bluuebunny/crossref_metadata_2025 huggingface dataset:
Recurrent Mutations in APC and CTNNB1 and Activated Wnt/β-catenin Signaling in Intraductal Papillary Neoplasms of the Bile Duct
Authors: Fujikura Kohei , Akita Masayuki , Ajiki Tetsuo , Fukumoto Takumi , Itoh Tomoo , Zen Yoh
Published: September 2018

This study aimed to elucidate the genetic landscape of biliary papillary neoplasms. Of 28 cases examined, 7 underwent whole exome sequencing, while the remaining 21 were used for validation studies with targeted sequencing. In the whole exome sequencing study, 4/7 cases had mutations in either APC or CTNNB1, both of which belong to the Wnt/β-catenin pathway. Somatic mutations were also identified in genes involved in RAS signaling (KRAS, BRAF), a cell cycle regulator (CDC27), histone methyltransferase (KMT2C, KMT2D), and DNA mismatch repair (MSH3, MSH6, PMS1). Combined with discovery and validation cohorts, mutations in APC or CTNNB1 were observed in 6/28 subjects (21%) and were mutually exclusive. When the cases were classified into intraductal papillary neoplasms of the bile duct (IPNBs, n=14) and papillary cholangiocarcinomas (n=14) based on the recently proposed classification criteria, mutations in APC and CTNNB1 appeared to be entirely restricted to IPNBs with 6/14 cases (43%) harboring mutations in either gene. These genetic alterations were detected across the 3 nonintestinal histologic types. In immunohistochemistry, the aberrant cytoplasmic and/or nuclear expression of β-catenin was found in not only 5/6 IPNBs with APC or CTNNB1 mutations, but also 6/8 cases with wild-type APC and CTNNB1 (total 79%). In addition, APC and CTNNB1 alterations were exceptional in nonpapillary cholangiocarcinomas (n=29) with a single case harboring CTNNB1 mutation (3%). This study demonstrated recurrent mutations in APC and CTNNB1 in nonintestinal-type IPNBs, suggesting that activation of the Wnt/β-catenin signaling pathway is relevant to the development and progression of IPNBs.
Prevalence of Seizures in Pediatric Extracorporeal Membrane Oxygenation Patients as Measured by Continuous Electroencephalography
Authors: Okochi Shunpei , Shakoor Aqsa , Barton Sunjay , Zenilman Ariela R. , Street Cherease , Streltsova Svetlana , Cheung Eva W. , Middlesworth William , Bain Jennifer M.
Published: September 2018

Objectives:

Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children’s hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients.

Design:

Retrospective, single-center study.

Setting:

Neonatal ICU and PICU in an urban, quaternary care center.

Patients:

All neonatal and pediatric patients requiring extracorporeal membrane oxygenation.

Interventions:

None.

Measurements and Main Results:

During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02).

Conclusions:

Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.
Development and Implementation of a Bedside Peripherally Inserted Central Catheter Service in a PICU*
Authors: Conlon Thomas W. , Himebauch Adam S. , Cahill Anne Marie , Kraus Blair M. , Madu Chinonyerem R. , Weber Mark D. , Czajka Carol A. , Baker Ruby L. , Brinkley Torron M. , Washington Melanie D. , Frey Anne Marie , Nelson Eileen M. , Jefferies Cara T. , Woods-Hill Charlotte Z. , Wolfe Heather A. , Davis Daniela H.
Published: September 2018

Objectives:

To create a bedside peripherally inserted central catheter service to increase placement of bedside peripherally inserted central catheter in PICU patients.

Design:

Two-phase observational, pre-post design.

Setting:

Single-center quaternary noncardiac PICU.

Patients:

All patients admitted to the PICU.

Interventions:

From June 1, 2015, to May 31, 2017, a bedside peripherally inserted central catheter service team was created (phase I) and expanded (phase II) as part of a quality improvement initiative. A multidisciplinary team developed a PICU peripherally inserted central catheter evaluation tool to identify amenable patients and to suggest location and provider for procedure performance. Outcome, process, and balancing metrics were evaluated.

