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Our earlier studies showed that inhibiting prolyl-4-hydroxylase enzymes (PHD-1 and PHD-3) improves angiogenesis, heart function, and limb perfusion in mouse models via stabilizing hypoxia-inducible transcription factor-alpha (HIF-1α). The present study explored the effects of the prolyl-4-hydroxylase enzyme, PHD-2, on ischemic heart failure using cardiac-specific PHD-2 gene knockout (KO) mice (PHD2 -/- ).Adult wild-type (WT) and PHD2 -/- mice, 8-12 weeks old, were subjected to myocardial infarction (MI) by irreversibly ligating the left anterior descending (LAD) coronary artery. All sham group mice underwent surgery without LAD ligation. Animals were divided into 4 groups: (1) wild-type sham (WTS); (2) wild-type myocardial infarction (WTMI); (3) PHD2KO sham (PHD2 -/- S); (4) PHD2KO myocardial infarction (PHD2 -/- MI). Left ventricular tissue samples collected at various time points after surgery were used for microRNA expression profiling, Western blotting, and immunohistochemical analysis.Volcano plot analysis revealed 19 differentially-expressed miRNAs in the PHD2 -/- MI group compared with the WTMI group. Target analysis using Ingenuity Pathway Analysis showed several differentially regulated miRNAs targeting key signaling pathways such as Akt, VEGF, Ang-1, PTEN, apoptosis, and hypoxia pathways. Western blot analysis showed increased HIF-1α, VEGF, phospho-AKT, β-catenin expression and reduced Bax expression for the PHD2 -/- MI group compared with the WTMI group. Echocardiographic analysis showed preserved heart functions, and picrosirius red staining revealed decreased fibrosis in PHD2 -/- MI compared with the WTMI group.PHD2 inhibition showed preserved heart function, enhanced angiogenic factor expression, and decreased apoptotic markers after MI. Overall, cardiac PHD2 gene inhibition is a promising candidate for managing cardiovascular diseases.

Introduction: Increased production of reactive oxygen species contributes to the etiology of diabetic complications. It acts as an intracellular antioxidant by scavenging reactive oxygen species (ROS) and protect the cells against oxidative stress and cell death. Hypothesis: To determine the long-term effect of streptozotocin (STZ) induced type 1 diabetes on aging Trx-1 transgenic mice related to survivability, heart function, fibrosis, and apoptosis up to 180 days (d) compared to its corresponding wild-type (WT C57Bl/6J). Method: WT and Trx-1 overexpressed mice (Trx-1 Tg/+ ) (8-12 weeks old) were injected with STZ (i.p. 50mg/kg.body weight(bw)-male; 75mg/kg.bw-female for 5 consecutive days) for induction of diabetes (Dia). Fasting blood sugar level (FBS) was measured 30d after the final injection, and FBS >220mg/dL is used as the cut-off for diabetes. Echocardiography, Survival, FBS measurements were performed on 30, 60, 90, 120, 150, and 180d. Immunohistochemistry was performed on heart tissues (30, 90, and 180d). Results: Dia-Trx-1 Tg/+ mice maintained EF at 60d (61.14±2.3%), 120d (56.1±1.94%) and 180d (60.8±4.3%), when compared to 30d (64.4±1.94%) representing preserved cardiac functions. On the other hand, Dia-WT mice show significant progressive depression of EF at 60d (53.8±1.9%), 120d (48.8±2.1%), and 180d (48.9±1.5%), (pTg/+ mice show significantly higher EF than their corresponding Dia-WT counterparts at each time point measured after diabetic induction (n=8-12, pTg/+ mice (n=71) also exhibited increased survival rate over Dia-WT (n=47) counterparts with a median survival of 150 days compared to 60 days (Log Rank test: p=0.004). Dia-Trx-1 Tg/+ mice also showed a significant reduction in cardiac fibrosis (4.18±1.08% vs. 17.5±5.1%; p=0.03, n=4) and TUNEL positive cells (3.81±1.49 vs. 7.66±1.46; p=0.03, n=4) when compared to their counterpart (Dia-WT) after 180d of diabetes. Conclusion: These results show that Trx-1 Tg/+ mice preserved cardiac functions, increased survival, decreased apoptosis and fibrosis up to 180d under diabetic conditions, and hence suggesting Trx-1 based treatment strategy could prevent heart failure in aging.

