Background: Arteriovenous Fistula (AVF) stenosis is responsible for a very significant morbidity, mortality and economic cost. Despite the magnitude of the clinical problem there are currently no effective therapies for AVF stenosis. The focus of this project was therefore to identify uremia specific functional and histological differences in AVF stenosis in a mouse model. Methods: Mice were made uremic through the removal of the upper and lower poles of one kidney followed by a nephrectomy of the contralateral kidney. AVFs were created through an end (vein) to side (artery) anastomosis using standard techniques. Functional parameters included flow mediated dilation (FMD) and the area enclosed within the elastic lamina at 100 micron intervals x 12 from the AV anastomosis. The histological end point was the ratio of thrombus area/perimeter at 100 micron intervals x 12 from the AV anastomosis (with the first 600 microns being considered proximal and the second 600 microns as distal). Results: A total of 22 mice were used in these experiments. The mean +/- SE for BUN in the uremic animals was 109+/-4.8 mg/dL as compared to 17.4 +/- 1.0 mg/dL in the control animals (p<0.05). FMD at 60 seconds was decreased significantly in uremic animals (13.4 +/- 1.5%) as compared to the control animals (19.5 +/- 1.1%), although there was no difference at the 90 second peak. There was a trend towards a smaller area enclosed by the elastic lamina (an indicator of inward remodeling) in the uremic animals, although this achieved statistical significance only in the distal segments (at 1000-1200 microns beyond the AV anastomosis). Finally, uremic animals had significantly more attached thrombus (thrombus area/perimeter) in the distal portions of the AVF (9414.7 +/- 7187.5) as compared to the proximal portions (1055.0 +/- 529.5). Conclusion: These data document impairment of endothelial linked, functional (FMD and inward remodeling) and histological (thrombus formation) pathways in a mouse model of AVF stenosis. Further elucidation of the uremia specific mechanistic pathways responsible for these differences, could result in the development of novel drugs and devices for the treatment of AVF stenosis in patients with CKD and ESRD.

Background Patients undergoing radical cystectomy are frequently prescribed prolonged courses of opioids for pain management and have high rates of readmission postoperatively. We aim to determine the association between opioid use and complication rate or length of hospital stay. Methods 185 total patients who underwent radical cystectomy between 2016 and 2021 were identified in IRB-approved retrospective and prospective databases. data was analyzed using the Wilcoxon-Rank-Sums tests, Chi Squared and Fisher's Exact Tests where appropriate. Multivariate logistic regressions were performed to analyze independent factors associated with postop outcomes. Results This study included 185 patients of median age and BMI of 71.0 and 27.0, respectively. There was no statistically significant difference found in age, BMI, prior tobacco use, or incidence of comorbidities between patients who did and did not require readmission. 21.62% were readmitted within 90 days of surgery. Patients who were readmitted were significantly more likely to have received a longer course of opiates than those who did not undergo readmission. When adjusting for independent demographic variables, multivariate regression analysis demonstrated that each individual day of postoperative opioid use was associated with an increase in the odds of major postoperative complication by 26.84% and an increase in the odds of readmission by 22.23%. Conclusion Opioid use represents a possible risk factor for postoperative complications and readmission following radical cystectomy. Further studies are needed to demonstrate if certain classifications of complications are avoidable with conservative administration of opiates in the postoperative period.