Measurements and Main Results:

Bedside peripherally inserted central catheter service placed 130 of 493 peripherally inserted central catheter (26%) resulting in 2,447 hospital central catheter days. A shift in bedside peripherally inserted central catheter centerline proportion occurred during both phases. Median time from order to catheter placement was reduced for peripherally inserted central catheters placed by bedside peripherally inserted central catheter service compared with placement in interventional radiology (6 hr [interquartile range, 2–23 hr] vs 34 hr [interquartile range, 19–61 hr]; p < 0.001). Successful access was achieved by bedside peripherally inserted central catheter service providers in 96% of patients with central tip position in 97%. Bedside peripherally inserted central catheter service central line-associated bloodstream infection and venous thromboembolism rates were similar to rates for peripherally inserted central catheters placed in interventional radiology (all central line-associated bloodstream infection, 1.23 vs 2.18; p = 0.37 and venous thromboembolism, 1.63 vs 1.57; p = 0.91). Peripherally inserted central catheters in PICU patients had reduced in-hospital venous thromboembolism rate compared with PICU temporary catheter in PICU rate (1.59 vs 5.36; p < 0.001).

Conclusions:

Bedside peripherally inserted central catheter service implementation increased bedside peripherally inserted central catheter placement and employed a patient-centered and timely process. Balancing metrics including central line-associated bloodstream infection and venous thromboembolism rates were not significantly different between peripherally inserted central catheters placed by bedside peripherally inserted central catheter service and those placed in interventional radiology.
Left-Sided Appendicitis
Authors: Cramer Natan , Coombs Carmen
Published: September 2018

Classic appendicitis is a common condition easily diagnosed by emergency care providers. However, atypical cases represent a diagnostic challenge and can contribute to increased morbidity from a delay in definitive care. It is important to recognize that atypical presentations have an increased risk for underlying anatomic variants, which may require additional imaging as part of management. We present a case of a 13-year-old previously healthy adolescent boy with acute onset of left-sided abdominal pain who was found to have appendicitis in the setting of underlying malrotation.
Acupuncture as a Nonpharmacologic Treatment for Pain in a Pediatric Emergency Department
Authors: Tsai Shiu-Lin , Reynoso Elena , Shin Da Wi , Tsung James W.
Published: September 2018

Objectives

With epidemic opioid deaths and abuse in the United States, government agencies recommend nonpharmacological treatments for pain. However nonopioid treatment options for moderate to severe pain in the pediatric emergency department (PED) are limited. Acupuncture has been shown to be effective for pain. The objective of this study was to evaluate the feasibility of using traditional acupuncture (TA) and battlefield acupuncture (BFA) in the treatment of pain in the PED.

Methods

A pediatric cohort treated with acupuncture for pain in an urban PED was assessed. All subjects received TA or BFA as treatment, and pre/postacupuncture pain scores, feedback, and adverse events were assessed. The primary outcome was a change in pain score.

Results

Twelve patients received BFA, and 13 received TA for these pain conditions: headaches, sciatica, paraphimosis, torticollis, joint pains (knee, shoulder, jaw), sprains (foot, wrist, thumb), dysmenorrhea, otitis externa, sickle cell, and muscle knot. The mean ± SD pain score change, 5.8 ± 2.5 (P < 0.05; 95% confidence interval, 4.9–7.0), was clinically and statistically significant. Over 90% of subjects reported significant improvement or resolution of pain; 96% were satisfied with pain relief and would receive acupuncture again. Two adverse events were noted: one patient reported dizziness, and another, a tinge of blood at 1 of 90 needled points.

Conclusions

This study suggests that acupuncture is a potential nonpharmacologic therapeutic option for acute pain management in the PED.
Pediatric Intraosseous Access Performed by Emergency Department Nurses Using Semiautomatic Devices
Authors: Feldman Oren , Nasrallah Najib , Bitterman Yuval , Shavit Roni , Marom Dana , Rapaport Zofia , Kabesa Shauli , Benacon Michael , Shavit Itai
Published: September 2018

Background

No study has examined the performance of emergency department (ED) nurses in establishing intraosseous access (IO) access. This study aimed to evaluate ED nurses' success rate in establishing pediatric IO access using semiautomatic devices.