Introduction: Sepsis remains a significant cause of mortality in the intensive care unit till today. Recent research suggests nearly one in four deaths in people with heart failure is caused by sepsis. Overexpression of mammalian Pellino-1 (Peli1), a E3 ubiquitin ligase, causes inhibition of apoptosis, oxidative stress, and preservation of cardiac function in a myocardial infarction model. Therefore, in the present study, we explored the possibility to overcome sepsis mediated heart failure by overexpressing Peli1 (AMPEL1Tg/+) in a mouse model of severe sepsis. Methods: C57BL/6J (WT) and AMPEL1 Tg/+ mice were divided into Wild-type sham (WTS), Wild-type Cecal Ligation and Puncture (WTCLP), AMPEL1 Tg/+ sham (AMPEL1 Tg/+ S) and AMPEL1 Tg/+ CLP. Cardiac function (LVEF, FS) by two-dimensional echocardiography was assessed pre-procedure, at 6, and 24 hours post-surgery. Serum IL-6 and TNF-alpha (ELISA) at 6 hours and cardiac apoptosis (TUNEL assay) at 24 hours were measured. Results are expressed as mean ± SEM. Results: Analysis of echocardiographic parameters (EF, FS) preoperatively and among the sham groups were similar however there was significant preservation of post-procedure LVEF (%) in the AMPEL1 Tg/+ CLP at the 6 hour (AMPEL1 Tg/+ :52.7 ± 3.71 vs WT:40.7 ±2.46, p=0.013, n=10-11) and 24-hour time point (AMPEL1 Tg/+ :63.1 ± 1.63 vs WT:49.3 ± 4.41, p=0.002, n=9-11) compared to WT. Similar trend was observed in estimation of FS (%) at 6 hours (AMPEL1 Tg/+ :26.3 ± 2.22 vs WT:19.3 ±1.37, p=0.014, n=10-11) and 24 hours (AMPEL1 Tg/+ :32.4 ± 1.89 vs WT:24.4 ± 2.67, p=0.031, n=9-11). A marked decrease in serum IL-6 (AMPEL1 Tg/+ :259.7 ± 18.70 vs WT:483.2 ± 24.01, pTg/+ :86.89 ± 14.36 vs WT:161.8 ± 20, p=0.012, n=6, pg/mL) was observed in the AMPEL1 Tg/+ CLP at 6 hours. The preserved cardiac function in CLP was further supported by a noticeable decrease in cardiac apoptosis (% TUNEL positive cells) at 24 hours in the AMPEL1 Tg/+ CLP group (4.7 ± 0.94 vs 11.7 ± 2.82, p=0.040, n=6,) compared to WTCLP. Conclusions: Thus, Peli1 overexpression is a novel approach that preserved cardiac function, reduced inflammatory markers, and apoptosis following severe sepsis in a murine genetic model.

Introduction: Ischemic heart disease is the leading cause of death in adults in the US. We have shown that overexpression of E3 ligase Pellino1 (Peli1) increased vessel density, triggered anti-apoptotic signaling, and preserved cardiac function in the infarcted myocardium. In the present study, we aimed to explore whether the loss of Peli1 function in cardiomyocytes has any effect on cardiac function using a genetically-modified murine myocardial infarction (MI) model. Methods: Wild type (WT) and cardiomyocyte-specific Peli1 knockout (CP1KO -/- ) mice were divided into 4 groups [wild-type-sham (WTS), CP1KO -/- sham (CP1KO -/- S), WTMI and CP1KO -/- MI] to undergo either left anterior descending artery ligation or sham surgery. Phosphorylation of Mitogen-Activated Protein Kinase-Activated Protein Kinase-2 (p-MK2) and expression of VEGF, Bcl2, and cIAP2 were quantified by Western blot analysis. Cardiac function by two-dimensional echocardiography was performed at 30 days post-op to assess ejection fraction (EF), fractional shortening (FS), left ventricular internal diameter in both systole and diastole (LVIDs and LVIDd). Results: We observed no significant change in cardiac functions between WTS and CP1KO-/-S group. However, in MI groups, CP1KO -/- mice showed significant loss of systolic functions, represented by both EF (26.60%±2.340 vs. 33.46%±1.84; p-/- group compared to WT mice. Similarly, expression of VEGF (p=0.0227), BCl-2 (p=0.0073) and cIAP2 (p=0.0483) was also found to be significantly downregulated in CP1KO -/- group compared to WTMI group at 4-day post-MI. We also analyzed oxidative stress marker, 3-NT, which was significantly upregulated (p=0.0001) in CP1KO mice compared to WTMI. Conclusion: Loss of Peli1 in cardiomyocyte results in the impairment of cardiac function along with increased oxidative stress, reduced angiogenic and survival protein expression, which suggests Peli1 plays an important role in the cardiomyocyte signaling during myocardial infarction.

Introduction: Peripheral vascular disease (PVD) is a major cause of morbidity in the US. Vascular endothelial growth factor (VEGF) induces angiogenesis through Fetal-Liver Kinase-1 (Flk-1 or VEGFR-2), an endothelial tyrosine kinase receptor which activates a downstream signaling cascade involving MAPKAPKinase2 (MK2). We have demonstrated poorer recovery in hind limb ischemia models using Flk-1 +/- and MK2 -/- knockout mice compared to wild type mice. We also demonstrated overespression of Pellino1 (Peli1), an E3 Ligase, can attenuate ischemic damage and increase neovascularization and survivability of ischemic myocardium and skin flaps. Therefore, in this study we aim to show if Peli1 gene therapy can help rescue function in Flk-1 +/- and MK2 -/- after femoral artery ligation. Methods: 8-12 week-old Flk-1 +/- and MK2 -/- mice were subjected to femoral artery ligation of the right hind limb and treated with either adenovirus carrying Peli1 (Ad.Peli1) or LacZ (Ad.LacZ), for a total of 4 groups: Flk-1 +/- Ad.LacZ, Flk-1 +/- Ad.Peli1, MK2 -/- Ad.LacZ and MK2 -/- Ad.Peli1. Perfusion was assessed with laser Doppler imaging preop and on days 0, 3, 7, 14, 21 and 28. Extent of limb ischemia was also quantified using a standardized scoring scale (0 = no ischemia, to 8 = full limb amputation). Results: Perfusion was significantly higher in the Flk-1 +/- Ad.Peli1 group compared to Flk-1 +/- Ad.LacZ on days 7 (0.19±0.03 vs 0.08±0.02), 14 (0.41±0.07 vs 0.09±0.03), 21 (0.33±0.05 vs 0.14±0.05) and 28 (0.31±0.05 vs 0.15±0.02) (n=9-15, p+/- Ad.Peli1 group when compared to Flk-1 +/- Ad.LacZ on days 3 (1.89±0.56 vs 4.88±0.85), 7 (2.11±0.54 vs 5.69±0.92), 14 (2.18±0.52 vs 6.31±1.02), 21 (1.83±0.58 vs 6.50±1.05) and 28 (1.67±0.62 vs 6.50±1.05) (n=8-9, p-/- Ad.Peli1 and MK2 -/- Ad.LacZ groups. Values are mean +/- SEM. Conclusions: Treatment with Ad.Peli1 resulted in improved perfusion and decreased tissue ischemia in Flk-1 +/- mice. These results were not paralleled in MK2 -/- mice suggesting that Peli1 acts upstream to MK2 but downstream of VEGF/Flk-1. Overall, Peli1 gene therapy is a promising candidate in the management of PVD.

