bluuebunny/crossref_metadata_2025 huggingface dataset:
Brief Report: Heplisav-B Seroprotection in People With HIV: A Single-Center Experience
Authors: Schnittman Samuel R. , Zepf Roland , Cocohoba Jennifer , Sears David
Published: November 2020

Background:

Heplisav-B, a hepatitis B virus (HBV) vaccine with an immunostimulatory adjuvant, was FDA approved in 2017 for adults ≥18 years. In randomized controlled trials, Heplisav-B demonstrated seroprotection rates (SPR) of 90%–95% versus 65%–80% for Engerix-B. No studies have included people with HIV (PWH), and the SPR and its predictors in this population are unknown.

Setting:

Quaternary care center HIV clinic.

Methods:

This retrospective cohort study evaluated PWH aged ≥18 years without current HBV seroprotection (anti-HBV surface antibody level [anti-HBs] <10 mIU/mL) who were administered Heplisav-B. Patients without post-immunization titers were excluded. The primary outcome was the SPR, the proportion of participants with HBV seroprotection at any point after the first vaccination.

Results:

Among 64 PWH included, median time to anti-HBs measurement after vaccination was 13 weeks. The median age was 58 years, 81% were men, and 95% had a viral load <200. The SPR was 81% in the entire cohort (and 86% in those without significant non-HIV immunosuppression), 79% in those with no prior HBV vaccination and no anti-HBc positivity, and 84% in those with prior vaccine nonresponse. Lower current and nadir CD4+ counts were associated with progressively lower seroprotection.

Conclusion:

In the first single-center retrospective study of Heplisav-B in PWH, the SPR compared favorably with the SPR seen among PWH from prior HBV vaccines across key subgroups. Given these findings, Heplisav-B should be considered for expanded use for HBV vaccination in PWH. Further research on the effectiveness of a repeat vaccination series or higher dosing in nonresponders is needed.
Diagnostic Impact of Quantitative Dual-Energy Computed Tomography Perfusion Imaging for the Assessment of Subsegmental Pulmonary Embolism
Authors: Celtikci Pinar , Hekimoglu Koray , Kahraman Gokhan , Bozbas Serife , Gultekin Bahadir , Akay Hakki Tankut
Published: November 2020

Objective

The aim of this study was to investigate the quantitative differences of dual-energy computed tomography perfusion imaging measurements in subsegmental pulmonary embolism (SSPE), between normal lung parenchyma (NLP) and hypoperfused segments (HPS) with and without thrombus on computed tomography angiography (CTA).

Methods

Lung attenuation, iodine density, and normalized uptake values were measured from HPS and NLP on iodine maps of 43 patients with SSPE. Presence of pulmonary embolism (PE) on CTA was recorded. One-way repeated-measures analysis of variance and Kruskal-Wallis analyses with post hoc comparisons were conducted.

Results

The numbers of HPS with and without SSPE on CTA were 45 (55.6%) and 36 (44.4%), respectively. Lung attenuation of NLP was significantly different from HPS (P < 0.001). Iodine density and normalized uptake values of HPS with PE were significantly lower than those of HPS without PE, which is significantly lower than NLP (P < 0.001).

Conclusions

Subsegmental pulmonary embolism causes HPS on dual-energy computed tomography perfusion imaging, which demonstrates different iodine density and normalized uptake values depending on the presence of thrombus.
Comparison of Field-of-view Optimized and Constrained Undistorted Single Shot With Conventional Intravoxel Incoherent Motion Diffusion-Weighted Imaging for Measurements of Diffusion and Perfusion in Vertebral Bone Marrow
Authors: Cao Jibin , Zhu Jingyi , Sun Wenge , Cui Lingling
Published: November 2020

Background and Purpose

A limited number of studies have used the intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) approach on bone marrow. The purpose of this study was to qualitatively and quantitatively compare the clinical value of IVIM based on field-of-view optimized and constrained undistorted single shot (FOCUS) with the standard single-shot echo-planar imaging (ss-EPI) in the vertebral bone marrow.

Materials and Methods

Twenty healthy volunteers underwent ss-EPI and FOCUS IVIM-DWI of the lumbar spine. Intravoxel incoherent motion parameters (the apparent diffusion coefficient [ADC], true diffusion coefficient [D], pseudodiffusion coefficient [D*], and perfusion fraction [f]) were calculated.

Results

The FOCUS IVIM protocol allowed for measurement of ADC, D, D*, and f in all volunteers: ADC, 0.28 ± 1.33 ×10−3 mm2/s; D = 0.25 ± 3.98 ×10−3 mm2/s, f = 0.36 ± 4.01; and D* = 102.16 ± 71.21 ×10−3 mm2/s. There were no significant differences between the values of ADC, D, and f obtained with ss-EPI and FOCUS. The D* was significantly different (P < 0.05) between ss-EPI and FOCUS IVIM. Image quality assessments showed that the image qualities of FOCUS were superior to ss-EPI (P < 0.001).