Methods

A randomized crossover simulation study was conducted. The success rates of ED nurses were compared with those of paramedics with similar years of experience. The study instruments were the new spring-loaded injector (NIO) and the battery power drill (EZ-IO). Uncooked piglets' bones were used as the study model. All attempts were filmed by a video camera. Successful placement was defined as the visualization of flow from the marrow cavity. Participants recorded their ranking of the “ease of use” of each device.

Results

No differences in 1-attempt success rate was found between nurses and paramedics (27/34 [79.4%] vs 25/30 [83.3%], P = 0.68). Nurses and paramedics had similar success rates with the 2 semiautomatic IO devices (12/17 vs 12/15 with the spring-loaded injector, P = 0.69, and 15/17 vs 13/15 with the battery power drill, P = 0.9). The number of failed attempts and the causes for failure were equally distributed between nurses and paramedics. Median ease-of-use Likert-scale scores of the spring-loaded injector and the battery power drill were 4 (interquartile range [IQR] = 3–4) and 5 (IQR = 5–5) (P < 0.04) for the nurses and 5 (IQR = 4–5) and 5 (IQR = 4–5) (P = 0.44) for the paramedics, respectively.

Conclusions

Emergency department nurses and paramedics had a similarly high insertion success rates on a pediatric bone model. This pilot study suggests that ED nurses can successfully perform this procedure.
Multidisciplinary, In Situ Simulation Improves Experienced Caregiver Confidence With High-Risk Pediatric Emergencies
Authors: Cristallo Tara , Walters Michelle , Scanlan James , Doten Ian , Demeter Theresa , Colvin David
Published: September 2018

Objectives

Emergency department (ED) caregivers have reported feeling uncomfortable performing emergency pediatric procedures, likely because of either a lack of training or infrequent exposure to these events. To address these gaps, ongoing education for experienced ED caregivers must aim to improve caregiver confidence with high-risk, low-volume pediatric emergency care. This study used multidisciplinary, in situ simulations to facilitate improved caregiver confidence when treating pediatric emergencies in an ED setting.

Methods

Two-hour pediatric code blue simulations were held in 7 EDs throughout the Seattle, Washington, metropolitan area. Questionnaire data were collected from 353 simulation participants (60% nurses, 19.5% ED technicians, 14% ED physicians; median team size = 5) via pre simulation and post simulation surveys assessing confidence and understanding regarding interventions/treatments, standard protocols, culture of safety behavior, and team members' roles/responsibilities. Paired t tests were used to analyze changes in self-reported confidence.

Results

Confidence improved across all questions (37%–57% of participants reported good/complete confidence pre simulation, improving 94%–98% post simulation; P < 0.00001 for all). Participants cited learning equipment location/use (37%), hands-on practice (32%), and discussion (22%) as the most helpful aspects of the simulations. Identified changes to practice made post simulation included more effective communication (18%) and utilization of a pediatric emergency drug sheet (13%).

Conclusions

Multidisciplinary, in situ simulation improves experienced ED caregivers' confidence with pediatric emergencies in an ED setting. These findings suggest that investment in simulation-based education may improve clinical care and quality and safety improvement plans for the treatment of pediatric emergencies in general EDs.
Cerebellar Metastasis From Ovarian Carcinoma Harboring PIK3CA-Activating Mutation: A “Clear” Explanation for Unexpected “Vertigo”
Authors: Piermattei Alessia , Santoro Angela , Angelico Giuseppe , Inzani Frediano , Valente Michele , Pettinato Angela , Vatrano Simona , Scambia Giovanni , Fraggetta Filippo , Zannoni Gian Franco
Published: September 2018

