Anasua Deb: NO financial relationship with a commercial interest | Malak Faragallah: NO financial relationship with a commercial interest | Sebastian Sanchez: NO financial relationship with a commercial interest | Thanita Thongtan: NO financial relationship with a commercial interest | Marawan Elmassry: NO financial relationship with a commercial interest | Busara Songtanin: NO financial relationship with a commercial interest | Sameer Islam: NO financial relationship with a commercial interest

Introduction: Stoma retraction resulting from inadequate mobilization of the colon is seen in 1-6% patients undergoing colostomy. It is usually managed by surgical revision. We discuss successful management of such a case unamenable to surgical revision by an esophageal stent placement. Case Description/Methods: A 36-year-old obese man with paraplegia from gunshot wound, stage 4 sacral decubitus ulcer, and urostomy tube placement presented to ER with fever, vomiting, diarrhea and infection of his sacral wound. He was diagnosed with osteomyelitis of the right ischium and inferior pubic ramus. To avoid fecal contamination of sacral wound, surgery created a diverting sigmoid loop colostomy which 5 days later retracted deep to the level of fascia along with gross fecal leakage through a fistulous track at the laparotomy site. A revision of the retracted colostomy was unsuccessful due to dense intra-abdominal adhesions. (Figure). Gastroenterologic evaluation with a colonoscopy through the stoma showed a moderately stenosed retracted colostomy with gross fecal leakage through mid-line wound. A 23 mm x 155 mm fully covered esophageal stent was then placed within the afferent loop (descending colon) of the colostomy to divert the fecal matter to colostomy bag. ( Figure). The outer end of the stent was sutured to abdominal wall skin. Following this, fecal leakage stopped completely through the mid line wound, and he was discharged home. Over the next 3 weeks, his course was complicated by an episode of external migration of the stent addressed with similar stent replacement followed by fixation of the inner end of stent to the colon wall using lassoes and resolution endo-clips, and the outer end to the abdominal wall skin with surgical sutures. He continues to do well as of today on a regular yet stent favorable diet along with a bowel regimen with Miralax producing a good stool output through colostomy, and to date, there was no fecal leakage through the mid line wound. Discussion: Stoma retraction is a common early post-colostomy complication often requiring months to heal with conservative management with frequent wound care. Surgical revision of retracted stoma or creation of an upstream stoma was not possible in our case due to dense adhesions. A covered esophageal stent was thus placed for the management of the retracted stoma with a favorable outcome thus far. Review of literature showed only one case using esophageal stent in similar clinical scenario with a successful clinical outcome.Figure 1.: A: Fecal contamination of mid-line wound through retracted colostomy, B: Esophageal stent placement in the afferent loop of the colostomy in progress, red rubber catheter at the site of retracted stoma placed by surgery during colostomy revision attempt, C: Stoma site following fully covered esophageal stent placement, D: Fluoroscopy image confirming esophageal stent placement, E: Midline wound free of fecal contamination 5 days after stent placement, F: Midline wound in 3 weeks after the stent placement.

Many persons with opioid use disorder (OUD) initiate medication for opioid use disorder (MOUD) with one clinic and switch to another clinic during their course of treatment. These switches may occur for referrals or for unplanned reasons. It is unknown, however, what effect switching MOUD clinics has on continuity of MOUD treatment or on overdoses.To examine patterns of switching MOUD clinics and its association with the proportion of days covered (PDC) by MOUD, and opioid-related overdose.Cross-sectional retrospective analysis of Pennsylvania Medicaid claims data.MOUD clinic switches (i.e., filling a MOUD prescription from a prescriber located in a different clinic than the previous prescriber), PDC, and opioid-related overdose.Among 14,107 enrollees, 43.2 % switched clinics for MOUD at least once during the 270 day period. In multivariate regression results, enrollees who were Non-Hispanic black (IRR = 1.43; 95 % CI = 1.24–1.65; p < 0.001), had previous methadone use (IRR = 1.32; 95 % CI = 1.13–1.55; p < 0.001), and a higher total number of office visits (IRR = 1.01; CI = 1.01−1.01; p < 0.001) had more switches. The number of clinic switches was positively associated with PDC (OR = 1.12; 95 % CI = 1.10–1.13). In secondary analyses, we found that switches for only one MOUD fill were associated with lower PDC (OR = 0.97; 95 % CI = 0.95−0.99), while switches for more than one MOUD fill were associated with higher PDC (OR = 1.40; 95 % CI = 1.36–1.44). We did not observe a relationship between opioid-related overdose and clinic switches.Lack of prescriber continuity for receiving MOUD may not be problematic as it is for other conditions, insofar as it is related to overdose and PDC.

Atherosclerosis is a systemic disease with different faces. Despite identical or similar pathogenetic mechanisms, atherosclerotic lesions and their clinical manifestations vary in different parts of the vascular system. Peripheral arterial disease (PAD) represents one of the most frequent clinical manifestations of atherosclerosis with predominant location in the superficial femoral artery (SFA). Morphological characteristics of atherosclerotic plaques in peripheral arteries differ from lesions in the coronary and carotid arteries. Plaques in SFA have more fibrotic components, less lipids and inflammatory cells, which makes them more stable and less prone to rupture. Factors that determine the different structure of plaques in SFA compared to coronary arteries include hemodynamic forces, vasa vasorum and calcification. Low shear stress in SFA in the adductor canal is one of the factors which determines frequent atherosclerotic lesions in this region. Lower lipid content and fewer inflammatory cells explain higher stability of SFA plaques. The specific structure of SFA plaques may require preventive and therapeutic measures, which to some extent differ from prevention of coronary atherosclerosis and may include inhibition of fibrotic proliferation in SFA plaques and calcification. Revascularization of PAD differs from procedures used in coronary arteries and requires specific technical expertise and devices.