Publications by authors named "Shahram Aarabi"

24 Publications

  • Page 1 of 1

Limb Salvage Does Not Predict Functional Limb Outcome after Revascularization for Traumatic Acute Limb Ischemia.

Ann Vasc Surg 2020 Jul 30;66:220-224. Epub 2019 Oct 30.

Division of Vascular Surgery, University of Washington, Seattle, WA.

Background: Traumatic vascular injury leading to acute limb ischemia (ALI) is an uncommon problem with a potential for high morbidity. We describe a contemporary series of patients with traumatic ALI managed primarily by vascular surgeons at a tertiary referral center and review factors associated with limb salvage and functional limb outcomes.

Methods: We conducted a single institution, retrospective review of all patients requiring revascularization for upper extremity (UE) and lower extremity (LE) ALI secondary to trauma from 2013 to 2016. Demographic data, transfer timing, injury severity score (ISS), Rutherford classification (RC), preoperative imaging, level of occlusion, procedural information, fasciotomy characteristics, and discharge disposition were reviewed. Outcome measures included limb salvage and functional limb outcomes.

Results: We identified 68 patients with traumatic ALI requiring revascularization. The majority of patients had moderate ISS scores, were RC 2a or 2b on presentation (65%), were transferred from another institution (53%), and underwent preoperative imaging (62%) with expeditious time to operation (median 4.5 hr). The most common location of vascular injury for UE was axillary-brachial (88%) and for LE was femoral-popliteal (69%). Open vascular procedures dominated the treatment strategy, and the median number of operations was 3. Fasciotomy was performed in 25% of UE and 58% of LE injuries. Shunts were utilized in only 2 patients. Overall LS was 94% for UE and 78% for LE. The median length of stay (LOS) was 11 days, with 25% of patients discharged to a skilled nursing facility. Follow-up was obtained for 59% of patients. For UE injuries, 57% of patients had no or minimal functional deficits, while 33% had major functional deficits and 10% underwent amputation. For LE injuries, 68% of patients had no or minimal functional deficits, while 6% had major functional deficits, and 26% had undergone amputation. Rutherford class and the number of operations performed were independent predictors of amputation and functional limb at follow-up in our logistic regression model (P < 0.05).

Conclusions: Revascularization for traumatic ALI yields high limb salvage rates in patients with RC 1 and 2 ischemia and patients with UE injuries. However, limb salvage does not necessarily equate to good functional outcomes. This signifies the complex nature of injuries in this patient population, especially when multiple operations are required.
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http://dx.doi.org/10.1016/j.avsg.2019.10.068DOI Listing
July 2020

Safety of transfer, type of procedure, and factors predictive of limb salvage in a modern series of acute limb ischemia.

J Vasc Surg 2019 04 15;69(4):1174-1179. Epub 2019 Feb 15.

Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, Wash.

Objective: The primary objective was to evaluate the safety of transfer, type of procedure, and factors associated with limb salvage in patients with acute limb ischemia (ALI) treated at a quaternary referral center.

Methods: A retrospective review of all patients with ALI secondary to thrombotic or embolic occlusion at a quaternary referral hospital from 2013 to 2016 was conducted. Patients were transferred from throughout Washington and Alaska by ambulance, helicopter, or fixed-wing modes of transportation. Demographics, transport and operative timing, Rutherford classification, level of occlusion, procedural information, and fasciotomy characteristics were reviewed. Outcomes measured included limb salvage rates, discharge disposition, and mortality.

Results: One hundred twelve patients with ALI were identified, with 82% due to thrombosis and 18% due to arterial embolization. Fifty-seven percent of patients were transferred from a referring hospital with low mean transfer times (1.9 hours for embolic, 2.7 hours for thrombotic). Although the initial operative strategy varied according to the etiology, with 50% of thrombotic occlusions treated with endovascular therapies and 80% of embolic occlusions treated with open thrombectomy, the rates of limb salvage did not vary based on operative approach (92% endovascular first, 90% open first). Further, limb salvage rates were identical between transferred and nontransferred patients (77%). Limb salvage was successful in 91% of patients with Rutherford class 1 and 2 disease, but only 8% in patients with Rutherford class 3 disease. In-hospital and 30-day mortality rates were not different based on ischemic etiology (5%), although patients with Rutherford class 3 disease had significantly higher mortality rates (15%) compared with patients with class 1 (6%), class 2a (6%), and class 2b (2%) disease. Fasciotomy was performed in 29% of patients, with 59% of fasciotomy wounds closed primarily. Predictors of amputation include multiple attempts at limb salvage, higher Rutherford class, multilevel occlusion, more proximal levels of occlusion, and nonviable muscle seen after fasciotomy, with ischemic times trending toward higher amputation rates without statistical significance. There was no difference in discharge disposition based on ischemic etiology.

