, minority participation in clinical trials is also low, with African Americans making up between 4-6% of CCT participants, despite constituting 15% of all US cancer patients. The goal of this study is to examine factors contributing to low African American participation in cancer clinical trials, specifically within the Louisville area. Previous research attributes low CCT participation to generational mistrust stemming from historical abuses of Blacks in clinical research. Research has demonstrated that low cancer literacy, lack of familiarity with clinical trials, and implicit bias can contribute to low minority recruitment to clinical trials. In order to make CCTs more representative of the general population, increasing generalizability of results, barriers must be understood before successful interventions can be trialed. Methods: By conducting focus groups and individual interviews with African American cancer survivors (AACS) (n=33), we sought to understand the barriers to CCT participation in the Louisville area. Results: The qualitative study revealed that a majority of AACS had not received information about CCTs from their healthcare teams, but a majority expressed interest in receiving information about CCTs. Conclusion: This data, though potentially confounded by the composition of the cohorts analyzed, suggests a need for community outreach and education specifically centered around CCTs.
Keywords:[Cancer clinical trials, representation, barriers, cancer survivors]Bristol Myers Squibb Foundatio
A Case of Pediatric Tracheal Stenosis Secondary to Chronic Retching in the Setting of Bulimia Nervosa
No full textResearch Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 Pediatric Case Study AwardBackground: Tracheal stenosis is an important life threatening pathology in the pediatric population. The prompt diagnosis and management of tracheal stenosis is crucial to prevent complications of airway obstruction. Common etiologies include congenital anomalies, traumatic injury, complications of infection, and autoimmune disorders. Diagnosis is made with a combination of cross sectional imaging and rigid bronchoscopy. Endoscopic assessment and intervention will generally relieve acquired tracheal stenosis, with more severe cases requiring open surgical approaches. Historically, pediatric tracheal stenosis has had a poor prognosis; however, notable advances in endoscopic and open surgical treatments have led to a decline in morbidity and mortality.
Case Information: A 14 year old female presented to the Emergency Department at Cook Children’s Medical Center with biphasic stridor and evidence of airway obstruction. The patient had never been tracheally intubated, and had no other significant medical history except for one year of frequent retching in the setting of bulimia nervosa. Symptoms were gradual in onset over the course of several weeks, with an initial working diagnosis of asthma with no improvement with inhaled steroids. A CT scan was obtained that revealed severe tracheal stenosis involving the cervical trachea. Initial lab work revealed an elevated WBC of 16.7, Potassium of 2.8mmol/L, Normal c-reactive protein, erythrocyte sedimentation rate, and procalcitonin. Her initial assessment was concerning for impending airway obstruction and she was taken to the operating room for emergent rigid bronchoscopy. She was found to have an irregular circumferential scar extending for 1.5cm, starting 2cm distal to the glottis involving the second through fourth tracheal rings. The initial stenosis was grade three with pinpoint 2-3mm patency. The scar was biopsied, and the stenosis easily dilated to normal caliber. Circumferential submucosal Kenalog was applied and the patient ultimately did very well clinically and was discharged on postoperative day 1 in stable condition. Her workup included anti-neutrophil cytoplastic antibodies, myeloperoxidase antibodies, serine proteinase 3 antibodies which were all normal. Her pathology revealed chronic tracheitis without evidence of bacterial tracheitis or vasculitis. Intraoperative cultures were unremarkable. She was taken back to the operating room six weeks later with findings of a normal lumen trachea with no evidence of restenosis or granulation. Of note, she had refrained from further retching since her initial presentation. At the time of this report, the patient was doing well with no concern for recurrent stenosis and compliant with avoidance of retching.
