Wichita Clinic

Carotid artery stenting (CAS) is a well-established alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis, particularly in patients at high surgical risk. However, in-stent restenosis (ISR) remains a notable long-term complication, occurring in up to 20% of patients within five years. The optimal management strategy for ISR remains unclear, as endovascular reintervention carries a significant risk of recurrence, and evidence supporting surgical explantation is limited.We present two patients who developed severe carotid ISR and were successfully treated with CEA and complete stent explantation followed by bovine pericardial patch angioplasty. The first patient, an 84-year-old woman with bilateral carotid disease and a history of left carotid stenting, developed 90% restenosis at surveillance and underwent staged bilateral carotid revascularization with durable patency at three-year follow-up. The second patient, a 70-year-old man, presented with acute visual loss and imaging demonstrating near-occlusive thrombosis within a previously placed carotid stent. He underwent urgent surgical stent removal and patch angioplasty, achieving full recovery and maintaining patency at one year. Neither patient experienced perioperative neurological or cardiovascular complications.These cases highlight the feasibility and safety of surgical stent explantation in the management of carotid ISR. Compared with repeat endovascular interventions, surgical removal directly addresses the underlying mechanical and neointimal causes of restenosis and may provide superior long-term durability in appropriately selected patients.CEA with stent explantation represents an effective treatment option for ISR, particularly when endovascular options are limited by calcification, thrombus, or mechanical failure. Larger prospective studies are needed to establish patient selection criteria and optimize management strategies for this challenging clinical scenario.

BackgroundUlcerative colitis (UC) is one of the two major types of inflammatory bowel disease (IBD), characterized by inflammation of the colon and rectum. The colorectal epithelium, which covers the mucosal surface, maintains homeostasis by supporting commensal microorganisms in the outer mucus layer. Most colorectal epithelial cells (CECs) are absorptive colonocytes distributed primarily in the upper portion of the crypts. These CECs constitute the front-line barrier that modulates mucosal immunity and facilitates the transfer of immune molecules into the lumen. In patients with UC, CECs undergo both apoptosis and pyroptosis. Apoptosis is a physiological, programmed, caspase-dependent, and tightly regulated form of cell death that eliminates aged and damaged cells. In contrast, pyroptosis is an inflammatory, caspase-dependent form of lytic cell death that occurs in response to harmful stressors and toxins. Pyroptosis in CECs involves a broad array of signaling and effector molecules, many of which serve as measurable biomarkers with diagnostic, prognostic, and therapeutic potential.ConclusionsDysregulated colorectal microflora significantly contributes to activating the pyroptotic pathway, initiating an inflammasome- and gasdermin-dependent inflammatory cell death process in UC patients. This review discusses the triggers and pathways of pyroptosis in CECs, evaluates recently identified biomarkers, highlights their potential roles in pyroptosis and as therapeutic targets in managing UC, and candidate compounds that have been shown effective UC therapeutics.

Background: Community-level social disadvantage is a recognized determinant of adverse cardiovascular outcomes, yet its relationship with hypertension-related hospitalizations (HTNH) among older adults remains unclear. Composite indices such as the Social Vulnerability Index (SVI) and Social Deprivation Index (SDI) have emerged as tools to quantify area-level social disadvantage. This study assessed the association of county-level SVI and SDI scores with HTNH rates among Medicare beneficiaries aged ≥65 years and compared the predictive utility of each index. Methods: We conducted a retrospective cross-sectional analysis using publicly available county-level data. The SDI, developed by the Robert Graham Center, is a measure of deprivation based on seven demographic characteristics. The SVI, developed by the CDC, is based on 16 social determinants of health. We linked 2019 SDI and 2018 SVI data to HTNH data from the CDC’s Interactive Atlas of Heart Disease and Stroke for adults aged 65 and older in the United States from 2019 to 2021 for each county. The linked dataset was divided into quartiles (Q1 = least disadvantaged; Q4 = most disadvantaged) based on SDI scores (0–100) and SVI scores (0–1). Mean HTNH rates per 1,000 person-years were calculated with 95% confidence intervals (CIs) and stratified by quartile, gender, and race/ethnicity. A higher rate in Q4 vs Q1, with nonoverlapping CIs, indicated a negative impact of SDI or SVI. Rate differences were calculated as excess or fewer hospitalizations per 1,000 person-years by subtracting Q1 from Q4. Results: The overall HTNH rate was 13.6 (95% CI: 13.4–13.8). For SDI, rates rose from 10.9 (10.6–11.2) in Q1 to 16.8 (16.4–17.2) in Q4, representing a 5.9 excess hospitalizations. Among men, rates increased from 12.6 to 18.2; among women, from 9.9 to 15.7. For SVI, rates rose from 10.6 (10.3–11.0) in Q1 to 16.5 (16.1–16.9) in Q4, again reflecting 5.9 excess hospitalizations. Disparities were also evident by race/ethnicity, with Q4 counties showing significantly higher HTNH rates than Q1 across Black, White, and Hispanic groups. Conclusion: Older adults with hypertension living in counties with high social disadvantage experience markedly higher HTNH rates. Both SDI and SVI effectively identify counties with elevated hospitalization risk and may support targeted public health interventions to reduce HTNH and healthcare resource utilization among Medicare beneficiaries.