Conclusions: The modern treatment of patients with ALI is effective, with high rates of limb salvage and low mortality regardless of transfer status, etiology, or initial operation performed. In situations where compartment syndrome is unclear, fasciotomy should not be withheld because it provides valuable predictive information regarding limb salvage.
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http://dx.doi.org/10.1016/j.jvs.2018.08.174DOI Listing
April 2019

Vertebroplasty and Kyphoplasty for Metastatic Spinal Lesions: A Systematic Review.

Clin Spine Surg 2018 06;31(5):203-210

Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences.

Introduction: The spine is the most common site of bone metastases. Vertebroplasty (VP) and kyphoplasty (KP) have been proposed as potential minimally invasive therapeutic options for metastatic spinal lesion (MSL) pain. However, the efficacy of VP and KP on MSL pain is currently unclear.

Objective: The aim of this study was to assess the effects of VP and KP compared with each other, usual care, or other treatments on pain, disability, and quality of life following MSL.

Methods: We included randomized controlled trials and prospective nonrandomized controlled clinical trials assessing VP or KP for the treatment of pain following MSL without cord compression. We searched MEDLINE, EMBASE, PubMed, and CENTRAL.

Results: The literature search revealed 387 citations. Of these, 9 trials met all eligibility criteria and were included in the qualitative analysis. In total, there were 622 patients enrolled in the trials and of them 432 were in the surgical treatment group (92 received KP, 97 received VP, 134 received VP and chemotherapy, 68 received VP and radiotherapy, and 41 received Kiva implant) and 190 were in the nonsurgical treatment group (83 received chemotherapy, 46 received radiotherapy, and 61 received other treatment). Using the grading of recommendations assessment, development and evaluation approach, pain (low-quality evidence) and functional scores (very low-quality evidence) improved more with VP plus chemotherapy than with chemotherapy alone (pain: mean difference, -3.01; 95% confidence interval, -3.21 to -2.80; functional score: mean difference, 15.46; 95% confidence interval, 13.58-17.34). KP seemed to lead to significantly greater improvement in pain, disability, and health-related quality of life (HRQoL) compared with nonsurgical management. VP plus Iodine-125 seemed to lead to significantly greater improvement in pain and disability in comparison with VP alone. VP plus radiochemotherapy resulted in better pain relief and HRQoL postoperatively in comparison with routine radiochemotherapy. There was low-quality evidence to prove that surgical treatment significantly decreases pain, and improves functional score and HRQoL following MSL in comparison with nonsurgical management.

Conclusion: On the basis of the analysis of currently published trial data, it is unclear whether VP for MSL provides benefits over KP.

Level Of Evidence: Level 2.
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http://dx.doi.org/10.1097/BSD.0000000000000601DOI Listing
June 2018

Accreditation Council for Graduate Medical Education (ACGME) Surgery Resident Operative Logs: The Last Quarter Century.

Ann Surg 2017 05;265(5):923-929

*Department of Surgery, University of Washington, Seattle, WA†Department of Surgery, Division of Endocrine Surgery, University of California, San Francisco, CA‡Department of Surgery, Division of Vascular Surgery, University of Washington, Seattle, WA§Department of Surgery, Carolinas Medical Center, Charlotte, NC¶Department of Surgery, Division of Pediatric Surgery, University of Washington, Seattle, WA.

Study Objective: To describe secular trends in operative experience for surgical trainees across an extended period using the most comprehensive data available, the Accreditation Council for Graduate Medical Education (ACGME) case logs.

Background: Some experts have expressed concern that current trainees are inadequately prepared for independent practice. One frequently mentioned factor is whether duty hours' restrictions (DHR) implemented in 2003 and 2004 contributed by reducing time spent in the operating room.

Methods: A dataset was generated from annual ACGME reports. Operative volume for total major cases (TMC), defined categories, and four index laparoscopic procedures was evaluated.

Results: TMC dropped after implementation of DHR but rebounded after a transition period (949 vs 946 cases, P = nonsignificance). Abdominal cases increased from 22% of overall cases to 31%. Alimentary cases increased from 21% to 26%. Trauma and vascular surgery substantially decreased. For trauma, this drop took place well before DHR. The decrease in vascular surgery also began before DHR but continued afterward as well: 148 cases/resident in the late 1990s to 107 currently.

Conclusions: Although total operative volume rebounded after implementation of DHR, diversity of operative experienced narrowed. The combined increase in alimentary and abdominal cases is nearly 13%, over a half-year's worth of operating in 5-year training programs. Bedrock general surgery cases-trauma, vascular, pediatrics, and breast-decreased. Laparoscopic operations have steadily increased. If the competence of current graduates has, in fact, diminished. Our analysis suggests that operative volume is not the problem. Rather, changing disease processes, subspecialization, reductions in resident autonomy, and technical innovation challenge how today's general surgeons are trained.
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http://dx.doi.org/10.1097/SLA.0000000000001738DOI Listing
May 2017

Iatrogenic Common Iliac Artery Rupture from Resuscitative Endovascular Balloon Occlusion of the Aorta.