Conclusions

As a high-resolution IVIM-DWI technique, the FOCUS technique has potential clinical utility in evaluating the diffusion and perfusion in the vertebral bone marrow.
The Prevalence of Internal Auditory Canal Diverticula Is Constant Over a Large Age Range Among Patients Not Imaged for Hearing Loss
Authors: Abualruz Abdul R. , Bunch Paul M. , Sachs Jeffrey R. , Zapadka Michael E. , Lack Christopher M.
Published: November 2020

Objective

The objective of this study is to establish the prevalence of internal auditory canal diverticula spanning all age groups imaged for reasons other than hearing loss and to investigate changes in prevalence with age to determine if it is a finding that develops over time.

Methods

We retrospectively evaluated 1000 cervical spine computed tomographies obtained in patients age 0–99 years for presence of internal auditory canal diverticula.

Results

A total of 405 patients (208 men; 197 women) were included. Internal auditory canal diverticula were identified in 23 patients (5.7%). No statistically significant association between internal auditory canal diverticula and patient age was found (P = 0.68).

Conclusions

The prevalence of internal auditory canal diverticula on cervical spine computed tomographies is 5.7%. No change in prevalence was observed with increasing age supporting the hypothesis that internal auditory canal diverticula represent a normal anatomic variant rather than acquired pathology.
Forward-projected Model-based Iterative Reconstruction SoluTion in Temporal Bone Computed Tomography: A Comparison Study of All Reconstruction Modes
Authors: Kurokawa Ryo , Hagiwara Akifumi , Nakaya Moto , Maeda Eriko , Yamaguchi Haruomi , Gonoi Wataru , Sato Jiro , Nakata Kenta , Ino Kenji , Ota Yoshiaki , Kurokawa Mariko , Baba Akira , Nyunoya Keisuke , Usui Yukiko , Tanishima Tomoya , Tsushima So , Torigoe Rumiko , Suyama Takeru Q. , Abe Osamu
Published: November 2020

Objective

Identify appropriate reconstruction modes of Forward-projected model-based Iterative Reconstruction SoluTion (FIRST) in temporal bone computed tomography (CT) and investigate the contribution of spatial resolution and noise to the visual assessment.

Methods

Sixteen temporal bone CT images were reconstructed. Two blinded radiologists assessed 8 anatomical structures and classified the visual assessment. These visual scores were compared across reconstruction modes among each anatomical structure. Visual scores and contrast-to-noise ratio, noise power spectrum (NPS) at low (NPSLow) and high (NPSHigh) spatial frequencies, and 50% modulation transfer function relationships were evaluated.

Results

Visual scores differed significantly for the stapedius muscle and osseous spiral lamina, with CARDIAC SHARP, BONE, and LUNG modes for the osseous spiral lamina scoring highest. Visual scores significantly positively correlated with NPSLow, NPSHigh, and 50% modulation transfer function but negatively with contrast-to-noise ratio.

Conclusions

Modes providing higher spatial resolution and lower noise reduction showed an improved visual assessment of CT images reconstructed with FIRST.
The Efficacy of Chest Computed Tomography in Pediatric Patients With Suspected COVID-19
Authors: Rona Günay , Voyvoda Nuray , Arifoğlu Meral , Karaaslan Ayşe , Çetin Ceren
Published: November 2020

Objective

The aim of the study was to investigate chest computed tomography (CT) findings and the value of CT in the diagnosis in children with suspected coronavirus disease 2019 (COVID-19).

Materials and Methods

Chest CT images of pediatric patients with suspected COVID-19 were retrospectively evaluated. Computed tomography findings were divided into 3 groups: normal, consistent, and inconsistent with COVID-19. The sensitivity and specificity of CT were calculated by reference to reverse transcriptase polymerase chain reaction.

Results

The study included patients with a mean age of 11.1 years (1 month–17 years). Of the patients, 43 (40.19%) had normal CT, 34 (31.77%) had CT findings consistent with COVID-19, and 30 (28.04%) had CT findings inconsistent with COVID-19. The sensitivity, specificity, positive predictive value, and negative predictive value of CT were 47.92%, 81.36%, 67.65%, and 65.75%, respectively.

Conclusions

Because the sensitivity of CT in the pediatric age group is low, it should be used cautiously for the evaluation of COVID-19 in the pediatric age group.
Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects
Authors: Ehrl Denis , Broer P. Niclas , Ninkovic Milomir , Giunta Riccardo E. , Moellhoff Nicholas
Published: November 2020

Background

Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions.

Methods

Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months.