Disclosure: R. Solomon: None. N. Mitre: None. R. Senguttuvan: None. F.J. Al Muhaisen: None.Introduction: Costello Syndrome (CS) is a rare genetic disorder with an estimated number of affected people 300 worldwide. It is caused by a heterozygous variant mutation in the HRAS gene. Clinical features of CS include dysmorphic facial features, developmental delay, cardiac abnormalities, and increased malignancy risk. Suboptimal growth and short stature have been reported in patients with CS. Growth hormone (GH) therapy is often considered to improve height and metabolic outcomes, though its efficacy and safety in syndromic short stature remain debated. This report highlights the role of GH therapy in CS, evaluates clinical response and growth outcomes, and contributes to evidence-guiding management. Case Presentation: We report a 16 year-year-old male referred to the endocrine clinic for severe short stature. His height was reported to be 147.2 cm (Z score -3.27). Weight was 35.9 kg (Z score -3.93). He was Tanner Stage III male. Physical exam findings included coarse facial features, micrognathia, hypertelorism, frontal bossing, and low-set ears. Initial lab work revealed normal total Testosterone at 601ng/dL (300-900). Further endocrine evaluation was within normal limits, including TSH, FT4, LH, FSH, celiac screening, 17OHP, and DHEAS. Bone age X-ray was read at 13.5 years at a chronological age of 16 and 1 month. GH stimulation testing was obtained, and the patient passed the test with a GH level of 21.3 ng/mL (>10). Given his abnormal physical exam findings, a Symptom Driven Exome sequence revealed a heterozygous pathogenic HRAS mutation, consistent with Costello syndrome. Given his severe short stature (Z score -3.27), GH therapy was initiated at the age of 16 years and 7 months. His GH dose was between 0.30-0.32 mg/kg/week in the last 2 years. His growth velocity improved with maximum GV at 10.3 cm/year, with a total increase of 13 cm over two years. His last bone age x-ray was consistent with 15 years at a chronological age of 18, 5 months. His current height is 164.1cm (Z score -1.71). Discussion: Costello Syndrome belongs to the RASopathy family, affecting growth. While the precise mechanisms remain unclear, GH insensitivity and impaired IGF-1 production have been implicated. Although this patient passed GH stimulation testing, GH therapy was beneficial, resulting in improved growth velocity. This suggests that even without classic GH deficiency, therapy may enhance growth outcomes in CS. Current literature highlights mixed results regarding GH efficacy, with concerns about potential risks such as hypertrophic cardiomyopathy and malignancy. No adverse effects were observed in this case. Endocrinologic evaluation in CS is complex, necessitating individualized management. This case underscores the importance of early genetic screening in short stature to avoid delayed diagnoses. It suggests that GH therapy can benefit even when conventional diagnostic criteria are unmet.Presentation: Saturday, July 12, 2025

Gastrointestinal subepithelial tumors (SETs), including neoplastic and non-neoplastic lesions, often require resection when symptomatic or when they possess malignant potential. Endoscopic full-thickness resection (EFTR) and submucosal tunnel endoscopic resection (STER) are minimally invasive techniques used for resecting these lesions. This meta-analysis aims to compare the efficacy and safety of EFTR and STER in the treatment of upper gastrointestinal (GI) lesions. A systematic search was conducted in Embase, Scopus, Web of Science, Medline/PubMed, and Cochrane databases up to August 2024. Studies comparing EFTR and STER for upper GI lesions were included. Outcomes assessed were en bloc resection rate, complete resection rate, procedure time, recurrence rate, hospital stay, perforation rate, bleeding, and follow-up duration. Data were pooled using a random-effects model, and statistical significance was set at P <0.05. Eight studies, including 725 patients, were included. EFTR showed a significantly higher en-bloc resection rate (OR=4.81, 95% CI=1.56-14.90, P =0.006) and complete resection rate (OR=3.58, 95% CI=1.19-10.76, P =0.02). Recurrence rates were lower with EFTR (OR=0.17, 95% CI=0.03-0.87, P =0.03). No significant differences were found between EFTR and STER in procedure time (MD=-6.50min, P =0.06), perforation rate (OR=9.38, P =0.41), or bleeding rates (OR=0.72, P =0.20). EFTR was associated with a shorter hospital stay (MD=0.66d, 95% CI=0.27-1.05). EFTR offers superior en-bloc and complete resection rates, and a lower recurrence rate compared with STER for upper GI lesions. Both techniques are comparable in terms of procedure time and adverse events, with EFTR offering shorter hospital stays. However, the choice between EFTR and STER should be guided by tumor characteristics (size and location), endoscopist experience, and institutional resources. Further multicenter randomized studies are needed to confirm these findings and address variability in perforation risk.