Conclusions: This case emphasizes the diverse etiologies of tracheal stenosis and, specifically, the potential development of acquired tracheal stenosis related to self-induced retching in patients with eating disorders. Furthermore, this case underscores the need to consider the systemic effects of mental health disorders in pediatric patients, and helps add to our fund of knowledge regarding aerodigestive complications of bulimia nervosa
SecurAcath Device Safety and Efficacy in Pleural Tube Placement in Children
No full textResearch Appreciation Day Award Winner - SaferCare Texas, 2024 Excellence in Patient Safety Research Award - 1st PlaceBackground:
Patients in the cardiac intensive care unit (CICU) may develop complications such as pneumothorax (PTX) or pleural effusion (PE), which may be bloody, chylous, or serous in composition. PTX or PE may require placement of a percutaneous chest tube (CT) to evacuate air or fluid in the pleural space. Historically, CTs are sutured to the skin, but migration and removal of CTs can occur inadvertently due to external factors. The securAcath device is a single-use securement device indicated for securement of percutaneous indwelling catheters/tubes and is in use at the Cook Children’s Medical Center (CCMC) CICU. In this study, we introduce a novel use for this securAcath device in CT securement and aim to determine the effectiveness of the securAcath device in CT securement by assessing the incidence in catheter/tube dislodgement and migration. We compared the efficacy of securAcath device to the typical suturing practice for patients admitted to the CICU at CCMC.
Case Information:
This is a retrospective cohort of patients undergoing CT placement while admitted to the CCMC CICU from March 1, 2018 to March 31, 2023. Patients under 18 years of age using the securAcath device or suture in CT placement while on admission were included. Initial screening for patient encounters yielded 176 subjects. 140 patients met inclusion/exclusion criteria with 204 CT insertions. The data collected included diagnosis prior to chest tube insertion, chromosome abnormalities, type of congenital heart disease, surgical history, chest tube insertions, date of insertion and removal, SecurAcath or suture usage, complications, inadvertent removal, infection, and bleeding. Differences in duration of CT insertion between the securAcath device group and suture group were analyzed by independent sample t-test for continuous data. Chi square test of independence was used to evaluate the association between dependent and independent variables. All statistical tests were two-sided. P-value of less than 0.05 was utilized as a cutoff for statistical significance.
Information:
Two hundred and four 8.5 French chest tubes were inserted by intensivists in the CICU on 140 patients. There was no statistical difference in gender, diagnosis or type of congenital heart disease between the securAcath device group and suture group. There was no significance in the number of CTs inserted or the duration of the CTs between groups. No significance was found between groups with infection at the CT site or bleeding complications. The securAcath device group was noted to have a lower incidence of inadvertent removal of the CT compared to the suture group.
Conclusions:
The securAcath device is as safe as suture securement in children in the CICU who require CT insertion. The securAcath device demonstrates a lower incidence of inadvertent removal compared to suture securement of CTs in children in the CICU
Right on Target? Analysis of LDL Levels and Medication Use in a Very High-Risk ASCVD Population
No full textPurpose: The American College of Cardiology (ACC) released an expert consensus pathway in 2022, introducing a new low-density lipoprotein (LDL) goal < 55 for very high-risk individuals with atherosclerotic vascular disease (ASCVD) and highlighting the need for additional non-statin therapies to achieve that goal and reduce the risk of recurrent cardiovascular (CV) events, hospitalization, and death. This study seeks to investigate whether this LDL target is being achieved and the antihyperlipidemic medications used in a very high-risk ASCVD primary care population at the UNTHSC Family Medicine Clinic.
Methods: This is a retrospective chart review using the NextGen electronic record to evaluate patients at the UNTHSC Family Medicine Clinic. Living adults with very high-risk ASCVD were included. Very high-risk was defined as multiple major ASCVD events (myocardial infarction [I25.2, I22] or stroke [I63, Z86.73]) or one major ASCVD event and multiple high-risk conditions (heart failure [I50], diabetes [E10-E13], hypertension [I10-16], chronic kidney disease [N18], age > 65 years old, and current tobacco use). Demographics such as gender, race/ethnicity, insurance, and medications were also collected. Very high-risk ASCVD patients were then stratified based on LDL goal achievement and analyzed using Chi-square analysis, independent sample T-test, and descriptive statistics using SPSS.