In the present study, we aimed to explore the functional role of Pellino-1 (Peli1) in inducing neovascularization after myocardial infarction (MI) and hindlimb ischemia (HLI) using Peli1 global knockout mice (Peli1−/−). Recently we have shown that Peli1, an E3 ubiquitin ligase, induce angiogenesis and improve survivability, with decreased necrosis of ischemic skin flaps. Peli1fl/fl and Peli1−/− mice were subjected to either permanent ligation of the left anterior descending coronary artery (LAD) or sham surgery (S). Tissues from the left ventricular risk area were collected at different time points post-MI. In addition, Peli1fl/fl and Peli1−/− mice were also subjected to permanent ligation of the right femoral artery followed by motor function scores, Doppler analysis for blood perfusion and immunohistochemical analysis. Global Peli1 knockout exacerbated myocardial dysfunction, 30 and 60 days after MI compared to wild type (WT) mice as measured by echocardiogram. In addition, Peli1−/− mice also showed decreased motor function scores and perfusion ratios compared with Peli1fl/fl mice 28 days after the induction of HLI. The use of Peli1 in adenoviral gene therapy following HLI in CD1 mice improved the perfusion ratio at 28 days compared to Ad.LacZ-injected mice. These results suggest new insights into the protective role of Peli1 on ischemic tissues and its influence on survival signaling.

Background There is keen interest in finding nonsurgical treatments for peripheral vascular disease (PVD). Previously, we demonstrated that selective activation of Thioredoxin1 (Trx1), a 12-kDa cytosolic protein, initiates redox-dependent signaling and promotes neovascularization after ischemic heart disease. Therefore, Trx1 might possess immense potential to not only treat murine hind limb ischemia (HLI) through effective angiogenesis but also provide PVD patients with nonsurgical therapy to enhance neovascularization and improve blood perfusion. Methods To determine whether activation of Trx1 increases blood perfusion in HLI, two different strategies were used—gene therapy and transgenic model system. In adenoviral-mediated gene therapy, 8- to 12-wk-old mice were divided into two groups: (1) control Adeno-LacZ (Ad-LacZ) and (2) Adeno-Thiroedoxin1 (Ad-Trx1). The mice underwent surgical intervention to induce right HLI followed by injection with Ad-LacZ or Ad-Trx1, respectively. In the second strategy, we used wild-type and transgenic mice overexpressing Trx1 (Trx1 Tg/+ ). All the animals underwent Doppler imaging for the assessment of limb perfusion followed by immunohistochemistry and Western blot analysis. Results Significant increases in perfusion ratio were observed in all the Trx1 overexpressed groups compared with their corresponding controls. Expressions of heme oxygenase-1, vascular endothelial growth factor, and the vascular endothelial growth factor receptors Flk-1 and Flt-1 were increased in Trx1 overexpressed mice compared with their respective controls. Blood perfusion in the ischemic limb gradually improved and significantly recovered in Trx1 Tg/+ and Ad-Trx1 groups compared with their corresponding controls. The capillary and arteriolar density in the ischemic zone were found to be higher in Trx1 Tg/+ group compared with wild type. Conclusions The overall outcomes of our study demonstrate that Trx1 enhances blood perfusion and increases angiogenic protein expression in a rodent HLI model. These results suggest that Trx1 is a potential target for clinical trials and drug therapy for the treatment of PVD.

Background Hibernating American black bears have significantly different clotting parameters than their summer active counterparts, affording them protection against venous thromboembolism during prolonged periods of immobility. We sought to evaluate if significant differences exist between the expression of microRNAs in the plasma of hibernating black bears compared with their summer active counterparts, potentially contributing to differences in hemostasis during hibernation. Materials and methods MicroRNA sequencing was assessed in plasma from 21 American black bears in summer active (n = 11) and hibernating states (n = 10), and microRNA signatures during hibernating and active state were established using both bear and human genome. MicroRNA targets were predicted using messenger RNA (mRNA) transcripts from black bear kidney cells. In vitro studies were performed to confirm the relationship between identified microRNAs and mRNA expression, using artificial microRNA and human liver cells. Results Using the bear genome, we identified 15 microRNAs differentially expressed in the plasma of hibernating black bears. Of these microRNAs, three were significantly downregulated (miR-141-3p, miR-200a-3p, and miR-200c-3p), were predicted to target SERPINC1, the gene for antithrombin, and demonstrated regulatory control of the gene mRNA expression in cell studies. Conclusions Our findings suggest that the hibernating black bears’ ability to maintain hemostasis and achieve protection from venous thromboembolism during prolonged periods of immobility may be due to changes in microRNA signatures and possible upregulation of antithrombin expression.