Background Hidradenitis suppurativa (HS) is a chronic, inflammatory skin condition of the follicular epithelium that impacts 1-4% of the population. HS presents clinically as recurrently inflamed nodules and sinus tracts, located in intertriginous areas of the body. The nodules can become infected and inflamed, leading to abscesses, pain, and scarring; all of which can have debilitating consequences on a patient’s quality of life. This study aims to improve HS outcomes by analyzing which pathogens are most frequently cultured based on lesion location and pathogen sensitivity profiles. These findings will allow physicians to tailor empiric antibiotic treatment based on HS lesion location. Methods A retrospective medical chart review of patients who were seen at The University of Texas Medical Branch with a diagnosis of HS from 2006-2021 was conducted. 485 patients were seen over 600 patient visits from 2006-2021. Results Of the 485 patients seen with documented HS lesions, 75% were female and cultures were performed 47% of the time. Staphylococcus aureus was the most commonly cultured bacteria in general, and, was the most frequently cultured bacteria in the axilla, buttocks, and groin. Proteus mirabilis was the second most commonly cultured bacteria. P. mirabilis and Enterococcus spp. were the most common bacteria cultured in the inframammary region. Sensitivity analysis of Staphylococcus aureus showed sensitivity to clindamycin in 70% of the cultures, rifampin in 93%, tetracycline in 89%, and trimethoprim-sulfamethoxazole (TMP/SMX) in 93%. A majority of Staphylococcus aureus was found to be resistant to erythromycin (59%) and oxacillin (55%). For P. mirabilis, ampicillin and levofloxacin were both found to be 100% sensitive. Lastly, Enterococcus spp. were found to be sensitive to ampicillin in 95% of the cultures. Conclusion The authors recommend TMP/SMX or tetracyclines as empiric therapy for axillary, buttocks and groin lesions. For only inframammary lesions, use of ampicillin should be strongly considered. For patients with multiple sites including the inframammary area, TMP/SMX should be used to ensure Gram (+) and Gram (–) coverage. Tetracyclines may be used as first line empiric therapy for multiple sites without inframammary involvement.

Background Yolk sac tumors are non-seminomatous germ cell tumors found most often in children and rarely in adults. Even in adult populations, a testicular mass is typically the first presenting sign of a primary testicular malignancy, and seldom is there a testicular cancer diagnosis with no mass palpated on physical exam. Case Presentation We present a 44-year-old man with family history of testicular cancer who presented initially with gastrointestinal symptoms and no testicular mass who was ultimately found to have pure yolk sac tumor pathology per liver metastasis biopsy. Discussion We compare our case to the other reports of post-pubertal yolk sac tumors currently reported in the literature. Though not only rare for an adult male to have a pure yolk sac tumor, but also an entirely gastrointestinal presentation, it is important for clinicians to weigh the importance of family oncological history combined with classic metastatic patterns when determining a primary tumor location. Furthermore, despite signs and symptoms pointing toward a likely gastrointestinal pathology, testicular cancer should remain on the differential for patients with any risk factors for malignancy. We present a rare case of yolk sac tumor, and testicular cancer in general, demonstrating the diversity of possible pathologic presentations of this cancer.

Background: Chronic Abdominal Wall Pain is a poorly recognized, debilitating, clinical problem that is often difficult to treat. Few clinical trials are available in regards to management of this condition. Injection of local anesthesia in combination with steroids provides relief for some patients, and when pain persists despite these treatments, neurectomy is an option. We report the first case of a transnasal sphenopalatine ganglion block that repeatedly provided greater than 80% pain relief for a patient suffering from intractable Chronic Abdominal Wall Pain. Case Presentation: A 28-year-old female with Crohn's disease and asthma presented with intractable chronic abdominal wall pain after several abdominal surgeries. The patient reported 1.5 years of “very severe,” constant, left upper quadrant abdominal pain that was exacerbated by all physical activity and was significantly affecting her quality of life. Imaging did not demonstrate any pathologic abnormality. Physical/occupational therapy, muscle relaxants, selective serotonin reuptake inhibitors, transcutaneous electrical nerve stimulation, trigger point injections, transversus abdominis plane block, and surgery provided minimal relief. Considering that the sphenopalatine ganglion block (SPGB) has previously been shown to relieve pain of various etiologies, we offered it to this patient. Long cotton-tips were soaked in viscous Lidocaine 2% and were advanced, atraumatically, into each nasal sinus until gentle resistance was met, and left in place for a total of 15 minutes, while the patient was supine. This process was repeated two more times, for a total of 45 minutes. After the first SPGB session, the patient, for the first time, had 80% pain relief that lasted for 3 weeks, with significant improvement in her daily function. Since then, the patient has been receiving this block monthly and each time experiencing the same effect, with sometimes even more than 80% pain relief. The patient reports that this is the only treatment that has so far provided her significant benefit. Discussion: Chronic Abdominal Wall Pain is often difficult to manage with physical/occupational therapy, analgesic medications, and invasive procedures. This case report demonstrates that the lidocaine sphenopalatine ganglion block could be a simple, safe, non-expensive, and non-invasive treatment option for those affected by chronic abdominal wall pain.