Brain metastasis is a rare and generally late manifestation of an advanced-stage, high-grade serous ovarian carcinoma. Nowadays, the improved control of intra-abdominal disease by surgery and platinum-based chemotherapy results in a longer survival, allowing distant metastasis to implant and grow in the brain parenchyma. Herein, we describe a unique case of a cerebellar metastasis from clear cell ovarian carcinoma that initially presented as a FIGO Stage IC cancer. Surprisingly, 6 mo after surgery, the patient was in good condition with complete disappearance of symptoms and no evidence of recurrence. This relatively good biologic behavior may be explained by the presence of a PIK3CA-activating mutation in exon 9 which as previously reported in the literature, may be associated with better prognosis. To the best of our knowledge, this is the first reported case of cerebellar metastasis from ovarian clear cell carcinoma. In the presence of neurological symptoms, both clinicians and pathologists must be aware of this rare possibility, to assure correct patient management and effective therapeutic options. Generally, the prognosis of epithelial ovarian cancer patients with brain metastases is poor. PIK3CA mutations could be a good prognostic indicator in clear cell carcinomas.
Harnessing Social Media to Advance Research in Plastic Surgery
Authors: Timberlake Andrew T. , Wu Robin T. , Cabrejo Raysa , Gabrick Kyle , Persing John A.
Published: September 2018

Background:

Social media have transformed plastic surgery, intersecting patient education, provider marketing, and academic interactions across the globe. Despite this, social media are seldom used in research. The authors sought to understand the primary incentives and deterrents for patient participation in research efforts.

Methods:

Facebook groups for craniosynostosis families were identified; the largest two had 11,000 and 7200 members. Facebook group administrators were asked to post an open invitation to enroll in the authors’ study. Interested participants contacted study personnel directly. Materials and written/video instructions were provided for collecting genetic specimens. Participants completed a follow-up survey to assess satisfaction. The authors subsequently conducted virtual neurocognitive sessions for functional assessment.

Results:

Three hundred thirty-one of 384 genetic study participants (86 percent) were recruited by means of social media. Three hundred forty-three of 472 mailed packages (73 percent) were returned. Novel mutations identified explained craniosynostosis in 10 percent of participants. One hundred ninety-five families completed the follow-up survey. One hundred percent and 95 percent reported that the written and video instructions were helpful, respectively. The most frequently cited obstacles barring participation in research studies was travel to the study site (63 percent), significantly more than indirect monetary costs (p = 0.007), information confidentiality (p < 0.001), time required to participate (p < 0.001), and invasive study procedures (p < 0.001). Ninety-nine percent preferred participating in a study from home rather than a research center. Follow-up neurocognitive studies are ongoing.

Conclusions:

With proper planning, participation in social media–based research is easy, cost-effective, and time conscious. Requiring travel to a research facility is the factor most likely to deter families from contributing to research. The results emphasize the unrealized potential of social media for advancing research in plastic surgery.
Inferior External Pudendal Artery Anastomosis: Additional Approach to Prevent Skin Necrosis in Replanted Penis
Authors: Lohasammakul Suphalerk , Turbpaiboon Chairat , Ratanalekha Rosarin , Ungprasert Patompong , Yodrabum Nutcha
Published: September 2018

Background:

Microsurgical anastomosis of the dorsal artery of the penis either with or without anastomosis of the cavernosal artery is the preferred technique for penile replantation. However, postoperative penile skin necrosis is commonly reported with this technique. This study aimed to characterize the anatomy of the vascular supply of the penis pertinent to penile replantation surgery and to report a successful case of penile replantation without postoperative necrosis using anastomosis of the inferior external pudendal artery.

Methods:

The authors dissected 15 penises of fresh cadavers under acrylic dye injection by means of the inferior external pudendal and dorsal arteries of the penis to identify vascular anastomoses between arteries supplying the penis and to measure other parameters of the arteries.

Results:

Mean diameters at the base of the penis of the inferior external pudendal, dorsal, and cavernosal arteries were 0.94, 1.43, and 0.80 mm, respectively. Penile skin is mainly supplied by the inferior external pudendal artery under three patterns with anastomoses across the midline. Preputial skin receives additional blood supply from perforators of the dorsal artery without visible anastomosis between the perforators and the inferior external pudendal artery. Deep structures receive blood supply from the dorsal, cavernosal, and urethral arteries, with visible anastomoses between the arteries. In a patient with amputated penis, the inferior external pudendal artery diameter was 0.7 mm, which was sufficient for microsurgical anastomosis. No postoperative necrosis developed, and patency of the inferior external pudendal artery was confirmed with duplex ultrasound.