The complete loss of dermal tissue due to ischemia is a serious challenge facing clinicians. Frequently, the failure of wound healing is due to ischemic conditions prevailing at the site of damaged tissue. Restoration of lost vasculature at the ischemic site can be achieved by supplementing proangiogenic stimuli through an engineered scaffold mimicking dermal extracellular matrix. Towards this objective, we have developed an electrospun scaffold loaded with the pro-angiogenic molecule resveratrol. The physical and chemical changes in the polymeric scaffold before and after loading of resveratrol were characterized using field emission scanning electron microscopy (FE-SEM), Fourier-transform infrared spectroscopy (FT-IR), differential scanning calorimetry (DSC), thermogravimetric analysis (TGA), coherence scanning interferometry (CSI) and X-ray diffraction (XRD). A sustained release of resveratrol from the scaffold was elucidated by UV-spectrophotometer analysis. The enhancement in cell-matrix interaction was studied using human umbilical vein endothelial cells (HUVECs) seeded on the scaffolds. The biocompatibility analysis of resveratrol loaded scaffolds was evaluated through a subcutaneous implantation study in mice. The therapeutic potential of resveratrol loaded scaffolds to accelerate tissue repair was analyzed in a full-thickness ischemic wound model in mice. Wound closure and H&E staining analysis showed rapid closure of ischemic wound area and re-epithelialization in resveratrol loaded scaffold treated groups compared to collagen and negative control groups. The immunostaining analysis further revealed the activation of thioredoxin-1 (Trx-1), heme oxygenase-1 (HO-1) mediated vascular endothelial growth factor (VEGF) signaling in resveratrol loaded scaffold treated group. The expression of Bcl-2 in healing wound edges post-treatment with resveratrol loaded scaffold confirmed the anti-apoptotic effect mediated by resveratrol. From this study, we explored a synergistic effect mediated by resveratrol and fibrous scaffolds to aid the ischemic wound healing process through effective vascularization.

Introduction Engraftment of mesenchymal stem cells (MSCs) has emerged as a powerful candidate for mediating myocardial repair. In this study, we genetically modified MSCs with an adenovector encoding thioredoxin-1 (Ad.Trx1). Trx1 has been described as a growth regulator, a transcription factor regulator, a cofactor, and a powerful antioxidant. We explored whether engineered MSCs, when transplanted, are capable of improving cardiac function and angiogenesis in a rat model of myocardial infarction (MI). Methods Rat MSCs were cultured and divided into MSC, MSC+Ad.LacZ, and MSC+Ad.Trx1 groups. The cells were assayed for proliferation, and differentiation potential. In addition, rats were divided into control-sham (CS), control-MI (CMI), MSC+Ad.LacZ-MI (MLZMI), and MSC+Ad.Trx1-MI (MTrxMI) groups. MI was induced by left anterior descending coronary artery (LAD) ligation, and MSCs preconditioned with either Ad.LacZ or Ad.Trx1 were immediately administered to four sites in the peri-infarct zone. Results The MSC+Ad.Trx1 cells increased the proliferation capacity and maintained pluripotency, allowing them to divide into cardiomyocytes, smooth muscle, and endothelial cells. Western blot analysis, 4days after treatment showed increased vascular endothelial growth factor (VEGF), heme oxygenase-1 (HO-1), and C-X-C chemokine receptor type 4 (CXCR4). Also capillary density along with myocardial function as examined by echocardiography was found to be increased. Fibrosis was reduced in the MTrxMI group compared to MLZMI and CMI. Visualization of Connexin-43 by immunohistochemistry confirmed increased intercellular connections in the MTrxMI rats compared to MLZMI. Conclusion Engineering MSCs to express Trx1 may prove to be a strategic therapeutic modality in the treatment of cardiac failure.

Clinical studies of Phyllanthus emblica (P. emblica) have shown that it increases production of nitric oxide, glutathione, and high-density lipoprotein (HDL); decreases low-density lipoprotein (LDL), total cholesterol, triglycerides, and high-sensitivity C-reactive protein (hsCRP); and significantly inhibits platelet aggregation. The following study was designed to examine the effect of P. emblica treatment on myocardial ischemia-reperfusion (I/R) injury and identify the molecular targets and its underlying mechanism(s). Experimental animals were divided into four groups: control sham (CS), P. emblica sham (PS), control I/R (CIR), and P. emblica I/R (PIR). Rats in the P. emblica groups were gavaged with aqueous P. emblica solution (100 mg/kg body weight) for 30 days. After 30 days of gavaging, the I/R group underwent I/R surgery (45-min ischemia) followed by 4 or 30 days of reperfusion. Rats in the sham group underwent surgery without ligation. Left ventricular tissue samples, 4 and 30 days after I/R, were used for Western blot analysis and immunohistochemistry, respectively. Western blot analysis showed upregulation of phosphorylated Akt and GSK3-β and increased nuclear translocation of β-catenin in the PIR group versus CIR. PIR rats also indicated reduced 3-nitrotyrosine and Caspase-3 expression. Increased phosphorylation of endothelial nitric oxide synthase (p-eNOS) and upregulation of anti-apoptotic protein Bcl-2 were found in the PIR group. Echocardiography showed increased ejection fraction and fractional shortening and decreased left ventricular internal diameter in experimental subjects compared to controls. There was decreased fibrosis in P. emblica-treated rats compared to controls. The results of this study indicate that P. emblica is capable of upregulating the PI3K/Akt/GSK3β/β-catenin cardioprotective pathway, thereby preserving cardiac tissue during ischemia-reperfusion injury.