J Vasc Interv Radiol 2017 04;28(4):619-620

Departments of Interventional Radiology, University of Washington, 1959 NE Pacific St., Seattle, WA98195.

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http://dx.doi.org/10.1016/j.jvir.2016.11.094DOI Listing
April 2017

Call for a new classification system and treatment strategy in blunt aortic injury.

J Vasc Surg 2016 07 27;64(1):171-6. Epub 2016 Apr 27.

Division of Vascular Surgery, Department of Surgery, Harborview Medical Center and University of Washington, Seattle, Wash. Electronic address:

Objective: The current Society for Vascular Surgery (SVS) classification scheme for blunt aortic injury (BAI) is descriptive but does not guide therapy. We propose a simplified classification scheme based on our robust experience with BAI that is descriptive and guides therapy.

Methods: Patients presenting with BAI between January 1999 and September 2014 were identified from our institution's trauma registry. We divided patients into eras by time. Era 1: before the first United States Food and Drug Administration (FDA)-approved thoracic endovascular aortic repair (TEVAR) device (1999-2005); era 2: FDA-approved TEVAR devices (2005-2010); and era 3: FDA-approved BAI-specific devices (2010-present). Baseline demographic information, Injury Severity Score, hospital details, and survival were collected and compared. Our classification scheme was minimal aortic injury, SVS grade 1 and 2; moderate aortic injury, SVS grade 3; and severe aortic injury, SVS grade 4.

Results: We identified 226 patients with a diagnosis of BAI: 75 patients in era 1, 84 in era 2, and 67 in era 3. Mean Injury Severity Score was 39.5 (range, 16-75). The BAI-related in-hospital mortality was significantly higher before endovascular introduction in era 1 (14.6% vs 4.8%; P = .03), but was not significantly different between eras 2 and 3 or before and after BAI-specific devices were introduced (P = .43). Of 146 patients (64.6%) who underwent aortic intervention, 91 underwent endovascular repair, and 55 underwent open repair. All but nine patients (94%) had a moderate or severe injury. Survival across all three eras of patients undergoing operative intervention was 80.2%. Survival in eras 2 and 3 was higher than in era 1 (86.4% vs 73.8%) but was not significant (P = .38). Of 47 patients in eras 2 and 3 with minimal aortic injury, 45 (96%) were managed nonoperatively, with no BAI-related deaths. After 2007, follow-up imaging was obtained in 38 patients (80%) with minimal aortic injury, and progression was not observed. Computed tomography scans showed the injury in 13 patients appeared stable, 19 had complete resolution (50%), and 6 had a decreasing size of injury.

Conclusions: Our experience confirms that BAI-related mortality for patients who survive to presentation is now 5%. From our findings during the past 15 years, we propose simplification of the SVS grading criteria of BAI into minimal, moderate, and severe based on treatment differences among the three groups. Minimal aortic injury can be successfully managed nonoperatively without mandatory follow-up imaging. Moderate aortic injury can be managed semielectively with TEVAR, and severe aortic injury, requires emergency TEVAR.
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http://dx.doi.org/10.1016/j.jvs.2016.02.047DOI Listing
July 2016

Global Surgery Fellowship: A model for surgical care and education in resource-poor countries.

J Pediatr Surg 2015 Oct 20;50(10):1772-5. Epub 2015 Jun 20.

Partners in Health, Boston, MA, United States.

Background/purpose: Surgical diseases have recently been shown to be a major cause of global morbidity and mortality. Effective methods to decrease the burden of surgical disease and provide care in resource-poor settings are unknown. An opportunity to meet this need exists through collaborative efforts to train local surgeons in specialty care, such as pediatric general surgery.

Methods: We present a novel model for the provision of surgical care and education in a resource-poor setting via a collaborative Global Surgery Fellowship program. Through Partners in Health in Haiti, this program placed a fully trained pediatric surgeon at an established rural hospital, both to temporarily serve that community and to teach local surgeons pediatric surgical care.

Results: The Global Surgery Fellow performed the cases presented here during his term, between July 2009 and June 2010. A total of 147 operative procedures were performed on 131 patients over the course of 12 weeks in Haiti. A total of 134 of the 147 total cases performed (91.2%) were educational cases, in which the Fellow operated with and trained one or more of the following: American medical students, American residents, Haitian residents, or Haitian staff surgeons.