Results

Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40–286 cm2; ±67.9 cm2), with a mean size of the MVL free flaps of 266.8 (range, 160–384 cm2; ±69.5 cm2). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients.

Conclusions

The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.
One-Stage Simultaneous Augmentation of 2 Regions of 3 Facial Reanimations After Mid Skull Base Surgery by Using a Neurovascular Latissimus Dorsi Chimeric Flap
Authors: Ogawa Kazuya , Okazaki Mutsumi , Tanaka Kentaro , Uemura Noriko , Homma Tsutomu
Published: November 2020

We report a patient who underwent secondary reconstruction for facial paralysis involving 2 regions of augmentation and 3 facial reanimations using a neurovascular latissimus dorsi (LD) chimeric flap.

A 53-year-old man underwent mid-skull base surgery for a chondrosarcoma at the temporomandibular joint and primary reconstruction using a free anterolateral thigh flap. At 28 months after surgery, he showed temporal and buccal depression and incomplete facial paralysis. We planned 1-stage reconstruction using a neurovascular LD chimeric flap, which was divided into dual compounds of the neurovascular muscle with soft tissue along the descending and transverse bifurcation of the thoracodorsal neurovascular bundle. We added adipose tissue to the muscle belly of the transverse branch using microperforators. We cut the transverse nerve 2.7 cm from the hilus and about 5 cm from the bifurcation, enabling the proximal stump of the transverse branch to be sutured to the ipsilateral buccal branch and function as a cross-face nerve graft. The transverse branch compound was placed on the temporal region and its neural pedicle was sutured to the zygomatic branch. The descending branch compound was placed in the buccal region and sutured to the contralateral buccal branch.

At 58 months after surgery, good contour remained, and smiling was voluntary and natural. On needle electromyography, the zygomatic major muscle and the muscle transferred to the buccal region showed good contraction, and the muscle transferred to the temporal region provided tonus to the lower eyelid. The versatility of the neurovascular chimeric flap facilitated multiple augmentations and 3 reanimations.
A Comparison of Intracranial Volumes and Metopic Index in Patients With Isolated Metopic Ridge, Metopic Craniosynostosis, and Normal Healthy Children
Authors: McKee Ryan M. , Kamel George N. , Cronin Brendan J. , Ewing Emily , Lance Samuel H. , Gosman Amanda A.
Published: November 2020

Background:

Previous research has shown that patients with metopic craniosynostosis have significantly reduced intracranial volumes (ICVs) compared to normal healthy children. Furthermore, the metopic index (ratio of midfrontozygomatic diameter to maximal cranial width) has been described as an anthropometric cranial index for patients with metopic craniosynostosis. We aimed to determine whether patients with isolated metopic ridge have significantly different ICVs or metopic indices than normal children and patients with metopic craniosynostosis.

Methods:

A retrospective chart review of all patients with a diagnosis of a metopic ridge or metopic craniosynostosis was performed from 2000 to 2015 at Rady Children's Hospital. Patients were grouped based on computed tomographic scans consistent with metopic craniosynostosis versus metopic ridge.

Results:

Data were available for 15 metopic ridge patients, 74 metopic craniosynostosis patients, and 213 normal patients. Mean metopic ridge ICV was greater than mean metopic craniosynostosis ICV at 4 to 6 months and 7 to 12 months. Controlling for age and sex, the difference in ICV associated with metopic ridging was 197.484 cm3 and 137.770 cm3 at 4 to 6 and 7 to 12 months, respectively. Similarly, mean metopic index was significantly greater in metopic ridge patients compared to mean metopic craniosynostosis at 4 to 6 months and at 7 to 12 months.

Conclusions:

Our study provides volumetric and anthropometric data to support the hypothesis that isolated metopic ridge is an intermediate phenotype between metopic craniosynostosis and normal cranial anatomy. We hope that characterizing the spectrum of disease involving premature closure of the metopic suture with regard to ICV and metopic index will aid physicians in their management of patients with isolated metopic ridge.
Microsurgical Three-Dimensional Reconstruction of Complex Nasal and Midfacial Defect: Multistep Procedure Respecting Aesthetic Unit Criteria
Authors: Iacoviello Paolo , Bacigaluppi Susanna , Gramegna Marco , Callegari Simone , Signorini Giuseppe , Verrina Giuseppe
Published: November 2020

Extended tumor resection in the middle third of the face leads to complex defects: wide, 3-dimensional, and multitissutal. Appropriate reconstruction is challenging but mandatory to obtain a functional and aesthetic outcome for the preservation of an acceptable quality of life. Three-dimensional combined flaps and multistep procedures concur to reach this scope.

