Publications

BACKGROUND: Angiomyolipomas are often associated with tuberous sclerosis and are typically benign soft tissue tumors found incidentally on imaging. The main complication is retroperitoneal hemorrhagic rupture, leading to Wunderlich's syndrome.

CASE PRESENTATION: This case report presents a unique case of a 48-year-old Hispanic female patient with Wunderlich's syndrome displaying atypical symptoms, including hematemesis, abdominal pain, and nausea. The workup revealed significant anemia and renal failure. The patient had no known history of tuberous sclerosis. Computed tomography imaging showed retroperitoneal hemorrhage from bilateral angiomyolipomas, and the patient was treated with arterial embolization for stabilization. No further hemorrhage occurred during the hospitalization, and the patient was eventually discharged in stable condition.

CONCLUSION: This report presents a case of Wunderlich's syndrome caused by hemorrhage of renal angiomyolipomas, presenting as a medical emergency. Although renal angiomyolipomas are rare benign tumors, complications such as bleeding can occur. Clinicians should consider renal angiomyolipomas in patients with acute renal failure, anemia, and abdominal pain to enable early diagnosis and treatment.

OBJECTIVE: To report and compare the range of stifle rotation in dogs predisposed to, or affected by, medial patellar luxation (MPL) or cranial cruciate ligament disease (CCLD) with that of Greyhounds.

METHODS: Greyhounds (negative controls), sound dogs of breeds predisposed to MPL or CCLD, and dogs with MPL or CCLD were enrolled in this clinical prospective study between December 5, 2022, and October 27, 2023. They underwent orthopedic examination and goniometric measurements of tibial torsion and stifle rotation, flexion, and extension. Limbs were classified as having low risk for, being predisposed to, or being affected by stifle disease. Body condition scores, tibial torsion, stifle rotation, flexion, and extension were compared between groups of limbs.

RESULTS: Data were collected on 208 limbs (104 dogs), classified as 48 controls, 37 limbs predisposed to MPL, 47 limbs predisposed to CCLD, 44 limbs with MPL, and 32 limbs with CCLD. Internal rotation was greater in stifles diagnosed with MPL (median, 38.83°; IQR, 35.67° to 46.83°) or CCLD (median, 32.17°; IQR, 25.67° to 35.67°) than in controls (median, 12.0°; IQR, 10.33° to 13.33°). Similar results were obtained when sound limbs predisposed to MPL (median, 32.22°; IQR, 27.67° to 35.67°) or CCLD (median, 32.17°; IQR, 25.67° to 35.67°) were compared to those of Greyhounds.

CONCLUSIONS: Internal rotation exceeded that of control limbs by approximately 20° in stifles predisposed to or affected by MPL or CCLD.

CLINICAL RELEVANCE: These findings provide evidence of an association between rotational laxity and the presence of or predisposition to MPL and CCLD in dogs.

INTRODUCTION:  Bladder trauma, often resulting from blunt or penetrating injuries, presents a significant challenge in trauma care due to its potential for serious complications and mortality. This retrospective study aimed to investigate demographic characteristics, mechanisms of injury, management strategies, and outcomes in bladder trauma patients, with a focus on comparing the differences between blunt and penetrating trauma cases.

METHODS:  Data were collected from trauma patients presenting to Arrowhead Regional Medical Center between February 17, 2013, and October 30, 2022. Patients aged 18 years and older diagnosed with bladder rupture were included in the final analysis. Patient demographics, mechanisms of injury, and treatment modalities were analyzed to compare the differences in outcomes. Statistical analyses were conducted using the Statistical Analysis System software for Windows version 9.4 (SAS Inc., Cary, NC).

RESULTS:  A total of 88 patients were included in the analysis. The majority of patients were men (n = 65, 73.9%), and blunt trauma accounted for 75% (n = 66) of cases. While there was a significantly higher proportion of men in penetrating trauma cases, differences in mortality, systolic and diastolic blood pressure, pulse, respiratory rate, oxygen saturation, Glasgow Coma Scale, injury severity score, and units of blood given were not statistically different between blunt and penetrating trauma cases.

CONCLUSION:  There is no statistical difference in regard to outcomes between blunt and penetrating bladder trauma. Future research should aim to validate these findings in larger cohorts, explore additional factors influencing treatment decisions and outcomes, and investigate optimal management strategies to enhance patient care and minimize complications in this challenging clinical scenario.