Conclusion: The Global Surgery Fellowship model overcomes many of the traditional challenges to providing adequate surgical care in resource-poor countries. Specifically, it meets the challenge of providing a broad educational experience for many levels of local and foreign physicians, while working within an established locally run health care system. We believe that this model is generalizable to many resource-poor hospitals with permanent local staff that are open to collaboration.
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http://dx.doi.org/10.1016/j.jpedsurg.2015.06.009DOI Listing
October 2015

Parenteral Nutrition Utilization After Implementation of Multidisciplinary Nutrition Support Team Oversight: A Prospective Cohort Study.

JPEN J Parenter Enteral Nutr 2016 11 28;40(8):1151-1157. Epub 2015 Apr 28.

Department of General Surgery, University of Washington, Seattle, Washington.

Background: Multidisciplinary nutrition teams can help guide the use of parenteral nutrition (PN), thereby reducing infectious risk, morbidity, and associated costs. Starting in 2007 at Harborview Medical Center, weekly multidisciplinary meetings were established to review all patients receiving PN. This study reports on observed changes in utilization from 2005-2010.

Materials And Methods: All patients who received PN from 2005-2010 were followed prospectively. Clinical data and PN utilization data were recorded. Patients were grouped into cohorts based on exposure to weekly multidisciplinary nutrition team meetings (from 2005-2007 and from 2008-2010). Patients were also stratified by location, primary service, and ultimate disposition.

Results: In total, 794 patients were included. After initiation of multidisciplinary nutrition meetings, the rate of patients who started PN decreased by 27% (relative risk [RR], 0.73; 95% confidence interval [CI], 0.63-0.84). A reduction in the number of patients receiving PN was observed in both the intensive care unit (ICU) and on the acute care floor (RR, 0.64; 95% CI, 0.53-0.77 and RR, 0.80; 95% CI, 0.64-0.99, respectively). The rate of patients with short-duration PN use (PN duration of <5 days) declined by 30% in the ICU (RR, 0.70; 95% CI, 0.51-0.97) and by 27% on acute care floors (RR, 0.73; 95% CI, 0.51-1.03).

Conclusions: Weekly multidisciplinary review of patients receiving PN was associated with reductions in the number of patients started on PN, total days that patients received PN, and number of patients who had short-duration (<5 days) PN use.
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http://dx.doi.org/10.1177/0148607115585354DOI Listing
November 2016

The ACGME case log: general surgery resident experience in pediatric surgery.

J Pediatr Surg 2013 Aug;48(8):1643-9

Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital and the University of Washington, Seattle, WA 98105, USA.

Background: General surgery (GS) residents in ACGME programs log cases performed during their residency. We reviewed designated pediatric surgery (PS) cases to assess for changes in performed cases over time.

Methods: The ACGME case logs for graduating GS residents were reviewed from academic year (AY) 1989-1990 to 2010-2011 for designated pediatric cases. Overall and designated PS cases were analyzed. Data were combined into five blocks: Period I (AY1989-90 to AY1993-94), Period II (AY1994-95 to AY1998-99), Period III (AY1999-00 to AY2002-03), Period IV (AY2003-04 to AY2006-07), and Period V (AY2007-08 to AY2010-11). Periods IV and V were delineated by implementation of duty hour restrictions. Student t-tests compared averages among the time periods with significance at P < .05.

Results: Overall GS case load remained relatively stable. Of total cases, PS cases accounted for 5.4% in Period I and 3.7% in Period V. Designated pediatric cases declined for each period from an average of 47.7 in Period I to 33.8 in Period V. These changes are due to a decline in hernia repairs, which account for half of cases. All other cases contributed only minimally to the pediatric cases. The only laparoscopic cases in the database were anti-reflux procedures, which increased over time.

Conclusions: GS residents perform a diminishing number of designated PS cases. This decline occurred before the onset of work-hour restrictions. These changes have implications on the capabilities of the current graduating workforce. However, the case log does not reflect all cases trainees may be exposed to, so revision of this list is recommended.
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http://dx.doi.org/10.1016/j.jpedsurg.2012.09.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235999PMC
August 2013

Traumatic laceration of the cisterna chyli treated by lymphangiography and percutaneous embolization.

Cardiovasc Intervent Radiol 2014 Feb 9;37(1):267-70. Epub 2013 Mar 9.

Section of Interventional Radiology, Department of Radiology, University of Washington and Harborview Medical Center, 1959 NE Pacific Street, Seattle, WA, 98195, USA,

Lymphangiography and percutaneous embolization has been described for the treatment of thoracic duct injury, usually occurring in the postsurgical period. We report a case of a traumatic gunshot-induced massive chylothorax. Inguinal lymphangiogram was performed demonstrating the site of injury at the cisterna chyli. The cisterna chyli was successfully accessed via a percutaneous approach, and embolization was performed. Chylothorax immediately resolved after two rounds of embolization. Although lymphangiography has been traditionally challenging and cumbersome, because of the need for pedal lymph access, the recent use of inguinal lymphangiography has made this technique more practical. Techniques used for embolization of the thoracic duct may be applied to the cisterna chyli, which is much more challenging to treat surgically.
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http://dx.doi.org/10.1007/s00270-013-0590-6DOI Listing
February 2014

Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials.