This is exemplified on the treatment of an invasive recurrent skin malignancy involving the cheek and maxillary bone in association with a full-thickness nasal defect. Reconstruction was performed with 3-dimensional multifolded anterolateral tigh chimeric flap, followed by multistep procedure respecting the aesthetic nasal reconstruction guidelines. Reconstructive surgery had the following targets: targets: rebuilding the oral and nasal lining, filling the paranasal cavities, covering the facial skin defect respecting the aesthetic unit concept and providing a proper support to the facial structures.

The aesthetic unit concept has to be respected throughout all steps, from tumor debulking, to reconstruction and even for the management of complications.
A Novel Repair Idea on Nasal Sidewall Defect in Asians: Local Tissue Regeneration
Authors: Zhang Minchen , Gao Weicheng , Hu Yuting , Zhang Jie , Liu Songjian , Zhuo Ran
Published: November 2020

Background:

The traditional ways indicate using different types of flap to repair the nasal sidewall defect, but the scar in the donor area or bloated flap is a problem that cannot be ignored. This study propose the clinical application of the principle of tissue regeneration priority in small defects (defect diameter <1.0 cm) of nasal sidewall.

Methods:

A retrospective study of 3 patients experienced the tumor excision and tissue regeneration healing in situ from January 2019 to January 2020. In this group, the nasal sidewall defect was treated with wound moist theory, preventing infection, to promote the wound regeneration and repair.

Result:

The longest follow-up time was 8 month, all patient undergone half a year follow-up at least. One of them were left small sunken scars but all of them healed up well and satisfied with the results.

Conclusion:

When dealing with the small defect of the skin and soft tissue on the nasal sidewall (defect diameter <1.0 cm), this article provided a new idea that is application of the priority principle for tissue regeneration repair rather than traditional flap used for 1-stage repair. For the small defects of the skin and soft tissue on the nasal sidewall, the tissue regeneration and natural repair in situ can achieve satisfactory effects. More importantly, it has the advantages of simplicity, ease of operation, and fewer complications.
Modified Cranioplasty and Latissimus Dorsi Flap for an Exophytic Invasive Brain Tumor
Authors: Ruiz-Garcia Henry , Huayllani Maria T. , Akinduro Oluwaseun O. , Tawk Rabih G. , Quiñones-Hinojosa Alfredo , Forte Antonio Jorge
Published: November 2020

We describe the clinical case of a 62-year-old man with an atypical grade II meningioma, invading bone and scalp, and present a step-by-step video description of a modified technique for cranioplasty and scalp reconstruction with latissimus dorsi flap. By using this technique, we aim to minimize the space between the dura and the flap, which would decrease the risk of fluid collections and infections.
Reconstruction of Oromandibular Defect After Tumor Resection by Sternomastoid-clavicular Flap
Authors: Zaid Amir M. , Elzahaby Isalm A. , Abdallah Ahmed , Elalfy Amr F. , Metwally Islam H. , Said Ahmed Wael M. , Eldamshety Osama
Published: November 2020

The study aims to evaluate sternocleidomastoid-clavicular osteo-myocutaneous flap (SCM-OMCF) for reconstruction of mandibular defects after tumor resection. In the period between 2010 and 2018, thirteen patients with primary mandibular tumors underwent mandibular resection and reconstruction with SCM-OMCF. Patients were followed up for 10 to 66 months. Hospital was 13 ± 4 days. All patients started fluid in the 2nd day. The mean time to start oral fluid was 7.5 ± 0.8 day. Four (30.8%) patients suffered from complications (infection and salivary leak in 1 case due to partial flap loss, donor wound dehiscence in 1 case, deep venous thrombosis in 1 case and chest infection in 1 case). None of our cases experienced motor disability. Two cases (15.9%) underwent reoperations. The overall aesthetic outcome was found excellent in 5 cases, satisfactory in 5 cases and fair in 3 cases. The functional outcomes were satisfactory. Tumor recurrences were detected in 2 (15.9%) patients. Two patients died during follow up within 2 years after 1st surgery due to local and distant recurrences. SCM-OMCF is a versatile, safe and simple technique for reconstructing mandibular defects less than 11 cm.
Anterior Skull Base Surgery via Endoscopic Endonasal Approach: Outcomes and Analysis
Authors: Aytaç Ismail , Tunç Orhan , Yazici Alper , Başaran Abdulkerim , Gönüldaş Burhanettin , Mumbuç Lütfi Semih
Published: November 2020

Background:

This study was retrospectively conducted to evaluate the postoperative surgical results of our patients with anterior skull base mass, defect, and/or cerebrospinal fluid rhinorrhea who underwent reconstruction via endoscopic endonasal approach and to share our experiences.

Methods:

Sociodemographic features of patients who had undergone endoscopic surgery in our clinic due to anterior skull base mass, defect, or rhinorrhea were evaluated in terms of etiological factors, surgical method, pathology, postoperative complications, need for revision surgery and comorbid disease.

