Challenges confronting rural hospitals accentuated during COVID-19.

The Balanced Budget Act of 1997 created a designation for critical access hospitals (CAHs) to sustain care for people living in rural communities who lacked access to care due to hospital closures over the preceding decade. Twenty-five years later, 1350 CAHs serve approximately 18% of the US population and a systematic policy evaluation has yet to be performed. This policy analysis serves to define challenges faced by CAHs through a literature review addressing the four major categories of payment, quality, access to capital, and workforce.

Acute care surgery: trauma, critical care, emergency general surgery … and preventative health?

Background: Acute care surgeons (ACS) often care for patients with limited access to health care. They may not participate in preventative screenings and interventions (PSIs) such as mammography, colonoscopy, or pneumococcal vaccinations (VAs). We sought to identify barriers to compliance and determine if ACS have an opportunity to facilitate PSI participation.

Endovascular repair of an aortopulmonary artery fistula with use of controlled-release coils.

Aortopulmonary artery fistula is traditionally treated surgically. The present case report describes endovascular repair of an aortopulmonary artery fistula in a patient in whom two thoracotomies had been performed. The fistula occurred at the site of a pseudoaneurysm from the proximal anastomosis of a graft placed to treat a type B aortic dissection.

Dr. Gary J. Becker Young Investigator Award: intraarterial adenovirus for metastatic gastrointestinal cancer: activity, radiographic response, and survival.

Purpose: To determine the antitumoral activity and radiographic response pattern of intraarterial administration of a selective replication-competent adenovirus in patients with hepatic metastases from gastrointestinal carcinomas.

Materials And Methods: Thirty-five patients were treated, seven in the dose-escalation phase and 28 at high doses. Inclusion criteria allowed mild laboratory value and performance status abnormalities and as much as 50% replacement of hepatic volume by tumor.

Treatment of abdominal aortic anastomotic pseudoaneurysm with percutaneous coil embolization.

Intraabdominal anastomotic pseudoaneurysms continue to be a late complication of aortic reconstructive procedures. Early surgical repair is critical but is associated with high operative mortality rates. We present a patient who was diagnosed with a distal anastomotic pseudoaneurysm 13 months after transabdominal repair of a symptomatic abdominal aortic aneurysm.

Aortic aneurysmal disease: assessment of stent-graft treatment-CT versus conventional angiography.

Purpose: To compare computed tomographic (CT) angiography and conventional angiography for determining the success of endoluminal stent-graft treatment of aortic aneurysms.

Materials And Methods: Forty patients underwent conventional angiography and CT angiography following treatment of aortoiliac aneurysms with endoluminal stent-grafts. Six additional sets of conventional angiographic-CT angiographic examinations were performed in five patients after placement of additional stent-grafts or coil embolization to treat perigraft leakage.

True-lumen collapse in aortic dissection: part II. Evaluation of treatment methods in phantoms with pulsatile flow.

Purpose: To discover and evaluate the effective treatment methods to prevent or relieve true-lumen collapse in models of aortic dissection.

Materials And Methods: Two phantoms were built to simulate type B aortic dissection. After true-lumen collapse was induced, experiments were conducted to evaluate the effectiveness of clinically relevant variables in relieving the collapse.

True-lumen collapse in aortic dissection: part I. Evaluation of causative factors in phantoms with pulsatile flow.

Purpose: To investigate the causative factors in true-lumen collapse in a model of aortic dissection.

Materials And Methods: Phantoms with an aortic arch, true and false lumina with abdominal branch vessels, and a distal bifurcation were used to model a Stanford type B aortic dissection. The effects of anatomic factors (entry-tear size, branch-vessel flow distribution, fenestrations, distal reentry communication) and physiologic factors (peripheral resistance in the branch vessels, pump output and rate, vascular compliance) on true-lumen collapse were investigated.

Management of misplaced or migrated endovascular stents.

Purpose: To report experience with techniques for management of misplaced or migrated endovascular stents.

Materials And Methods: During a 5-year period, percutaneous management of 27 misplaced or migrated endovascular stents (16 Palmaz, 11 Wallstents) in 25 patients was attempted. The 17 venous and 10 arterial stents were rescued from the aorta (n = 9), inferior vena cava (IVC) (n = 4), transjugular intrahepatic portosystemic shunt/IVC (n = 2), right atrium (n = 3), right ventricle (n = 2), pulmonary artery (n = 2), iliac vein (n = 2), iliac artery (n = 1), superior vena cava (n = 1), and superior mesenteric vein (n = 1).

Percutaneous balloon fenestration and stenting for life-threatening ischemic complications in patients with acute aortic dissection.

Objectives: Acute aortic dissection frequently causes life-threatening ischemia of end-organs, historically associated with mortality exceeding 60%. Reperfusion with the use of interventional radiologic methods has evolved as a promising treatment. We report results of our initial 6 years of experience with percutaneous balloon fenestration of the intimal flap and endovascular stenting.

Percutaneous creation of acute type-B aortic dissection: an experimental model for endoluminal therapy.