Exposure to UVR suppresses the immune system, which plays a primary role in skin cancer etiology. The β-blocker carvedilol prevents UV-induced skin cancer, but the mechanism is unknown. This study examined the effects of carvedilol and its enantiomers on UV-induced immunosuppression using contact hypersensitivity (CHS) response in SKH-1 mice. A single-dose UVR (224 mJ/cm2) strongly suppressed CHS, which was attenuated by intraperitoneal injection of carvedilol before UV exposure. Adoptive transfer of lymphocytes isolated from UV-irradiated mice to naïve mice without UV exposure triggered CHS suppression, which was not observed for lymphocytes isolated from carvedilol-treated mice. Topically applied carvedilol also prevented UV-induced CHS suppression. Both the β-blocking S-carvedilol and non-β-blocking R-carvedilol attenuated UV-induced CHS suppression. To evaluate the role of β2-adrenergic receptor, a knockout mouse model of β2-adrenergic receptor on the SKH-1 background was used. UV suppressed CHS in β2-adrenergic receptor-knockout mice, and carvedilol attenuated UV-induced CHS suppression in both genotypes. Furthermore, wild-type and knockout mice exposed to chronic UVR developed skin tumors with similar incidence, multiplicity, and tumor burden, whereas carvedilol inhibited skin tumor development in both genotypes. These data suggest that carvedilol prevents skin cancer not through β-blocking but through its activity overcoming UV-induced immunosuppression.

OBJECTIVE: To validate goniometric measurements of stifle rotational laxity in dogs in an ex vivo study and determine their reproducibility in a clinical setting.

METHODS: In phase 1, 16 normal pelvic limbs were harvested from 8 canine cadavers. Goniometric measurements, including tibial torsion (TT) and internal and external rotation of the stifle were compared within limbs and between groups before and after each of the following modifications: transection of the cranial cruciate ligament (CCL) as a model of rotational hyperlaxity (CCL deficiency [CCLD]), rotational osteotomy as a model of TT, and CCLD+TT. A lateral fabella suture (LFS) was then placed in each limb before measurements were repeated. Phase 2 was a clinical prospective study of 51 awake dogs (102 limbs). Torsion and stifle rotations were measured by 2 investigators, 1 in triplicate. Correlation coefficients were calculated to assess intra- and interinvestigator reproducibility.

RESULTS: In phase 1, internal rotation increased by 10.6 ± 7.2° after CCL transection. Placement of an LFS did not influence TT but decreased internal rotation within limbs. Internal rotation of the stifle was increased in all CCLD limbs (CCLD, 32.6 ± 7.6°; CCLD+TT, 33.0 ± 12.3°) compared to intact limbs (24.4 ± 5.8°) and CCLD limbs repaired with LFS (6.3 ± 5.1°). In phase 2, correlation coefficients within and between investigators were > 0.9 for TT and internal rotation angles of the stifle.

CONCLUSIONS: Goniometry allowed the detection of experimentally induced hyperlaxity and was reproducible in awake dogs.

CLINICAL RELEVANCE: Goniometric assessment of stifle rotation should be considered during routine orthopedic examination.

INTRODUCTION: Necrotizing Fasciitis (NF) is a rare life-threatening bacterial infection that necessitates emergent resuscitation and operative intervention. Most of the literature has emphasized the need for early surgical intervention. This is problematic for patients being treated at a facility lacking surgical support, with concerns for increasing mortality and morbidity rates.

METHODS: This is a 10-year retrospective study of emergency department (ED) documentation and surgical operative reports of patients seen at Arrowhead Regional Medical Center from January 1, 2011, to December 31, 2020. The patients were divided into two groups: the Transfer Group (TG), consisting of those transferred from another facility, and the Direct Admit Group (DAG), comprising those who presented directly to the ED. A comparison was conducted to identify statistically significant differences between the 2 groups of patients with a final diagnosis of NF, with specific emphasis on mortality rate, hospital length of stay (LOS), and intensive care unit (ICU) LOS.

RESULTS: A total of 134 patients with a confirmed diagnosis of NF were included in the final analysis. More than half (50.8%, n = 68) of the patients presented as transfers from area hospitals. Compared to the DAG, the TG had a significantly higher percentage of patients undergoing surgical intervention within six hours of ED presentation (95.6% vs. 10.6%, respectively; p < 0.0001). The TG had a lower mortality rate compared to the DAG (11.8% vs. 22.7%), though the difference did not reach statistical significance. There was no statistically significant difference in hospital LOS (13 days vs. 13.5 days, p = 0.9046) or ICU LOS (3 days for both groups, p = 0.4845) between these two groups.

CONCLUSION: Aggressive management with broad-spectrum antibiotics and intravenous fluid resuscitation may mitigate the effect on mortality in patients with necrotizing fasciitis when prompt surgical intervention is not available.

BACKGROUND: Elevated ambient noise levels during trauma resuscitation can disrupt team member communication, yet limited research has examined interventions to mitigate these noise levels.

OBJECTIVE: This study aims to measure the effect of trauma bay curtains on noise levels and the number of staff present during trauma resuscitations.