Results:

A total of 131 patients were included; 76 were male and mean age was 36.2 years. Endoscopic endonasal surgery was performed for nasal mass (70.2%) in 92 cases, rhinorrhea (17.6%) in 23 cases, chronic sinusitis (7.6%) in 10 cases, and gunshot injury (4.6%) in 6 cases. After surgery, benign mass pathology was detected in 75 patients and malignant mass pathology was detected in 23 patients. Osteoma was the most common among benign formations, and squamous cell carcinoma was the most common among malignant formations. The most common cause of surgical revision was nasal masses (25 cases, 77.4%).

Conclusion:

Endoscopic intracranial interventions and increased anterior skull base surgery are garnering increased interest of physicians as endoscopic approaches are gaining popularity in recent years. Successful results are achieved through appropriate diagnostic methods and endoscopic approaches. Success rates will be further increased due to developing technology and imaging methods, while the risk of complications and revision surgery will be further reduced.
Comparative Safety of Sleeve Gastrectomy and Gastric Bypass
Authors: Chhabra Karan R. , Telem Dana A. , Chao Grace F. , Arterburn David E. , Yang Jie , Thumma Jyothi R. , Ryan Andrew M. , Blumenthal Blanche , Dimick Justin B.
Published: November 2020

Objective:

To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation.

Summary of Background Data:

Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies).

Methods:

Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable—exploiting variation in the timing of payers’ decisions to cover sleeve gastrectomy as a natural experiment.

Results:

Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009).

Conclusions and Relevance:

In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.
Clinical Trajectories of Acute Kidney Injury in Surgical Sepsis
Authors: Ozrazgat-Baslanti Tezcan , Loftus Tyler J. , Mohandas Rajesh , Wu Quran , Brakenridge Scott , Brumback Babette , Efron Philip A. , Anton Stephen , Moore Frederick A. , Moldawer Lyle L. , Segal Mark S. , Bihorac Azra
Published: November 2020

Objective:

To characterize endothelial function, inflammation, and immunosuppression in surgical patients with distinct clinical trajectories of AKI and to determine the impact of persistent kidney injury and renal non-recovery on clinical outcomes, resource utilization, and long-term disability and survival.

Summary of Background Data:

AKI is associated with increased healthcare costs and mortality. Trajectories that account for duration and recovery of AKI have not been described for sepsis patients, who are uniquely vulnerable to renal dysfunction.

Methods:

This prospective observational study included 239 sepsis patients admitted and enrolled between January 2015 and July 2017. Kidney Disease: Improving Global Outcomes (KDIGO) and Acute Disease Quality Initiative (ADQI) criteria were used to classify subjects as having no AKI, rapidly reversed AKI, persistent AKI with renal recovery, or persistent AKI without renal recovery. Serial biomarker profiles, clinical outcomes, resource utilization, and long-term physical performance status and survival were compared among AKI trajectories.

Results:

Sixty-two percent of the study population developed AKI. Only one-third of AKI episodes rapidly reversed within 48 hours; the remaining had persistent AKI, among which 57% did not have renal recovery by discharge. One-year survival and proportion of subjects fully active 1 year after sepsis was lowest among patients with persistent AKI compared with other groups. Long-term mortality hazard rates were 5-fold higher for persistent AKI without renal recovery compared with no AKI.

Conclusions:

Among critically ill surgical sepsis patients, persistent AKI and the absence of renal recovery are associated with distinct early and sustained immunologic and endothelial biomarker signatures and decreased long-term physical function and survival.
Challenges and Opportunities for the Academic Mission Within Expanding Health Systems
Authors: Chhabra Karan R. , Diaz Adrian , Byrnes Mary E. , Rajkumar Abishek , Yang Phillip , Dimick Justin B. , Nathan Hari
Published: November 2020

Objective:

To explore challenges and opportunities for surgery departments’ academic missions as they become increasingly affiliated with expanding health systems.

Summary Background Data:

Academic medicine is in the midst of unprecedented change. In addition to facing intense competition, narrower margins, and decreased federal funding, medical schools are becoming increasingly involved with large, expanding health systems. The impact of these health system affiliations on surgical departments’ academic missions is unknown.

Methods:

Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August - December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. The topic of challenges and opportunities for the academic mission was an emergent theme, analyzed using thematic analysis.

Results:

Academic health systems typically expanded to support their business goals, rather than their academic mission. Changes in governance sometimes disempowered departmental leadership, shifted traditional compensation models, redirected research programs, and led to cultural conflict. However, at many institutions, health system growth cross-subsidized surgical departments’ research and training missions, expanded their clinical footprint, enabled them to improve standards of care, and enhanced opportunities for researchers and trainees.