J Bone Joint Surg Am 2012 Dec;94(23):2136-43

Division of Orthopaedic Surgery, QEII Health Sciences Center, 1796 Summer Street, Halifax, NS B3H 4M8, Canada.

Background: Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate.

Methods: A literature search, data extraction, and quality assessment were conducted by two independent reviewers. Publication bias was assessed with use of the Egger and Begg tests. Heterogeneity was assessed with use of the I2 test, and fixed or random-effect models were used accordingly. Pooled results were expressed as risk ratios, risk differences, and weighted or standardized mean differences, as appropriate. Meta-regression was employed to identify causes of heterogeneity. Subgroup analysis was performed to assess the effect of early range of motion.

Results: Ten studies met the inclusion criteria. If functional rehabilitation with early range of motion was employed, rerupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If such early range of motion was not employed, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of nonoperative management) for complications other than rerupture. Surgical patients returned to work 19.16 days sooner (p = 0.0014). There was no significant difference between the two treatments with regard to calf circumference (p = 0.357), strength (p = 0.806), or functional outcomes (p = 0.226).

Conclusions: The results of the meta-analysis demonstrate that conservative treatment should be considered at centers using functional rehabilitation. This resulted in rerupture rates similar to those for surgical treatment while offering the advantage of a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the rerupture risk in such patients.
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http://dx.doi.org/10.2106/JBJS.K.00917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509775PMC
December 2012

ACGME case logs: Surgery resident experience in operative trauma for two decades.

J Trauma Acute Care Surg 2012 Dec;73(6):1500-6

Department of Surgery, University of Washington Medical Center, Seattle, Washington, USA.

Background: Surgery resident education is based on experiential training, which is influenced by changes in clinical management strategies, technical and technologic advances, and administrative regulations. Trauma care has been exposed to each of these factors, prompting concerns about resident experience in operative trauma. The current study analyzed the reported volume of operative trauma for the last two decades; to our knowledge, this is the first evaluation of nationwide trends during such an extended time line.

Methods: The Accreditation Council for Graduate Medical Education (ACGME) database of operative logs was queried from academic year (AY) 1989-1990 to 2009-2010 to identify shifts in trauma operative experience. Annual case log data for each cohort of graduating surgery residents were combined into approximately 5-year blocks, designated Period I (AY1989-1990 to AY1993-1994), Period II (AY1994-1995 to AY1998-1999), Period III (AY1999-2000 to AY2002-2003), and Period IV (AY2003-2004 to AY2009-2010). The latter two periods were delineated by the year in which duty hour restrictions were implemented.

Results: Overall general surgery caseload increased from Period I to Period II (p < 0.001), remained stable from Period II to Period III, and decreased from Period III to Period IV (p < 0.001). However, for ACGME-designated trauma cases, there were significant declines from Period I to Period II (75.5 vs. 54.5 cases, p < 0.001) and Period II to Period III (54.5 vs. 39.3 cases, p < 0.001) but no difference between Period III and Period IV (39.3 vs. 39.4 cases). Graduating residents in Period I performed, on average, 31 intra-abdominal trauma operations, including approximately five spleen and four liver operations. Residents in Period IV performed 17 intra-abdominal trauma operations, including three spleen and approximately two liver operations.

Conclusion: Recent general surgery trainees perform fewer trauma operations than previous trainees. The majority of this decline occurred before implementation of work-hour restrictions. Although these changes reflect concurrent changes in management of trauma, surgical educators must meet the challenge of training residents in procedures less frequently performed.

Level Of Evidence: Epidemiologic study, level III; therapeutic study, level IV.
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http://dx.doi.org/10.1097/TA.0b013e318270d983DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4237587PMC
December 2012

Noningested intraperitoneal foreign body causing chronic abdominal pain: a role for laparoscopy in the diagnosis.

J Pediatr Surg 2012 Feb;47(2):e15-7

Department of Surgery, University of Washington Medical School, Seattle, WA, USA.

In this article, we present an unusual case of a young boy who presented with abdominal pain and was found to have a sewing needle that had migrated through the abdominal wall into the peritoneal space. After imaging and endoscopy, the needle was extracted laparoscopically without any evidence of intra-abdominal organ injury and with a good long-term outcome for the child. There are no other such reported cases in the literature. This case highlights the subtleties in management of intra-abdominal foreign bodies in children including rare causes such noningested foreign bodies.
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http://dx.doi.org/10.1016/j.jpedsurg.2011.10.052DOI Listing
February 2012

High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns.