METHODS: This single-center prospective randomized study was conducted at a U.S. Western Pacific State Level I trauma center from April 2019 through September 2023. The population inclusion was adult trauma patients meeting alert or activation criteria. The designated trauma bay secondary outer curtain was closed at the end of 2 min in the intervention group and at the end of 4 min in the control group. A t-test was used to compare control and intervention groups. The outcome variables were decibel levels, and the number of people in the designated area was recorded at the end of each minute for 6 min.

RESULTS: A total of n = 45 participants were included in this study. The control group (n = 19) had a mean of 9.89 decibels (SD = 8.42) compared to the intervention group (n = 24) with a mean of -1.50 decibels (SD = 5.29). These two groups had a statistically significant difference in average decibels and the total number of people between the first and fourth minute.

CONCLUSIONS: We found that visual interruption using a secondary curtain effectively reduced the number of people and noise levels in the periphery during resuscitation.

INTRODUCTION: In this study, we tested the hypothesis that pre-osteoclast signaling is key in triggering post-traumatic angiogenesis in alveolar bone via the SDF-1/CXCR4 pathway. Interruption of osteoclast differentiation through zoledronate (Zol) disrupts the crosstalk between pre-osteoclasts and endothelial cells, hindering the initial angiogenic reaction following dental trauma. This disruption could therefore play a role in the pathogenesis of medication-related osteonecrosis of the jaw (MRONJ).

METHODS: The effect of zoledronate on the expression of SDF1 was tested in pre-osteoclasts (POC) in vitro. Then, we tested the effect of pre-osteoclast conditioned medium on HUVEC cell differentiation, migration, tube-formation, and CXCR4 expression and activity in-vitro. Lastly, we quantified the effect of zoledronate treatment on post-traumatic vascular perfusion of alveolar bone, using microCT-angiography and immunohistochemistry.

RESULTS: SDF-1 mRNA expression decreased in Zol-treated POCs (p = 0.02). Flow-Cytometry analysis showed a decrease in CXCL-12+ (SDF-1α) expressing POCs with Zol treatment (p = 0.0058). On the other hand, CXCR4 mRNA expression was significantly inhibited in Zol-treated HUVECs (p = 0.0063). CXCR4 protein expression and activity showed a corresponding dose-dependent downregulation HUVEC surface treated with conditioned media from POC treated with Zol (p = 0.008 and 0.03, respectively). Similar inhibition was observed of HUVEC migration (p = 0.0012), and tube formation (p < 0.0001), effects that were reversed with SDF-1. Finally, there was a significant reduction of CD31+ HUVECs in Alveolar bone of Zol-treated rats (p = 0.0071), confirmed by significantly lower percentage of blood vessel volume (p = 0.026), and marginally lower vessel number (p = 0.062) in the alveolar bone.

CONCLUSION: Pre-osteoclasts play a crucial role in the initial angiogenic response in alveolar bone following dental extraction. Disruption of this process may be a predisposing factor to osteonecrosis.

Maggot therapy, also known as larval therapy or biosurgery, is the use of live, sterilized maggots to debride necrotic tissue. Alternatively, wound infestation by maggots, known as myiasis, can occur in patients with poor wound management, particularly in those living in poor socioeconomic conditions. In the case of myiasis, various maggot extraction solutions are used to encourage the live larvae to emerge from the wound on their own. Current recommendations include the use of hypochlorous acid, sodium hypochlorite solutions, isopropyl alcohol, betadine, and hydrogen peroxide for wound cleansing. This case report focuses on a unique utilization of commercial bacon strips for the extraction of maggots in an infested necrotic wound. The use of commercial bacon strips in selective patients as a noninvasive technique for the removal of maggots from necrotic wounds can be an additional tool for medical providers.

The epidemic of opioid overdose brought a major health crisis to the front line of public health in the United States. Early efforts have focused on the prevention of production, distribution, and consumption of the drugs. However, there is little information about youth populations at risk for opioid overdose and their response to targeted treatment plans. The San Bernardino County Youth Opioid Response (SBCYOR) coalition in collaboration with the San Bernadino County (SBC) Probation Department organized a safety net system for at-risk youth by improving communication among county resources. This program mainly focused on individuals aged 12 to 24 years in the county's detention centers along with educational and prevention projects such as naloxone programs for first responders in the region. To describe the impact of the SBCYOR program on at-risk youth, we compare the frequencies of patients referred and treated with medications for opioid use disorder (MOUD) at the SBC Probation Department, which was responsible for individuals from age 12 to less than 18 years, with those from the West Valley Detention Center (WVDC), which was responsible for adults (18 to 24 years of age), from September 2020 through June 2022. Similar proportions of youths were referred for treatment of opioid use disorder (OUD) at the respective sites (3.7% SBC Probation Department, 3.6% WVDC). Of these, however, 78.0% were treated with MOUD at SBC Probation Department compared with only 7.1% at WVDC. SBCYOR coalition partners were able to transform their services into a comprehensive medical and behavioral health program for the incarcerated youth population at risk for OUD.