Conclusions:

Although health system expansion generally intended to advance business goals, the accompanying academic and clinical opportunities were not always fully captured. Alignment between medical school and health system goals enabled some surgical department leaders to take advantage of their health systems’ reach and resources to support their academic missions.
Multicenter International Cohort Validation of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-sedation Scale
Authors: Rakhit Shayan , Wang Li , Lindsell Christopher J. , Hosay Morgan A. , Stewart James W. , Owen Gary D. , Frutos-Vivar Fernando , Pen~uelas Oscar , Esteban Andre´s , Anzueto Antonio R. , Raymondos Konstantinos , Rios Fernando , Thille Arnaud W. , Gonza´lez Marco , Du Bin , Maggiore Salvatore M. , Matamis Dimitrios , Abroug Fekri , Amin Pravin , Zeggwagh Amine A. , Ely E. Wesley , Vasilevskis Eduard E. , Patel Mayur B.
Published: November 2020

Objective:

In a multicenter, international cohort, we aimed to validate a modified Sequential Organ Failure Assessment (mSOFA) using the Richmond Agitation-Sedation Scale, hypothesized as comparable to the Glasgow Coma Scale (GCS)-based Sequential Organ Failure Assessment (SOFA).

Summary Background Data:

The SOFA score, whose neurologic component is based on the GCS, can predict intensive care unit (ICU) mortality. But, GCS is often missing in lieu of other assessments, such as the also reliable and validated Richmond Agitation Sedation Scale (RASS). Single-center data suggested an RASS-based SOFA (mSOFA) predicted ICU mortality.

Methods:

Our nested cohort within the prospective 2016 Fourth International Study of Mechanical Ventilation contains 4120 ventilated patients with daily RASS and GCS assessments (20,023 patient-days, 32 countries). We estimated GCS from RASS via a proportional odds model without adjustment. ICU mortality logistic regression models and c-statistics were constructed using SOFA (measured GCS) and mSOFA (measured RASS-estimated GCS), adjusted for age, sex, body-mass index, region (Europe, USA-Canada, Latin America, Africa, Asia, Australia-New Zealand), and postoperative status (medical/surgical).

Results:

Cohort-wide, the mean SOFA=9.4+/−2.8 and mean mSOFA = 10.0+/−2.3, with ICU mortality = 31%. Mean SOFA and mSOFA similarly predicted ICU mortality (SOFA: AUC = 0.784, 95% CI = 0.769–0.799; mSOFA: AUC = 0.778, 95% CI = 0.763–0.793, P = 0.139). Across models, other predictors of mortality included higher age, female sex, medical patient, and African region (all P < 0.001).

Conclusions:

We present the first SOFA modification with RASS in a “real-world” international cohort. Estimating GCS from RASS preserves predictive validity of SOFA to predict ICU mortality. Alternative neurologic measurements like RASS can be viably integrated into severity of illness scoring systems like SOFA.
Two-year Outcomes of Prehabilitation Among Obese Patients With Ventral Hernias
Authors: Bernardi Karla , Olavarria Oscar A. , Dhanani Naila H. , Lyons Nicole , Holihan Julie L. , Cherla Deepa V. , Berger David H. , Ko Tien C. , Kao Lillian S. , Liang Mike K.
Published: November 2020

Objective:

To determine if preoperative nutritional counseling and exercise (prehabilitation) improve outcomes in obese patients seeking ventral hernia repair (VHR)?

Summary Background Data:

Obesity and poor fitness are associated with complications following VHR. It is unknown if preoperative prehabilitation improves outcomes of obese patients seeking VHR.

Methods:

This is the 2-year follow-up of a blinded randomized controlled trial from 2015 to 2017 at a safety-net academic institution. Obese patients (BMI 30–40) seeking VHR were randomized to prehabilitation versus standard counseling. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years. Complications included recurrence, reoperation, and mesh complications. Primary outcome was compared using chi-square. We hypothesize that prehabilitation in obese patients with VHR results in more hernia- and complication-free patients at 2-years.

Results:

Of the 118 randomized patients, 108 (91.5%) completed a median (range) follow-up of 27.3 (6.2–37.4) months. Baseline BMI (mean±SD) was similar between groups (36.8 ± 2.6 vs 37.0 ± 2.6). More patients in the prehabilitation group underwent emergency surgery (5 vs 1) or dropped out of the program (3 vs 1) compared to standard counseling (13.6% vs 3.4%, P = 0.094). Among patients who underwent surgery, there was no difference in major complications (10.2% vs 9.1%, P = 0.438). At 2-years, there was no difference in percentage of hernia-free and complication-free patients (72.9% vs 66.1%, P = 0.424, 1.14, 0.88–1.47).