Results: Of the identified very high-risk ASCVD patients (n = 199), 60 (30.2%) had achieved an LDL goal < 55 mg/dL. The average LDL achieved in this group was 44.2 + 10.8 mg/dL vs. 98.6 + 44.0 mg/dL for non-achievers. All those who achieved an LDL goal < 55 mg/dL were on at least one antihyperlipidemic medication. Of those who achieved an LDL goal < 55 mg/dL, 49 (81.7%) were on a high-intensity statin, 8 (13.33%) were on ezetimibe, 6 (10%) were on fish oil, and 3 (5%) were on a PCSK9 inhibitor. No patients were prescribed bempedoic acid or inclisirin. For non-achievers, 81 (58.2%) were on a high-intensity statin, 10 (7.2%) were on ezetimibe, 14 (10.1%) were on fish oil, and only one (0.72%) patient was on a PCSK9 inhibitor. Twenty (14.4%) of the non-achievers were not on any antihyperlipidemic agents. This subset of patients had a much higher average LDL (108.1 + 33.3 mg/dL), and 20% had a history of multiple ASCVD events. LDL goal achievers were slightly older (average age 68.2 + 9.9 years vs. 65.5 + 10.5 years), male (60% vs. 33.6%), and commercially insured compared to non-achievers.
Conclusions: A majority of very high-risk ASCVD patients at the UNTHSC Family Medicine Clinic are not currently achieving the LDL goal < 55 mg/dL. Additionally, non-statin therapies are not being widely used to augment statin therapy. Further investigation is needed to determine potential barriers and limitations to achieving this lower LDL target
Characterization of Estrogen Receptor Mutant Breast Cancer Three-Dimensional Cell Cultures
No full textResearch Appreciation Day Award Winner - Texas College of Osteopathic Medicine, 2024 Medical Student Government Association Best in First Year ClassBackground: Breast cancer is one of the leading types of cancer among women globally. Many primary breast cancers are estrogen receptor-positive (ER+) and responsive to anti-estrogenic therapies; however, after long-term treatment, these tumors can mutate the estrogen receptor to survive. These mutations make the tumors more triple-negative-like and, therefore, more dangerous. Triple-negative breast cancer (TNBC) has been particularly challenging to treat due to its lack of estrogen (ER), progesterone (PR), and human epidermal growth factor (HER2) receptors. Due to the lack of treatment options, TNBC has a poor prognosis and contributes to a significant percentage of breast cancer mortalities. These ER mutants act more like TNBC, resulting in worse clinical outcomes. Current research on these ER mutants has been conducted using two-dimensional (2D) monolayer cell culture, which does not translate effectively in animal models and humans. Three-dimensional (3D) cell culture, which allows for the formation of spheroids, mimics actual tumors and provides results more consistent with actual tumor treatment in vitro. Due to the lack of research on these ER mutants in 3D culture, they first must be characterized to determine baseline gene expression and behavior. After characterization, identifying changes resulting from drug treatment will be possible. Methods: Three different MCF-7 ER+ mutant cells (D538G, E380Q, and Y537S) were seeded at a density of 3000 cells per well in a low-attachment, round-bottomed 96-well plate. After seven days of culture, spheroids were imaged. Spheroids were measured, and size differences were quantified compared to the control, wild-type, ER+ MCF-7 cell line. RNA was extracted from spheroids, quantified, and reverse transcribed to make cDNA. cDNA was used to perform qRT-PCR to determine baseline gene expression differences between ER+ control MCF-7s and ER+ mutant MCF-7 cell lines. Results: The wild-type ER+ spheres have smaller diameters, spherocity values closer to one, and are more compact. They express different levels of EMT markers from the controls, indicating alterations to signaling pathways in the mutant lines. These 3D cultures also vary in expression from the 2D cultures of the same cell lines. Conclusions: MCF-7 ER+ breast cancer cells aggregate more readily than ER+ mutants. The ER must be involved in signaling that promotes aggregation, as reduced ER signaling decreases the ability for spheroid formation. This phenomenon and the differences in gene expression may explain why these mutants tend to behave in a more triple-negative manner in humans. Cells cultured in 3D express some genes to different extents, confirming the importance of 3D culture to identify future therapies – cells behave differently in different culturing contexts, 3D being more consistent with actual tumor behavior. Therefore, characterizing ER+ mutants before beginning drug treatment studies is crucial to understanding how compounds affect cancer cells and identifying differences in different ER+ mutants to know better how to treat them in the future.Cancer Prevention and Research Institute of Texas (CPRIT