Background Nonhealing wounds are a continuing health problem in the United States. Overproduction of reactive oxygen species is a major causative factor behind delayed wound healing. Previously we reported that thioredoxin-1 treatment could alleviate oxidative stress under ischemic conditions, such as myocardial infarction and hindlimb ischemia. In this study, we explored the potential for thioredoxin-1 gene therapy to effectively aid wound healing through improved angiogenesis in a murine ischemic wound model. Methods Full-thickness, cutaneous, ischemic wounds were created in the dorsum skin flap of 8- to 12-week-old CD1 mice. Nonischemic wounds created lateral to the ischemic skin flap served as internal controls. Mice with both ischemic wounds and nonischemic wounds were treated with Adeno-LacZ (1 × 109 pfu) or Adeno-thioredoxin-1 (1 × 109 pfu), injected intradermally around the wound. Digital imaging was performed on days 0, 3, 6, and 9 to assess the rate of wound closure. Tissue samples collected at predetermined time intervals were processed for immunohistochemical analysis. Results No significant differences in wound closure were identified among the nonischemic wounds control, nonischemic wounds-LacZ, and nonischemic wounds–thioredoxin-1 groups. Hence, only mice with ischemic wounds were further analyzed. The ischemic wounds–thioredoxin-1 group had significant improvement in wound closure on days 6 and 9 after surgery compared with the ischemic wounds control and ischemic wounds-LacZ groups. Immunohistochemical analysis indicated increased thioredoxin-1, vascular endothelial cell growth factor, and β-catenin levels in the ischemic wounds–thioredoxin-1 group compared with the ischemic wounds control and ischemic wounds-LacZ groups, as well as increased capillary density and cell proliferation, as represented by Ki-67 staining. Conclusion Taken together, thioredoxin-1 gene therapy promotes vascular endothelial cell growth factor signaling and re-epithelialization and activates wound closure in mice with ischemic wounds.

We examined the effects of overexpressing HSPA12B on angiogenesis and myocardial function by intramyocardial administration of adenovirus encoding HSPA12B (Ad. HSPA12B) in a streptozotocin-induced diabetic rat subjected to myocardial infarction. Rats were divided randomly into six groups: control sham (CS) + Ad.LacZ, control myocardial infarction (CMI) + Ad.LacZ, control MI + Ad.HSPA12B, diabetic sham (DS) + Ad.LacZ, diabetic MI + Ad.LacZ and diabetic MI + Ad.HSPA12B. Following MI or sham surgery, the respective groups received either Ad.LacZ or Ad.HSPA12B via intramyocardial injections. We observed increased capillary and arteriolar density along with reduced fibrosis and preserved heart functions in DMI-AdHSPA12B compared to DMI-AdLacZ group. Western blot analysis demonstrated enhanced HSPA12B, vascular endothelial growth factor (VEGF), thioredoxin-1 (Trx-1) expression along with decreased expression of thioredoxin interacting protein (TXNIP) and A kinase anchoring protein 12 (AKAP12) in the DMI-AdHSPA12B compared to DMI-AdLacZ group. Our findings reveal that HSPA12B overexpression interacts with AKAP12 and downregulate TXNIP in diabetic rats following acute MI.

Colonoscopy is a widespread diagnostic and therapeutic procedure. The most common complications include bleeding and perforation. Splenic rupture following colonoscopy is rarely encountered and is most likely secondary to traction on the splenocolic ligament. Exploratory laparotomy and splenectomy is the most commonly employed therapeutic intervention for this injury reported in the literature. We present the case of a patient with this potentially fatal complication who was treated successfully at our institution. To our knowledge it is the first report in the literature of laparoscopic splenectomy as a successful minimally invasive treatment of splenic rupture following colonoscopy. The patient was a 62-year-old female who underwent screening colonoscopy with polypectomies at the cecum, descending colon and rectum. Immediately following the procedure she developed abdominal pain and had a syncopal episode. Clinical, laboratory and imaging findings were suggestive of hemoperitoneum and a ruptured spleen. A diagnostic laparoscopy was emergently performed and revealed a grade IV splenic laceration and hemoperitoneum. Laparoscopic splenectomy was completed safely and effectively. The patient’s postoperative recovery was uneventful. We conclude that splenic rupture after colonoscopy is a rare but dangerous complication. A high index of suspicion is required to recognize it early. Awareness of this potential complication can lead to optimal patient outcome. Laparoscopic splenectomy may be a feasible treatment option.

Cachexia has plagued clinicians for centuries. Although all cachexia is related to malnutrition, cachexia associated with malignant diseases differs from starvation cachexia in that it is more recalcitrant to nutritional therapy. All cachexia responds to judicious nutritional support; however, cancer cachexia worsens autonomously as the disease advances and cannot be arrested or reversed by any known form of nutrition, hormonal, or pharmacologic therapy. Cachexia must be treated cautiously to avoid overfeeding syndrome, which may result in serious or dangerous complications or death.