Purpose: To evaluate the feasibility of a percutaneously created type-B aortic dissection as an experimental model for percutaneous therapy. This model was used to evaluate the hemodynamic effects of single-balloon fenestration of the intimal flap.

Materials And Methods: Acute type-B dissections were created in descending aortae of 15 swine via a femoral (n = 6) or carotid (n = 9) approach.

Transbronchial Palmaz stent placement for tracheo-bronchial stenosis.

Purpose: Evaluation of the efficacy of transbronchial Palmaz stent placement in the treatment of tracheo-bronchial narrowing.

Materials And Methods: Twelve patients with stenoses of the tracheo-bronchial tree were treated with balloon-expandable Palmaz stents. Etiology was anastomotic stenosis after lung transplantation (n = 3), bronchogenic carcinoma (n = 2), external compression from thoracic aortic aneurysm (n = 2), Mycobacterium tuberculosis (n = 1), esophageal carcinoma (n = 1), after lobectomy (n = 1), after lobectomy and endobronchial radiation (n = 1), and lye ingestion (n = 1).

Treatment of aortoiliac aneurysms with use of single-piece tapered stent-grafts.

Purpose: The authors describe their experience with the use of single-piece, tapered stent-grafts for the treatment of abdominal aortic or aortoiliac aneurysms.

Materials And Methods: Single-piece, tapered stent-grafts were placed in 15 patients for the treatment of abdominal aortic aneurysms with small distal necks (n = 13), and aortoiliac aneurysms (n = 2). There were 13 men and two women who ranged in age from 59 to 83 years (mean, 71 years).

Mycotic aneurysms of the thoracic aorta: repair with use of endovascular stent-grafts.

Purpose: Standard therapy of mycotic aneurysms in the descending aorta consists of thoracotomy and in situ graft placement or extraanatomic bypass. The alternative use of endovascular stent-grafts was evaluated for management of infected aneurysms of the thoracic aorta.

Materials And Methods: In a retrospective analysis during a 5-year period, 112 patients underwent stent-graft placement for thoracic aortic aneurysms.

True lumen obliteration in complicated aortic dissection: endovascular treatment.

Purpose: To evaluate endovascular treatment of ischemic complications caused by true lumen obliteration in aortic dissection.

Materials And Methods: Endovascular techniques were used to treat true lumen obliteration in 11 patients with complicated aortic dissection. In all cases, the true lumen was compressed to a paper-thin sliver by the expanded false lumen.

Aortic dissection: percutaneous management of ischemic complications with endovascular stents and balloon fenestration.

Purpose: The purpose of this study was to evaluate endovascular stenting (EVS) and balloon fenestration (BF) of intimal flaps for the management of lower extremity, renal, and visceral ischemia in acute or chronic aortic dissection.

Methods: Twenty-two patients (16 male, 6 female) with a median age of 53 years (range 35 to 77 years) underwent percutaneous treatment for peripheral ischemic complications of 12 type A (five acute, seven chronic) and 10 type B (nine acute, one chronic) aortic dissections.

Results: Ten patients had leg ischemia, 13 had renal ischemia, and 6 had visceral ischemia.

Unilateral absence of right-lung perfusion with normal ventilation on radionuclide lung scan as a sign of aortic dissection.

A case of aortic dissection with unilateral absence of right-lung perfusion and normal ventilation on radionuclide ventilation/perfusion (V/Q) lung scan is presented with a review of the literature. Anticoagulation or thrombolytic therapy for presumed pulmonary embolism may be catastrophic if the clinical syndrome and V/Q scan appearance are instead due to aortic dissection. With this V/Q scan appearance, these therapies should not be instituted unless pulmonary embolism is diagnosed by pulmonary arteriography.

Diagnosis of prostatic carcinoma: value of random transrectal sonographically guided biopsies.

Objective: We studied the efficacy of random, transrectal sonographically guided biopsies in the diagnosis of prostatic carcinoma in a high-risk population.

Subjects And Methods: During a 2-year period, 570 transrectal sonographically guided prostatic biopsies were done because of clinical findings suggestive of prostatic carcinoma. Biopsies of hypoechoic lesions that were suggestive of carcinoma and segmental random biopsies of normal-appearing lobes of the prostate were performed.

MRI appearances of an ectopic pituitary adenoma: case report and review of the literature.

MR images of an ectopic pituitary adenoma have been published in only a single case, a suprasellar mass. We present a patient with Cushing's disease in whom MRI revealed a pituitary adenoma within the sphenoid sinus. Radiologic characteristics of ectopic pituitary adenomas are reviewed, with emphasis on MRI, which demonstrates a soft tissue mass, isointense with gray matter on T1-weighted images, which enhances in a heterogeneous manner.

Lack of syringe toxicity to amniotic fluid cells in culture.

Toxicity to amniotic fluid from many brands of syringes has been reported in the past few years. Thirty amniocentesis samples were exposed to Becton-Dickinson syringes for varying lengths of time and evaluated for growth rate. Six amniocentesis samples were exposed to the syringes for prolonged periods at varying temperatures and also evaluated for growth rate.