Conclusion:

There is no difference in 2-year outcomes of obese patients seeking VHR who undergo prehabilitation versus standard care. Prehabilitation may not be warranted in obese patients undergoing elective VHR.

Clinical Trial Registration: This trial was registered with clinicaltrials.gov (NCT02365194).
The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy
Authors: Trudeau Maxwell T. , Casciani Fabio , Maggino Laura , Seykora Thomas F. , Asbun Horacio J. , Ball Chad G. , Bassi Claudio , Behrman Stephen W. , Berger Adam C. , Bloomston Mark P. , Callery Mark P. , Castillo Carlos Fernandez-del , Christein John D. , Dillhoff Mary E. , Dickson Euan J. , Dixon Elijah , Fisher William E. , House Michael G. , Hughes Steven J. , Kent Tara S. , Malleo Giuseppe , Salem Ronald R. , Wolfgang Christopher L. , Zureikat Amer H. , Vollmer Charles M. ,   on behalf of the Pancreas Fistula Study Group
Published: November 2020

Objective:

To investigate the role of intraoperative estimated blood loss (EBL) on development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD).

Background:

Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development.

Methods:

This study consists of 5534 PDs from a 17-institution collaborative (2003–2018). EBL was progressively categorized (≤150mL; 151–400mL; 401–1,000 mL; > 1,000 mL). Impact of additive EBL was assessed using 20 3– factor fistula risk score (FRS) scenarios reflective of endogenous CR-POPF risk.

Results:

CR-POPF developed in 13.6% of patients (N = 753) and median EBL was 400 mL (interquartile range 250-600 mL). CR-POPF and Grade C POPF were associated with elevated EBL (median 350 vs 400 mL, P = 0.002; 372 vs 500 mL, P < 0.001, respectively). Progressive EBL cohorts displayed incremental CR-POPF rates (8.5%, 13.4%, 15.2%, 16.9%; P < 0.001). EBL >400mL was associated with increased CR-POPF occurrence in 13/20 endogenous risk scenarios. Moreover, 8 of 10 scenarios predicated on a soft gland demonstrated increased CR-POPF incidence. Hypothetical projections demonstrate significant reductions in CR-POPF can be obtained with 1–, 2–, and 3-point decreases in FRS points attributed to EBL risk (12.2%, 17.4%, and 20.0%; P < 0.001). This is especially pronounced in high-risk (FRS7–10) patients, who demonstrate up to a 31% reduction (P < 0.001). Surgeons in the lowest-quartile of median EBL demonstrated CR-POPF rates less than half those in the upper-quartile (7.9% vs 18.8%; P < 0.001).

Conclusion:

EBL independently contributes significant biological risk to CR-POPF. Substantial reductions in CR-POPF occurrence are projected and obtainable by minimizing EBL. Decreased individual surgeon EBL is associated with improvements in CR-POPF.
Intermittent Pneumatic Compression in Addition to Standard Prophylaxis of Postoperative Venous Thromboembolism in Extremely High-risk Patients (IPC SUPER): A Randomized Controlled Trial
Authors: Lobastov Kirill , Sautina Ekaterina , Alencheva Eleanora , Bargandzhiya Astanda , Schastlivtsev Ilya , Barinov Victor , Laberko Leonid , Rodoman Grigoriy , Boyarintsev Valeriy
Published: November 2020

Objective:

To assess the efficacy of adjunctive IPC to standard prophylaxis of postoperative VTE in patients at extremely high-risk.

Summary of Background Data:

The standard prophylaxis for postoperative VTE is insufficient in extremely high-risk patients. It is unclear whether an adjunctive use of IPC would result in a lower incidence of postoperative venous thrombosis.

Methods:

We randomly assigned patients who underwent major surgery and had a Caprini score of ≥11 to receive either IPC in addition to standard prophylaxis with anti-embolic stockings (pressure of 18–21 mm Hg at the ankle) and low-molecular-weight heparin (IPC group) or standard prophylaxis alone (control group). The primary outcome was an asymptomatic venous thrombosis of the lower limbs, as detected by duplex ultrasound scan performed before inclusion and every 3–5 days after surgery.

Results:

A total of 407 patients underwent randomization, of which 204 were assigned to the IPC group and 203 to the control group. The primary outcome occurred in 1 (0.5%) patient in the IPC group and 34 (16.7%) patients in the control group [relative risk, 0.03, 95% confidential interval (CI): 0.01–0.21]. Pulmonary embolism occurred in none of the 204 patients in the IPC group and in 5 (2.5%) patients in the control group (relative risk, 0.09; 95% CI, 0.01–1.63), and postoperative death occurred in 6 (2.9%) patients in the IPC group and 10 (4.9%) in the control group (relative risk, 0.50; 95% CI, 0.50–1.60).