Cochrane Database Syst Rev 2012 Jan 18;1:CD006122. Epub 2012 Jan 18.

Sports Institute Northern Ireland, University of Ulster, Newtownabbey, Northern Ireland, BT370QB, UK.

Background: Severe burn injuries increase patients' metabolic needs. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing.

Objectives: To examine the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds).

Search Methods: We searched the Cochrane Injuries Group Specialised Register (searched 28 Nov 2011), Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4), MEDLINE (Ovid) 1950 to Nov (Week 3) 2011, EMBASE (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Nov 2011), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Nov 2011), PubMed (Searched 28 Nov 2011). Online trials registers and conference proceedings were also searched to April 2010.

Selection Criteria: We included all randomized controlled trials (RCTs) comparing high-carbohydrate enteral feeds to high-fat enteral feeds for treatment of patients with 10% or greater total body surface area (TBSA) burns in the immediate post-burn period, with data for at least one of the pre-specified outcomes.

Data Collection And Analysis: Two authors collected and analysed the following data: mortality, incidence of pneumonia and days on ventilator. Meta-analysis could only be performed for the outcomes mortality and incidence of pneumonia. A random-effects model was used for all comparisons.

Main Results: Two RCTs, reporting results from 93 patients, were included in this review. Patients given a high-carbohydrate feeding formula had an odds ratio (OR) of 0.12 (95% confidence interval (CI) 0.04 to 0.39) for developing pneumonia compared to patients given a high-fat enteral formula (P value = 0.0004). Patients given a high-carbohydrate formula had an OR of 0.36 (95% CI 0.11 to 1.15) for risk of death compared to patients given a high-fat enteral formula; this difference did not reach statistical significance (P value = 0.08). Risk of bias in these studies was assessed as high and moderate.

Authors' Conclusions: The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% TBSA burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias. Further research is needed in this area before strong conclusions can be drawn.
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http://dx.doi.org/10.1002/14651858.CD006122.pub3DOI Listing
January 2012

Comparison of minimally invasive versus conventional open harvesting techniques for iliac bone graft in secondary alveolar cleft patients.

Plast Reconstr Surg 2011 Aug;128(2):485-491

New York, N.Y.; and Seattle, Wash. From the Institute of Reconstructive Plastic Surgery, New York University School of Medicine, and the University of Washington Medical Center.

Background: Autologous bone grafts, often harvested from the iliac crest, are the criterion standard for secondary alveolar cleft repair. The best technique for harvest remains controversial. Minimally invasive techniques have been used for bone graft harvest in cleft patients, but outcome studies have been limited by small numbers of patients.

Methods: A total of 104 patients undergoing bone grafting for alveolar cleft were reviewed. Fifty-five consecutive patients underwent minimally invasive iliac bone graft harvest using the Acumed power-driven trephine system performed by the same surgeon. These patients were compared with 49 control patients undergoing a similar procedure in which the traditional method of open iliac bone harvest with an osteotome was used.

Results: Operative time for the bone graft harvest was significantly shorter with the Acumed device when compared with the osteotome (2.37 hours versus 3.26 hours, p < 0.001). Patients who underwent minimally invasive Acumed bone harvest required significantly less postoperative analgesia than did patients who underwent osteotome harvest, for both narcotic (0.31 mg/kg versus 1.64 mg/kg, p < 0.001) and nonnarcotic (15.1 mg/kg versus 27.2 mg/kg, p < 0.01) pain medication. Acumed patients had significantly less pain on discharge (0.26 versus 3.1 pain scores on a scale from 0 to 10, p < 0.001) and left the hospital more quickly (23.3 hours versus 30.1 hours, p < 0.001).

Conclusion: Minimally invasive bone graft harvest technique using the trephine system offers a superior alternative to the conventional open iliac bone harvest method for patients undergoing secondary alveolar cleft repair, with shorter operative time, decreased requirement for pain medications, less pain on discharge, and a shorter hospital stay.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0b013e31821b6336DOI Listing
August 2011

Pediatric appendicitis in New England: epidemiology and outcomes.

J Pediatr Surg 2011 Jun;46(6):1106-14

University of Washington, Seattle, WA 98102, USA.

Background: Acute appendicitis is among the most common indications for surgery in children in the Western world. The epidemiology of acute appendicitis in the United States has not been recently analyzed in a population-based cohort study.

Methods: Here, we describe the epidemiology of acute appendicitis in the pediatric population in New England from 2000 to 2006.

Results: Our results show that there is clustering of perforated and nonperforated appendicitis by hospital catchment area (Moran I index 0.01 and 0.03, respectively). The overall incidence of nonperforated appendicitis decreased over our study period by 9.7% (P < .05), the proportion of perforated appendicitis did not change significantly over our study period, and there was a 38% decrease in the proportion of negative appendectomies (P < .05).