Conclusion:

The diameter of the inferior external pudendal artery at the base and midshaft of the penis is sufficiently large for microsurgical anastomosis, and additional vascular anastomosis of at least one inferior external pudendal artery may help to prevent postoperative penile skin necrosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Immediate Implant-Based Breast Reconstruction with Acellular Dermal Matrix: A Comparison of Sterile and Aseptic AlloDerm in 2039 Consecutive Cases
Authors: Parikh Rajiv P. , Brown Gabriella M. , Sharma Ketan , Yan Yan , Myckatyn Terence M.
Published: September 2018

Background:

Sterile ready-to-use acellular dermal matrix, introduced as an alternative to aseptic freeze-dried acellular dermal matrix for implant-based breast reconstruction, has been investigated in a limited number of studies. This study compared outcomes in implant-based breast reconstruction with ready-to-use and freeze-dried acellular dermal matrix.

Methods:

The authors analyzed patients undergoing implant-based breast reconstruction with either freeze-dried or ready-to-use acellular dermal matrix, including demographics, clinical variables, and outcomes. An a priori power analysis was performed and logistic regression modeling was used to quantify the effect of acellular dermal matrix on outcomes while controlling for potential confounders.

Results:

A total of 1285 consecutive patients undergoing 2039 immediate prosthetic breast reconstructions constituted the population: 612 (n = 910 breasts) with freeze-dried matrix and 673 (n = 1129 breasts) with ready-to-use acellular dermal matrix. The freeze-dried matrix cohort had a significantly higher rate of explantation compared with the ready-to-use matrix cohort (18.0 percent versus 12.0 percent; p = 0.0036), but surgical-site infection, wound dehiscence, mastectomy flap necrosis, seroma, and hematoma did not differ significantly between groups. On multivariate regression, patients undergoing reconstruction with freeze-dried matrix, compared to ready-to-use matrix, did not have higher odds of experiencing surgical-site infections (OR, 1.064; p = 0.7455), but did have higher odds of explantation (OR, 1.570; p = 0.0161). Tobacco use (OR, 2.809; p = 0.0002) and body mass index (OR, 1.054; p < 0.0001) were also independent predictors of explantation.

Conclusion:

Immediate implant-based breast reconstruction with sterile ready-to-use acellular dermal matrix has a comparable overall safety profile and a lower rate of prosthetic explantations compared with aseptic freeze-dried acellular dermal matrix.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
The Constriction Arm Band Deformity in Brachioplasty Patients: Characterization and Incidence Using a Prospective Registry
Authors: Chen Wendy , James Isaac B. , Gusenoff Jeffrey A. , Rubin J. Peter
Published: September 2018

Background:

Demand for brachioplasty in the United States has seen a dramatic increase, from 338 procedures in 2000 to 17,860 in 2016. In this article, the authors present their series of arm band deformities not yet described in the literature.

Methods:

This is a retrospective review of massive weight loss patients undergoing brachioplasty at their institution from 2000 to 2016. Preoperative and postoperative photographs were reviewed. Descriptive statistics and t test were used.

Results:

One hundred seventy-two patients underwent brachioplasty, and 25 patients (15 percent) were identified with the deformity. Twenty-four (96 percent) were women, with an average age of 60 years (range, 36 to 85 years) and a mean body mass index of 34 kg/m2 at the time of surgery (average, 2 years since gastric bypass; mean delta body mass index, 22 kg/m2). The bands were generally single bands (100 percent) found bilaterally (68 percent) in the distal third (74 percent) of the upper arm and exacerbated (50 percent) by brachioplasty. The average specimen weighed 1005 g. The authors found that arm banding was associated with a higher current body mass index, but not with a maximum body mass index or delta body mass index.