Conclusions:

Among patients with a Caprini score of ≥11 who received standard prophylaxis for VTE, adjunctive IPC resulted in a significantly lower incidence of asymptomatic venous thrombosis.
Artificial Intelligence for Intraoperative Guidance
Authors: Madani Amin , Namazi Babak , Altieri Maria S. , Hashimoto Daniel A. , Rivera Angela Maria , Pucher Philip H. , Navarrete-Welton Allison , Sankaranarayanan Ganesh , Brunt L. Michael , Okrainec Allan , Alseidi Adnan
Published: November 2020

Objective:

The aim of this study was to develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC).

Summary Background Data:

Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively.

Methods:

Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by 4 high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection- over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation.

Results:

AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions, and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20). and 0.94 (±0.03), respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21), and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder, and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19), and 0.65 (±0.22), respectively.

Conclusions:

AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.
Optimising patient fitness: strategies to reduce the effects of cancer cachexia in patients with advanced lung cancer
Authors: Phillips Iain , Kestenbaum Samantha
Published: November 2020

Purpose of review

Outcomes for patients with advanced lung cancer have traditionally been very poor. This patient group are often comorbid, less fit and experience multiple symptoms. This review discusses strategies for minimizing the impact of cachexia on patients with advanced lung cancer. This is timely, as in recent years there has been a rapid increase in available systemic therapy options, with the potential of long-term survival for some patients.

Recent findings

The review discusses current strategies in combating cachexia, including: symptom control, systemic therapy for cancer and for cachexia, nutritional interventions and exercise interventions. It discusses current clinical trials, combining interventions and the paradigm of prehabilitation.

It is likely that the optimal way of minimizing the impact of cachexia in advanced lung cancer is through a combination of early interventions including symptom management.
The 2020 breakthroughs in early secondary prevention: dual antiplatelet therapy versus single antiplatelet therapy
Authors: Kargiotis Odysseas , Tsivgoulis Georgios
Published: November 2020

Purpose of review

Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA.

Recent findings

Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed.

DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
Acute stroke treatment during coronavirus disease 2019 pandemic
Authors: Baracchini Claudio , Pieroni Alessio
Published: November 2020

Purpose of review

The coronavirus disease 2019 (COVID-19) pandemic has caused a major impact on stroke care. This review synthesizes the available data and provides a framework for optimal management of stroke patients with confirmed or suspected COVID-19 infection and eligible to reperfusion treatments.

Recent findings

Reorganization of health services has led to the conversion of stroke units and relocation of stroke staff to COVID units. During the pandemic surge, there has been a general decline of stroke presentations, increased time delays, and reduced activity across all areas of stroke care, specifically the delivery of acute treatment. Moreover, COVID-19 patients seem to have a worse outcome despite prompt recanalization. Periprocedural monitoring studies are needed in these patients to target a more adequate therapy.

The COVID-19 pandemic has jeopardized the ability of stroke centers to provide timely assessment and acute therapies such as reperfusive treatments. Yet, as stroke remains a medical emergency, efforts to maintain stroke teams and safe provision of highly effective stroke treatments should be prioritized despite healthcare systems reorganization. This can be accomplished through the activation of telestroke networks, protected stroke pathways, 24/7 open-access high-quality stroke centers, and stroke awareness programs.
Systematic evaluation during early-phase ischemia predicts outcomes in middle cerebral artery occlusion mice
Authors: Xiao Xiang-Tian , Luo Chun , Yuan Yuan , Xiao Li , Qu Wen-Sheng
Published: November 2020

Identifying outcome predictors for ischemic stroke is beneficial for choosing correct intervention protocols. Thus, it is necessary to systemically evaluate histological outcome-associated changes such as hemodynamics, behavior, and body weight during the early phase of ischemia. Here, 50 mice were subjected to 45-min middle cerebral artery occlusion (MCAO) using Longa’s method. Hemodynamic changes were monitored by Doppler laser probe, and behaviors were evaluated by scales while the tissues were visualized by staining. The results by correlation analysis demonstrated that with a probe located near the posterior boundary zone of MCA territory, the latency of anoxic depolarization, as well as the cerebral blood flow reduction during MCAO were confirmed to be predictors for the infarct volume on day 3 post-ischemia; histology showed that the risk of a space-occupying secondary hemorrhage was significantly correlated with the increase of infarct volume versus the traditional Bederson’s neurological deficit scale, a renewed combined behavioral scoring method performed nicely to reflect the severity of tissue lesions. Weight loss was a valuable metric for the enlargement of both infarct volume and secondary hemorrhage. Monitoring changes during early-phase ischemia may benefit the optimization of ischemia models and the discovery of potential intervention targets.

See Video Abstract, http:/links.lww.com/WNR/A601).