Conclusions: There were trends toward increased operative volume for pediatric surgeons as well as sharp increases in the use of laparoscopy and early discharge with home health services. Our results demonstrate that the epidemiology, outcomes, and trends in treatment of acute appendicitis continue to change.
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http://dx.doi.org/10.1016/j.jpedsurg.2011.03.039DOI Listing
June 2011

Mesothelial cyst presenting as an irreducible inguinal mass.

J Pediatr Surg 2010 Jun;45(6):e19-21

Department of Surgery University of Washington, Seattle, WA 98105, USA.

Inguinal hernias are common in the pediatric population. We describe a 10-year-old child who presented with signs and symptoms suggestive of an incarcerated inguinal hernia. Ultrasound examination demonstrated an aperistaltic multicystic inguinal mass of uncertain origin. The mass was resected, and the adjacent hernia was repaired. Histologic examination identified the mass as a mesothelial cyst. Mesothelial cysts are rare groin lesions in children that can masquerade as an incarcerated inguinal hernia in a child.
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http://dx.doi.org/10.1016/j.jpedsurg.2010.03.034DOI Listing
June 2010

Don't ignore home grown medical systems.

BMJ 2010 Jun 17;340:c3187. Epub 2010 Jun 17.

University of Washington, Washington, DC, USA.

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http://dx.doi.org/10.1136/bmj.c3187DOI Listing
June 2010

Bisphosphonate-associated osteonecrosis of the jaw: successful treatment at 2-year follow-up.

Plast Reconstr Surg 2008 Aug;122(2):57e-59e

Stanford, Calif.; and New York, N.Y. From the Department of Surgery, Stanford University School of Medicine, and the Department of Surgery, New York University School of Medicine.

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http://dx.doi.org/10.1097/PRS.0b013e31817d5fd7DOI Listing
August 2008

Pulsed electromagnetic fields accelerate normal and diabetic wound healing by increasing endogenous FGF-2 release.

Plast Reconstr Surg 2008 Jan;121(1):130-141

Palo Alto, Calif.; New York, N.Y.; and Parsippany, N.J. From Stanford University Medical Center, New York University Medical Center, and EBI, L.P., Inc.

Background: Chronic wounds, particularly in diabetics, result in significant morbidity and mortality and have a profound economic impact. The authors demonstrate that pulsed electromagnetic fields significantly improve both diabetic and normal wound healing in 66 mice through up-regulation of fibroblast growth factor (FGF)-2 and are able to prevent tissue necrosis in diabetic tissue after an ischemic insult.

Methods: Db/db and C57BL6 mice were wounded and exposed to pulsed electromagnetic fields. Gross closure, cell proliferation, and vascularity were assessed. Cultured medium from human umbilical vein endothelial cells exposed to pulsed electromagnetic fields was analyzed for FGF-2 and applied topically to wounds. Skin flaps were created on streptozocin-induced diabetic mice and exposed to pulsed electromagnetic fields. Percentage necrosis, oxygen tension, and vascularity were determined.

Results: Pulsed electromagnetic fields accelerated wound closure in diabetic and normal mice. Cell proliferation and CD31 density were significantly increased in pulsed electromagnetic field-treated groups. Cultured medium from human umbilical vein endothelial cells in pulsed electromagnetic fields exhibited a three-fold increase in FGF-2, which facilitated healing when applied to wounds. Skin on diabetic mice exposed to pulsed electromagnetic fields did not exhibit tissue necrosis and demonstrated oxygen tensions and vascularity comparable to those in normal animals.

Conclusions: This study demonstrates that pulsed electromagnetic fields are able to accelerate wound healing under diabetic and normal conditions by up-regulation of FGF-2-mediated angiogenesis. They also prevented tissue necrosis in response to a standardized ischemic insult, suggesting that noninvasive angiogenic stimulation by pulsed electromagnetic fields may be useful to prevent ulcer formation, necrosis, and amputation in diabetic patients.
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http://dx.doi.org/10.1097/01.prs.0000293761.27219.84DOI Listing
January 2008

Age decreases endothelial progenitor cell recruitment through decreases in hypoxia-inducible factor 1alpha stabilization during ischemia.

Circulation 2007 Dec 26;116(24):2818-29. Epub 2007 Nov 26.

Department of Surgery, Stanford University, Stanford, CA 94305, USA.

Background: Advanced age is known to impair neovascularization. Because endothelial progenitor cells (EPCs) participate in this process, we examined the effects of aging on EPC recruitment and vascular incorporation.