Abstract Introduction: Actinomycosis is a rare, chronic infection caused by Actinomyces species, anaerobic Gram-positive bacteria that can invade deeper tissues when mucosal barriers are disrupted. These infections typically follow trauma, surgery, or dental procedures. Although cervicofacial involvement is most common, thoracic actinomycosis can develop if oropharyngeal secretions are aspirated into the lungs or mediastinum. We present a unique case of mediastinal lymphadenitis due to actinomycosis in a patient with prior resection of a submandibular gland carcinoma. Case: A 55-year-old male with no smoking, cardiac, or pulmonary history was evaluated for mediastinal lymphadenopathy in the pulmonary clinic. He had recently undergone surgical resection of a high-grade secretory carcinoma in the right submandibular gland. A PET scan post-surgery showed an FDG-avid submandibular mass with mediastinal lymphadenopathy, raising concerns of metastasis or a second primary malignancy. The scan highlighted a 2.0 cm FDG-avid right paratracheal lymph node and a mildly FDG-avid 10 mm antero-posterior window lymph node. The patient reported persistent trismus and pain around his right ear since the initial surgery but denied respiratory symptoms or fever. Physical examination showed no respiratory distress. Given the concerning PET findings, he underwent bronchoscopy with endobronchial ultrasound (EBUS) and transbronchial needle aspiration biopsy (TBNA) of the enlarged lymph nodes, specifically at stations 2R and 7. No endobronchial lesions were seen. Cytology from TBNA showed non-necrotizing granulomatous inflammation, with GMS staining revealing filamentous organisms. AFB-Fite staining was negative for acid-fast bacteria, and no malignant cells were found. Further microbiological testing confirmed Actinomyces species, diagnosing the patient with mediastinal lymphadenitis secondary to actinomycosis. He was started on a prolonged course of amoxicillin and doxycycline, with close follow-ups planned for 6 to 12 months. Discussion: Actinomycosis lymphadenitis presents diagnostic challenges due to its resemblance to malignancy, and mediastinal lymph node involvement is exceptionally rare. In this case, the patient's prior submandibular gland surgery likely created a route for bacterial invasion, facilitating infection in adjacent tissues and mediastinal lymph nodes. Initially, the FDG-avid lymphadenopathy on PET imaging suggested metastatic spread of his carcinoma, necessitating EBUS-TBNA biopsy to differentiate infection from malignancy. This case highlights the need for tissue sampling to distinguish between actinomycosis and malignancy on imaging, ensuring an accurate diagnosis and preventing unnecessary treatments. Treatment typically requires long-term antibiotics, with penicillin as the first-line choice; alternatives include amoxicillin, amoxicillin-clavulanate, or doxycycline. Multidisciplinary evaluation remains critical to avoid misdiagnosis and ensure optimal patient care.

PurposeThis study examines the relationship between social-emotional behavior (SEB) risk and literacy outcomes among marginalized youth attending Title I elementary schools. It evaluates the impact of a targeted mentoring initiative using a collective impact framework and explores how SEB risk influences academic achievement, particularly English Language Arts (ELA) performance.Design/methodology/approachThe study analyzed data from 396 mentees in grades K-6 using the Social, Academic and Emotional Behavior Risk Screener (SAEBRS) and FastBridge ELA benchmark assessments. Descriptive statistics, correlation analyses, and regression models were used to assess changes in student outcomes and examine the relationship between SEB risk and literacy achievement. The mentoring program, implemented in partnership with a nonprofit, a university and a school district, provided tiered SEL and academic supports.FindingsThe mentoring program significantly improved school connectedness, self-efficacy, self-regulation and reduced absenteeism and disciplinary incidents. Significant correlations were observed between lower SEB risk and higher ELA performance. Regression analysis revealed that Fall SEB risk significantly predicted Spring ELA scores, highlighting the importance of addressing SEB challenges to support literacy development.Research limitations/implicationsThe study was limited to a single urban district, and causal relationships cannot be established. Future research should explore long-term outcomes and scalability across diverse settings.Practical implicationsFindings emphasize the value of collective impact frameworks in integrating SEL and academic supports. Schools can leverage SEB risk as an early indicator to inform targeted interventions.Social implicationsThis study highlights the critical role of addressing SEB risk in promoting academic success for marginalized youth. By demonstrating the effectiveness of mentoring interventions delivered through a collective impact framework, the findings emphasize the need for systemic approaches to reduce educational disparities in underserved communities. Addressing SEB risk through relationship-driven, tiered supports not only improves academic outcomes but also fosters emotional resilience, self-regulation and school connectedness, essential for long-term success. These results suggest that policymakers and educators should prioritize investments in SEL-focused programs to create equitable learning environments that empower at-risk students to thrive academically and socially.Originality/valueThis research contributes original insights into the interplay between SEB risk and literacy outcomes, specifically within the context of a collective impact mentoring initiative for marginalized youth in Title 1 schools. By integrating SEL frameworks into academic interventions, this study highlights how addressing SEB risk can significantly enhance both social-emotional and academic outcomes. The use of a composite SEB variable provides a novel approach to capturing the interconnected nature of social, academic and emotional domains. The study’s collective impact framework, uniting a nonprofit, university and school district, offers a replicable model for addressing educational inequities holistically.