Clostridium difficile infection (CDI) is an increasing nosocomial problem. New, more-virulent strains of C. difficile have spread across North America and Europe. Health care institutions now face a greater incidence of disease, often with greater severity. A need for surgical management for control of infection is on the increase. The clinical appearance of CDI is changed.We report four unusual and severe cases of CDI in surgical patients with a review of the relevant literature.One patient developed CDI and required a colectomy for a perforated viscus. He developed C. difficile ileitis 12 days later that responded to medical therapy. Another patient who underwent a colectomy for infrarenal aortic occlusion, later in his hospital course, developed C. difficile ileitis and died. The third patient was hospitalized for several months for hypertension and associated morbidities. Eventually he developed severe abdominal pain and was found to have a small bowel mural abscess that grew C. difficile on culture. A fourth patient, taking long-term antibiotics for a surgical site infection of the knee, developed unexplained leukocytosis without diarrhea. Colonoscopy revealed pseudomembranous colitis that advanced to toxic megacolon. She required a colectomy and ultimately died from the disease.Patients are at high risk from CDI in this modern era. Disease manifestations may differ from the typical presentation. A heightened awareness for diagnosing this dangerous, evolving disease is paramount.

Verrucous carcinoma, a variant of well-differentiated squamous cell carcinoma, is usually described in the literature as arising in the oral cavity, skin, and larynx. The reports on verrucous carcinoma arising in the genital tract, usually originating in the vagina, vulva, or uterine cervix, are few. Verrucous carcinoma arising in the ovary has not been previously reported. In this article, a unique hybrid carcinoma, a large aggressive verrucous carcinoma in combination with squamous carcinoma of the left ovary and synchronously occurring with a squamous cell carcinoma in the endometrium, is presented. This unique case of a hybrid carcinoma includes the first-known case of this type of carcinoma involving the ovary. The negative cervical evaluation findings, together with the histologic patterns of the tumors in the uterus and the ovary, support the conclusion that these 2 carcinomas are synchronous, one arising in the left ovary and the other arising in the uterus.

Background Cancer of unknown primary (CUP) origin is a very aggressive disease with a poor prognosis. Most of the literature reports of CUP are generated from tertiary cancer centers. Methods A retrospective chart review of all patients with a diagnosis of CUP was performed between January 1995 and January 2005. Age, gender, diagnostic evaluation, histologic diagnosis, location of metastases, treatment, and survival were recorded. Results Ninety-one patients met the inclusion criteria. The pathologic diagnoses included adenocarcinoma (42.8%), undifferentiated carcinoma (34.5%), squamous cell carcinoma (9.8%), neuroendocrine cancer (6.5%), sarcoma (3.2%), and nonspecific malignant neoplasm (3.2%). The overall mean survival was 9.2 months (95% confidence interval, 6.1–12.4 mo), and for squamous cell carcinoma was 26.9 months (standard error, 5.7; P = .007). Conclusions CUP encompasses a variety of different pathologic entities with an overall dismal 5-year survival. Nonetheless, squamous cell and neuroendocrine CUP are associated with a significantly better early prognosis than the other malignancies.

Objectives Sentinel lymph node biopsy (SLNB) is widely used for staging breast cancer. SLNB accurately determines axillary lymph node status with a low false negative rate. There remains concern that omitting axillary dissection may lead to recurrence in the axilla, and impact long term survival. The purpose of this study was to determine the frequency of axillary lymph node recurrence in patients who had a negative sentinel lymph node and did not undergo axillary node dissection. Methods Data was collected on all patients who had negative SLNB at Roswell Park Cancer Institute between July 1997 and June 2002. Demographics, type of operation, postoperative systemic, and radiation therapy, co-morbidity score, hormone receptor status, and the pathologic features of the tumor were abstracted for each patient. For each woman with recurrence, the dates of recurrence, the site(s) of recurrence, and the treatment for recurrence were recorded. Results With a median follow-up of 33 months, 15 of 335 (4.5%) women who had negative SLNBs and who did not undergo completion axillary dissection developed a cancer recurrence. Only two patients (0.6%) had an axillary recurrence. Conclusions The rate of axillary recurrence following a negative sentinel node biopsy is the same or less than axillary lymph node dissection (ALND) alone. Concerns that omitting completion axillary dissection following a negative SLNB will increase the rate of axillary recurrence appear unfounded. J. Surg. Oncol. 2006;93: 129–132. © 2006 Wiley-Liss, Inc.

Soft tissue sarcomas, a rare and extremely low prevalence tumor, has no uniform treatment recommendation because there have been few randomized prospective trials to guide management. Recently, there have been surgical, medical, biologic, and genetic advances toward improved treatment. A multidisciplinary approach at specialized treatment centers should be sought because the skill set necessary to implement these advances can be provided and outcomes improved. Centralized care will be crucial to improving survival and functional outcome because it will allow for patients to be effectively entered into prospective randomized trials and create regional and national tissue banks to generate meaningful data.

Background There is an emerging focus on investigating innovative therapeutic molecules that can potentially augment neovascularization in order to treat peripheral arterial disease (PAD). Although prolyl hydroxylase domain proteins 1 and 3 (PHD1 and PHD3) may modulate angiogenesis via regulation of hypoxia inducible factor-1α (HIF-1α), there has been no study directly addressing their roles in ischemia-induced vascular growth. We hypothesize that PHD1 −/− or PHD3 −/− deficiency might promote angiogenesis in the murine hind-limb ischemia (HLI) model. Study design Wild type (WT), PHD1 −/− and PHD3 −/− male mice aged 8–12 weeks underwent right femoral artery ligation. Post-procedurally, motor function assessment and laser Doppler imaging were periodically performed. The mice were euthanized after 28 days and muscles were harvested. Immunohistochemical analysis was performed to determine the extent of angiogenesis by measuring capillary and arteriolar density. VEGF expression was quantified by enzyme-linked immunosorbent assay (ELISA). Bcl-2 and HIF-1α were analyzed by immunofluorescence. Fibrosis was measured by picrosirius red staining. Results PHD1 −/− and PHD3 −/− mice showed significantly improved recovery of perfusion and motor function score when compared to WT after femoral artery ligation. These mice also exhibited increased capillary and arteriolar density, capillary/myocyte ratio along with decreased fibrosis compared to WT. VEGF, Bcl-2 and HIF-1α expression increased in PHD1 −/− and PHD3 −/− mice compared to WT. Conclusions Taken together these results suggest that PHD1 and PHD3 deletions promote angiogenesis in ischemia-injured tissue, and may present a promising therapeutic strategy in treating PAD.