Abstract Title: Investigating and summarizing information resources for the clinical presentation and diagnosis of cutaneous manifestations of infectious diseases in patients with skin of color (SOC). Background: Skin of color presents disease differently in many circumstances, yet we see a lack of information regarding the presentation and diagnosis of cutaneous manifestations, specifically of those with SOC who are experiencing infectious disease. Many studies have found that SOC is underrepresented in preclinical courses for medical students and may later lead to misdiagnosis of diseases in dark-skinned populations (Louie & Wilkes, 2018; Mangione-Smith et al., 2004; Martin et al., 2016; Tsai et al., 2016). Because SOC is less represented in medical textbooks, patients with diseases such as Lyme disease presenting with cutaneous manifestations such as Erythema migrans may experience a delay in diagnosis (Fix, 2000; Ly, 2021; Palmieri, 2019). Methods: The databases PubMed and ScienceDirect were used to acquire research and review articles. Only resources provided in English were considered in the literature search. Articles were reviewed if they addressed cutaneous manifestations of infectious diseases in patients with SOC as a key topic. Only articles after the year 1980 were included. For inclusion, articles needed to include information regarding cutaneous manifestations of infectious diseases, specifically in patients with SOC. Articles were excluded if they contained no information regarding both Infectious disease and SOC. Duplicates were also removed. Results: Overall, 17 articles were identified out of 2,565 results. Searches regarding the general phrase “skin manifestations of infectious disease in “dark skin” and “HIV in "pigmented skin" yielded the most results. Many articles contained only a few sentences regarding infectious disease manifestations in patients with SOC. HIV had the highest representation of infectious disease cutaneous manifestations in patients with SOC, with five of the seventeen articles pertaining to the discussion of HIV in patients with SOC. 1,5,6,11,14,15. The most recent article discussed a study looking at the use of Perceptual and Adaptive Learning Modules (PALMs) to increase skin assessment in patients with SOC Conclusion: This review identified significant gaps in the literature regarding cutaneous manifestations of infectious disease in SOC, such as lack of visual examples and representations of common infectious diseases in Skin of Color. Healthcare disparities in both Infectious Disease and Dermatology are present and affect the care of patients with skin of color. Increased research is needed in both fields, as well as collaboration between fields to help alleviate the barriers patients with skin of color face when obtaining care.

Abstract Title: The Use of Preoperative CRP and ESR as Predictive Markers of Prosthetic Joint Infection in Primary Total Hip and Knee Arthroplasty Background Total hip (THA) and total knee (TKA) arthroplasty are two of the most performed orthopedic surgeries each year in the United States. Prosthetic joint infection (PJI) remains one of the most common serious complications among all patients undergoing total joint arthroplasty (TJA). There has been a significant amount of literature on the use of c-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in the field of TJA, specifically for the diagnosis of PJI. However, there is much less data focused on the use of preoperative CRP and ESR in the setting of primary TJA. The purpose of this study was to further investigate any correlation that exists between preoperative CRP/ESR and PJI in primary TJA. Methods All patients of one of two surgeons who underwent primary THA or TKA between 2016 and 2020 at the same institution were identified and studied via a retrospective chart review. After exclusion criteria, 806 patients were included in the final cohort for analysis. Positive CRP was set at >0.3 mg/dL and ESR as >30 mm/hr. Results In our current study, which is the second-largest cohort to date that looks at preoperative inflammatory markers before primary TJA, we found no statistically significant correlation between pre-operative CRP or ESR and PJI. We did find that a higher proportion of patients with PJI had elevated preoperative CRP (70.6%) vs those with normal CRP (29.4%). However, among patients with no PJI, the preoperative CRP was still found to be elevated in half of all patients (49.7%). Conclusion This study is unable to validate the use of preoperative CRP/ESR as a predictive measure of future risk of PJI in primary total joint arthroplasty. However, it does provide quantitative insight into the prevalence of elevated preoperative inflammatory markers in all patients prior to TJA with a considerable proportion of patients having modifiable risk factors. Since there is such a large proportion of patients with elevated inflammatory markers that do not go on to develop PJI, we do not recommend cancellation of TJA unless there is an obvious identified modifiable risk factor that puts them at increased risk of PJI.