Methods And Results: Murine neovascularization was examined by use of an ischemic flap model, which demonstrated aged mice (19 to 24 months) had decreased EPC mobilization (percent mobilized 1.4+/-0.2% versus 0.4+/-0.1%, P<0.005) that resulted in impaired gross tissue survival compared with young mice (2 to 6 months). This decrease correlated with diminished tissue perfusion (P<0.005) and decreased CD31+ vascular density (P<0.005). Gender-mismatched bone marrow transplantation demonstrated significantly fewer chimeric vessels in aged mice (P<0.05), which confirmed a deficit in bone marrow-mediated vasculogenesis. Age had no effect on total EPC number in mice or humans. Reciprocal bone marrow transplantations confirmed that impaired neovascularization resulted from defects in the response of aged tissue to hypoxia and not from intrinsic defects in EPC function. We demonstrate that aging decreased hypoxia-inducible factor 1alpha stabilization in ischemic tissues because of increased prolyl hydroxylase-mediated hydroxylation (P<0.05) and proteasomal degradation. This resulted in a diminished hypoxia response, including decreased stromal cell-derived factor 1 (P<0.005) and vascular endothelial growth factor (P<0.0004). This effect can be reversed with the iron chelator deferoxamine, which results in hypoxia-inducible factor 1alpha stabilization and increased tissue survival.

Conclusions: Aging impairs EPC trafficking to sites of ischemia through a failure of aged tissues to normally activate the hypoxia-inducible factor 1alpha-mediated hypoxia response.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.107.715847DOI Listing
December 2007

db/db mice exhibit severe wound-healing impairments compared with other murine diabetic strains in a silicone-splinted excisional wound model.

Wound Repair Regen 2007 Sep-Oct;15(5):665-70

Laboratory of Microvascular Research and Vascular Tissue Engineering, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, New York, USA.

The pathophysiology of diabetic wound healing and the identification of new agents to improve clinical outcomes continue to be areas of intense research. There currently exist more than 10 different murine models of diabetes. The degree to which wound healing is impaired in these different mouse models has never been directly compared. We determined whether differences in wound impairment exist between diabetic models in order to elucidate which model would be the best to evaluate new treatment strategies. Three well-accepted mouse models of diabetes were used in this study: db/db, Akita, and streptozocin (STZ)-induced C57BL/6J. Using an excisional model of wound healing, we demonstrated that db/db mice exhibit severe impairments in wound healing compared with STZ and Akita mice. Excisional wounds in db/db mice show a statistically significant delay in wound closure, decreased granulation tissue formation, decreased wound bed vascularity, and markedly diminished proliferation compared with STZ, Akita, and control mice. There was no difference in the rate of epithelialization of the full-thickness wounds between the diabetic or control mice. Our results suggest that splinted db/db mice may be the most appropriate model for studying diabetic wound-healing interventions as they demonstrate the most significant impairment in wound healing. This study utilized a novel model of wound healing developed in our laboratory that stents wounds open using silicone splints to minimize the effects of wound contraction. As such, it was not possible to directly compare the results of this study with other studies that did not use this wound model.
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http://dx.doi.org/10.1111/j.1524-475X.2007.00273.xDOI Listing
February 2008

Hypertrophic scar formation following burns and trauma: new approaches to treatment.

PLoS Med 2007 Sep;4(9):e234

Department of Surgery, Stanford University School of Medicine, Stanford, California, United States of America.

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http://dx.doi.org/10.1371/journal.pmed.0040234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1961631PMC
September 2007

Mechanical load initiates hypertrophic scar formation through decreased cellular apoptosis.

FASEB J 2007 Oct 15;21(12):3250-61. Epub 2007 May 15.

Department of Surgery, Stanford University School of Medicine, Stanford, California, USA.

Hypertrophic scars occur following cutaneous wounding and result in severe functional and esthetic defects. The pathophysiology of this process remains unknown. Here, we demonstrate for the first time that mechanical stress applied to a healing wound is sufficient to produce hypertrophic scars in mice. The resulting scars are histopathologically identical to human hypertrophic scars and persist for more than six months following a brief (one-week) period of augmented mechanical stress during the proliferative phase of wound healing. Resulting scars are structurally identical to human hypertrophic scars and showed dramatic increases in volume (20-fold) and cellular density (20-fold). The increased cellularity is accompanied by a four-fold decrease in cellular apoptosis and increased activation of the prosurvival marker Akt. To clarify the importance of apoptosis in hypertrophic scar formation, we examine the effects of mechanical loading on cutaneous wounds of animals with altered pathways of cellular apoptosis. In p53-null mice, with down-regulated cellular apoptosis, we observe significantly greater scar hypertrophy and cellular density. Conversely, scar hypertrophy and cellular density are significantly reduced in proapoptotic BclII-null mice. We conclude that mechanical loading early in the proliferative phase of wound healing produces hypertrophic scars by inhibiting cellular apoptosis through an Akt-dependent mechanism.
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http://dx.doi.org/10.1096/fj.07-8218comDOI Listing
October 2007
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