Background and Objective Nd:YAG laser photothermal ablation has been accepted as a treatment modality for hemorrhoidal disease. There is little reported on its use in treating pilonidal disease. We hypothesized that laser would be an excellent tool for pilonidal cystectomy, facilitating improved outcome and patient satisfaction. Study Design/Materials and Methods A 5-year retrospective study was performed comparing Nd:YAG laser to the standard surgical technique. A telephone questionnaire addressing the length of time the cyst was debilitating both preoperatively and postoperatively as well as length of convalescent time before return to work was administered. Pain was assessed by using an analog pain scale. Results Operative time for the traditional pilonidal cystectomy was 20 minutes longer than Nd:YAG laser cystectomy. Postoperative hospital stay was similar. Laser patients returned to work an average of 2.4 days earlier, and their postoperative pain was less than those treated traditionally. Conclusion In an era when the medical consumer makes decisions based on the efficacy of treatment by using criteria such as pain, length of hospitalization, and speed of return to work, Nd:YAG lasers have emerged as a surgical tool that can fulfill these criteria for certain procedures. Patient postoperative satisfaction after laser excision was greater when compared with those who had traditional excisions. Postoperative pain was less, as was the pain experienced during the first week of recovery. Cost for both was comparable. Lasers Surg. Med. 26:380–385, 2000. © 2000 Wiley-Liss, Inc.

Background Surgical complications worldwide are dreaded by both patients and physicians alike. They represent significant and serious morbidity and mortality, and contribute substantially to increased costs of healthcare. Case presentation Our Case Report describes a 65yo Caucasian man with an extensive operative history for Crohn’s disease, including 4 laparotomies with small bowel resections to ameliorate small bowel obstructions. He presented with signs and symptoms of a chronic draining sinus, but was found to have a Blind Loop of bowel. This finding is believed to be the result of a surgical complication. Conclusion While the Case Reports discusses this particular patient presentation, the paper defines, describes and offers treatment strategies for Enterocutaneous Fistulas (ECF). We offer aim to add Blind Loop to the differential diagnosis when presented with a patient with signs and symptoms of ECF.

The most significant events and discoveries regarding the development of enteral nutrition (EN) dating back to 1500 BC are chronicled. A more detailed description and discussion of subsequent more recent progress during the past two decades is focused primarily on 3 of the most dynamic areas of endeavor: tight glycemic control; timing and combining of EN and total parenteral nutrition to meet early target nutrition goals in intensive care unit patients; and the role, advances, and future of immunonutrition. An abridged classification of solutions for enteral feeding, and a brief outline of key prudent oral dietary guidelines are also presented.

The events and discoveries thought to be the most significant prerequisites to the development of total parenteral nutrition (TPN) dating back to the early 17th century are chronicled. A more detailed description and discussion of the subsequent early modern highlights of the basic and clinical research beginning in the mid-20th century and the advances culminating in the first demonstration of the feasibility and practicality of TPN, and its successful, safe and efficacious applications clinically, are presented. Some of the reasoning, insights, and philosophy of a pioneer clinician-scientist in the field are shared with readers.

A 53-year-old Caucasian female presented with an erythematous, tender, fluctuant mass in the periumbilical region. A computerized tomography scan of the abdomen and pelvis suggested a large tumor extending from the umbilicus to the dome of the bladder with elements of tissue within the bladder consistent with a malignancy of either bladder or urachal origin. The patient subsequently underwent a cystoscopic biopsy which was positive for papillary adenocarcinoma arising in a villous adenoma. Metastatic workup revealed multiple hepatic and bilateral pulmonarynodules. Palliative laparotomywithlysis of adhesions, smallbowel resection, partial cystectomy, omentectomy, abdominal wall and umbilical resection were performed.

Meckel's diverticulum is the most commonly occurring congenital anomaly of the gastrointestinal tract. Diagnosis is usually made by scintigraphy using 99Tc(m) pertechnetate, with low accuracy in adults. We describe a case report and review the literature for difficulties in identifying a recurrent bleeding Meckel's diverticulum. Our patient had a "bladder diverticulum" on scintigraphy, which led to delay in diagnosis. The use of bladder lavage during scintigraphy may assist in distinguishing a Meckel's diverticulum from a bladder diverticulum.

