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Background Spontaneous isolated visceral artery dissection is an uncommon condition encountered by clinicians. Presentation may vary from asymptomatic to acute intestinal ischemia, although a clear natural history has yet to be elucidated. No consensus exists on how best to manage these patients in the absence of true intestinal ischemia; however, much of the literature suggests that intervention is required. We present our institution's experience with 10 patients, both symptomatic and asymptomatic, all but 1 of whom was managed medically. Methods From September 2009 to August 2013, 10 patients presented to our institution with celiac or mesenteric artery dissection. We retrospectively reviewed these patients' clinical presentation, treatment, and follow-up. Results The mean age of the patients was 61.5 ± 10.3 (standard deviation [SD]) years (range, 41–77 years), and the mean follow-up period was 14.7 ± 11.6 (SD) months (range, 1–31 months). Four (40%) patients had abdominal pain and no ischemic changes of the bowel. There were 1 type I, 6 type II, 2 type III, and 1 type IV dissections according to Sakamoto classification. Treatments included observation without anticoagulation treatment in 8 patients (80%), anticoagulation treatment in 1 patient (10%), and endovascular stenting in 1 patient (10%) with unremitting abdominal pain. Anticoagulation was used in the 1 symptomatic patient with radiographic evidence of associated thrombus. The disease stabilized in all patients during follow-up. Conclusions Most authors tend to advocate an endovascular or even operative repair for these processes. In our experience, most of these patients have a self-limited course of symptoms or their dissections are found incidentally. We believe that the results of conservative management in our cohort of patients support the conservative approach over the once recommended operative repair.

Standard negative pressure wound therapy (NPWT) has been shown to help close wounds despite increasing planktonic bioburden. Both planktonic and biofilm critical colonization are associated with delayed wound healing; therefore, reducing microbial colonization is thought to aid wound healing. The use of NPWT with topical antimicrobial irrigation solution has previously shown reduction in quantitative planktonic bioburden when combined with sharp debridement in chronic wounds.The goal of this study was to evaluate the effectiveness of NPWT with instillation (NPWTi) on biofilm of chronic wounds.A prospective, randomized trial was conducted. Following sharp debridement, 20 patients with chronic wounds were randomized to 1 week of either NPWTi with 0.125% sodium hypochlorite solution (n = 10) or NPWT without instillation (n = 10). Serial wound biopsy was performed predebridement, postdebridement, and after 1 week of study therapy to test for quantitative nonplanktonic or biofilm-protected bacteria.As expected, there was no difference in change in wound size between the 2 groups at 1 week. The NPWTi group had a mean reduction in quantitative biofilm-protected bacteria of 48%, while the NPWT without instillation group had a mean increase of 14% (P.05).Consistent with previous studies, this trial demonstrates that NPWTi with dilute sodium hypochlorite solution is effective at reducing nonplanktonic bioburden of chronically, critically colonized wounds.Therefore, based on this and previously published work, this therapy provides both planktonic and nonplanktonic bioburden reduction as well as NPWT benefits and may be a tool for the preparation of infected wound beds prior to definitive closure.

Objectives: Peripheral vascular disease (PVD) is a systemic disorder, which can affect all territories of arteries. In order to maximize screening survey yield: we aimed to describe the association between positive lower extremity (LE) non-invasive flow studies in symptomatic patients and occult carotid occlusive disease (COD). Methods: A retrospective chart review was performed on 420 patients who underwent carotid duplex ultrasound and non-invasive flow studies (NIFS; aka Pulse volume recordings) for evaluation of COD and LE PVD respectively. Additional clinical variables collected included age, gender, and indication for NIFS and indication for carotid duplex. The respective studies were performed within a year of each other. Statistical analysis was performed using SPSSv20 software and SAS statistical software. Univariate analysis was performed using Mann-Whitney, student t-test and receiver operating curve (ROC). Results: 66% (266/420) of the patients were male and 43% (181/420) of patients had documented history of bruit. Patients with mild PVD (ABI between 0.81 and 1) were more likely to have clinically significant COD than patients with moderate to severe PVD (ABI < 0.8) (25% vs 16.19%, P=0.03). Therefore, severity of peripheral vascular disease did not correlate with likelihood of clinically significant COD (p>0.05). ROC analysis was performed (AUC=0.602, p=0.05). Low ABI 0.50 was found to be 92% sensitive (Se) but only 14% specific (Sp). The optimal ABI cutoff point for predicting COD was 0.95 (Se=40%,Sp 60%, Youden’s index 0.194) Conclusion: Therefore, routine screening for COD in patients with lower extremity peripheral vascular disease is unlikely to uncover clinically significant carotid stenosis. These findings do not indicate a population of patients for which a combined prospective screening is warranted.

Objective Massive (≥100 cm 2 ) venous leg ulcers (VLUs) demonstrate very low closure rates with standard compression therapy and are costly to manage. Negative-pressure wound therapy (NPWT), followed by a split-thickness skin graft (STSG), can be a cost-effective alternative to this standard care. We performed a cost analysis of these two treatments. Methods A retrospective review was performed of 10 ulcers treated with surgical debridement, 7 days of inpatient NPWT with topical antiseptic instillation (NPWTi), and STSG, with 4 additional days of inpatient NPWT bolster over the graft. Independent medical cost estimators were used to compare the cost of this treatment protocol with standard outpatient compression therapy. Results The average length of time ulcers were present before patients entered the study was 38 months (range, 3-120 months). Eight of 10 patients had complete VLU closure by 6 months after NPWTi with STSG. The 6-month costs of the proposed treatment protocol and standard twice-weekly compression therapy were estimated to be $27,000 and $28,000, respectively. Conclusions NPWTi with STSG treatment is more effective for closure of massive VLUs at 6 months than that reported for standard compression therapy. Further, the cost of the proposed treatment protocol is comparable with standard compression therapy.

Background While much has been written about multiple methods of neuromonitoring during carotid endarterectomy (CEA), there has been relatively little discussion of the use of triple monitoring via somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) in conjunction with electroencephalography (EEG). Our objective was to evaluate the rate of detection and prevention of neurologic events by multinerve SEP, MEP, and EEG in patients undergoing CEA while under general anesthesia. Methods A prospective study of 181 consecutive patients undergoing CEA between June 2005 and September 2010 was reviewed. Intraoperative changes, including a 50% reduction in the amplitude of SEP waveforms, loss of MEP, and/or a 50% change in EEG frequency were noted as indications for shunting. This was correlated with the actual use of intraoperative shunting and postoperative neurologic sequelae at both 24 hours and 30 days. Median and tibial nerve SEPs and MEPs were also correlated. Results Eleven patients (6%) experienced intraoperative monitoring changes (SEP: 11/11; MEP: 6/11). Five of 11 patients with MEP/SEP changes underwent shunting, while the other 6 had normalization with the elevation of their blood pressure. Of the 11 patients that had neurophysiologic changes, 54% (6/11) were patients with symptomatic disease. No patients had significant EEG changes. The total shunt rate was 2.7% (5/181). No postoperative neurologic sequelae were noted. Conclusion The ratio of shunting at 2.7% is equal to the lowest rates reported in the awake patient literature. Interestingly, the predicted synergy of multimodality monitoring cannot be directly attributed to an increased specificity resulting from the addition of SEP and MEP to EEG, because no patients had EEG changes. In addition, in today's cost-conscious world of health care, our results do not justify implementing this particular technique of neuromonitoring across the board—but it is apparent that the combination of these 3 modalities is both safe and effective with potential applications in symptomatic patients.