Background The incidence of colorectal cancer (CRC) in young adults is rising, and young age is a predictor of poor survival. The purpose of this study was to examine factors leading to increased mortality in patients ≤ 50 years of age, and to examine this population for characteristics that could lead to benefit from CRC screening. Methods Charts of patients 50 years of age and under, diagnosed with CRC from 1998 through 2007, at our community teaching hospital, were reviewed retrospectively. Demographics, social and family history, staging, treatment and death were evaluated. Mann Whitney, Fisher Exact, and χ2 tests were used with P

Background: The insertion and subsequent removal of chest tubes are frequently performed procedures. We hypothesize that routine chest radiographs obtained after chest tube removal to confirm the absence of any post-procedure complications have little impact on clinical management. Materials and methods: A 5-year retrospective study of 73 patients with tube thoracostomies was performed in a level II trauma center’s intensive care unit. Patients were identified from billing records for chest tube placement. Medical records and official chest x-ray film reports, both before and after removal, were reviewed, and demographic data were collected. Results: Of the 73 patients examined, only 8 had postprocedure reports that differed from the preprocedure reports. Two of these 8 patients required reinsertion of a chest tube to treat the recurrence of a significant pneumothorax. However, the decision to reinsert the chest tube was based on the patient’s clinical appearance rather than on the x-ray findings. Conclusion: Chest radiography following the removal of chest tubes should not be a routinely performed procedure, but should preferably be based on the good clinical judgement and discrimination of the surgeon.

During free tissue transfer, much effort is made to keep patients normothermic. It is feared that hypothermia, which is common in patients having such operations, can induce vasospasm leading to stasis and ultimately thrombogenesis. The present study was undertaken to determine the effect of core body temperature on the survival of free flaps in an animal model. Rats were anesthetized with inhaled isoflurane and randomly assigned to one of the following four core temperature groups: 34 degrees C, 35 degrees C, 37 degrees C, and 39 degrees C (n = 10 animals per group). Bilateral groin free flaps were then performed (n = 20 flaps per group) while each animal was maintained at the temperature of its assigned group. Flap survival was evaluated on postoperative day 5 by a blinded observer. The best flap survival occurred in the 34 degrees C group, with an overall flap survival rate of 95%. There was a statistical difference between the survival rate of the combined 34 degrees C and 35 degrees C group (survival rate 90%, n = 40) and the combined 37 degrees C and 39 degrees C group (survival rate 67.5%, n = 40; P = 0.027). Hypothermia may have a beneficial effect on the success of free tissue transfer.

Introduction Over a 10-y period at our community hospital, more than 50% of women 40 y of age and younger underwent a mastectomy as first line breast cancer treatment. These results catapulted a study to identify personal and physical implications of a mastectomy and to determine if, in women of all ages, breast conservation therapy with close follow-up is a better alternative to mastectomy. Methods Six hundred eight women underwent a mastectomy for breast cancer from 1989 to 2005 at our teaching institution; 77% ( n = 120) of 156 successfully contacted women agreed to participate in the study, and 70% ( n = 84) of them completed a questionnaire. Results Most women discovered their breast cancer through mammography or self breast examination, 31% and 28%, respectively. Five patients were diagnosed at Stage 0, 35 at Stage 1, 26 at Stage 2, 8 at Stage 3, 1 at Stage 4, and 9 patients had an unknown stage of disease. Sixty-three patients primarily discussed their treatment plan with a surgeon; 80 were satisfied with the time spent discussing their treatment. Twenty-four patients underwent various reconstruction procedures; most (75%) were satisfied with their treatment and reconstruction choices. Conclusions Mastectomy as a treatment choice for breast cancer did not have the negative personal and physical outcome that we had predicted. Personal choice and a surgeon's advice were the primary influencing factors on the women's treatment choice of mastectomy. Adequate preoperative discussion time and a multimodality cancer team can be most helpful in providing comprehensive treatment options for all women with breast cancer.

Objective To examine the epidemiology and clinical characteristics of small-bowel cancer. Design Patients with small-bowel tumors reported between 1980 and 2000, studied retrospectively. Setting Data from the Connecticut Tumor Registry. Patients One thousand sixty small-bowel cancer cases: 628 men (49.84%) and 632 women (50.16%). Mean age at presentation was 65.2 years. Results The most common location of small-bowel tumors was the ileum (374 cases; 29.7%), followed by the duodenum (320 cases; 25.4%) and the jejunum (193 cases; 15.3%). In 367 patient cases (29.1%: 192 men [30.6%] and 175 women [27.7%]), a prior or subsequent tumor of the gastrointestinal tract was reported. The most prevalent histologic type was carcinoid (417 cases; 33%), followed by adenocarcinoma (341 cases; 27%) and lymphoma (205 cases; 16.3%). The patient population was predominantly white (1159 patients; 92%), followed by African American patients (91 patients; 7.2%). Stratification by consecutive 7-year intervals showed the following: from 1980 to 1986, there were 10.5 cases per 100 000 individuals; from 1987 to 1993, there were 13.05 cases per 100 000 individuals; and from 1994 to 2000, there were 14.86 cases per 100 000 individuals. Men comprised 44.8% of cases from 1980 to 1986, 50.2% of cases from 1987 to 1993, and 53.3% of cases from 1994 to 2000. African American patients accounted for 7.5% of all cases from 1980 to 1986, 5.8% from 1986 to 1993, and 8.2% of cases from 1994 to 2000. In 1106 patients (87.7%), the primary therapy was surgical, including intestinal bypass, radical excision, excisional biopsy, and subtotal or total excision. Conclusions The incidence of small-bowel tumors in Connecticut has increased during the past 2 decades, with the highest rate of increase in men. Carcinoid tumors are the most common small intestinal cancers identified histologically, followed by adenocarcinomas. The former seems to be more frequently seen in the ileum, the latter in the duodenum. Surgery is the treatment of choice for the cure or palliation of small-bowel cancers.