Conclusions:

For massive weight loss patients, arm band deformity is a challenging problem that can be exacerbated by brachioplasty. It can be identified preoperatively to aid in counseling. The authors found patients with a higher current body mass index to be at a higher risk for the arm band deformity after brachioplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, IV.
Breast Implant Engineering and Performance
Authors: Mohebali Khashayar , Wixtrom Roger N.
Published: September 2018

The engineering of breast implants for both augmentation and reconstruction is centered on facilitating optimal aesthetic results pleasing to the patient, while minimizing both short- and long-term complications. Some of the key individual design elements that have been the primary focus over time have included gel cohesivity, shell thickness, shell surface, and implant gel fill. A review of these separate elements points to the potential benefits of increased focus on a combined overall performance perspective for engineering of new implants as exemplified in the recently introduced MemoryGel Xtra Breast Implants. Such an approach is expected to provide an improved and expanded range of options to facilitate obtaining desired aesthetic outcomes and long-term clinical performance.
State Variations in Public Payer Reimbursement for Common Plastic Surgery Procedures
Authors: Kaura Arminder S. , Berlin Nicholas L. , Momoh Adeyiza O. , Kozlow Jeffrey H.
Published: September 2018

Background:

Existing data suggest decreased willingness of plastic surgeons to participate in Medicare and Medicaid. Significant disparities exist in Medicare and Medicaid reimbursement for various general surgical procedures. The aims of this study were to investigate variations in Medicare and Medicaid reimbursement across the nation for common plastic surgery procedures.

Methods:

Medicare and Medicaid reimbursement data for 2017 were obtained by means of the Centers for Medicare & Medicaid Services and publicly available fee schedules from each state, respectively, for eight common plastic surgery procedures. The difference in Medicare and Medicaid reimbursement was calculated across all states. The difference in value ascribed to each procedure was determined by comparing the payment from each payer to the work relative value units.

Results:

Medicaid reimbursement rates were significantly lower for the selected procedures, with a median national discount of −25 percent ($16.09 per work relative value unit) compared to Medicare. There were higher median rates of reimbursement per work relative value unit by Medicaid in only five states when compared to Medicare. Significant variations of more than 15 percent in the Medicaid-to-Medicare reimbursement ratios between our selected procedures were identified in 28 states.

Conclusions:

Variations exist between Medicare and Medicaid reimbursement for common plastic surgery procedures. The within-state variations in Medicaid reimbursement are likely reflective of important yet nontransparent differences in determining Medicaid reimbursement. These variations likely affect access to care for underserved populations. Professional societies should continue to convey the value of these important procedures and raise awareness regarding disparities in access to care.
The Stacked Hemiabdominal Extended Perforator Flap for Autologous Breast Reconstruction
Authors: Beugels Jop , Vasile Julie V. , Tuinder Stefania M. H. , Delatte Stephen J. , St-Hilaire Hugo , Allen Robert J. , Levine Joshua L.
Published: September 2018

Background:

Options for bilateral autologous breast reconstruction in thin women are limited. The aim of this study was to introduce a novel approach to increase abdominal flap volume with the stacked hemiabdominal extended perforator (SHAEP) flap. The authors describe the surgical technique and analyze their results.

Methods:

A retrospective study was conducted of all SHAEP flap breast reconstructions performed since February of 2014. Patient demographics, operative details, complications, and flap reexplorations were recorded. The bipedicled hemiabdominal flap was designed as a combination of the deep inferior epigastric artery perforator (DIEP) and a second, more lateral pedicle: the deep or superficial circumflex iliac perforator vessels, the superficial inferior epigastric artery, or a lumbar artery or intercostal perforator.

Results:

A total of 90 SHAEP flap breast reconstructions were performed in 49 consecutive patients. Median operative time was 500 minutes (range, 405 to 797 minutes). Median hemiabdominal flap weight that was used for reconstruction was 598 g (range, 160 to 1389 g). No total flap losses were recorded. Recipient-site complications included partial flap loss (2.2 percent), hematoma (3.3 percent), fat necrosis (2.2 percent), and wound problems (4.4 percent). Minor donor-site complications occurred in five patients (10.2 percent). Most flaps were harvested on a combination of the DIEP and deep circumflex iliac artery vessels.

Conclusions:

This study demonstrated that the SHAEP flap is an excellent option for bilateral autologous breast reconstruction in women who require significant breast volume but have insufficient abdominal tissue for a bilateral DIEP flap. The bipedicled SHAEP flap allows for enhanced flap perfusion, increased volume, and abdominal contour improvement using a single abdominal donor site.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Developing a Rural, Community-Based Registry for Cardiovascular Quality Improvement
Authors: Langabeer James R. , Champagne-Langabeer Tiffany , Smith Derek
Published: September 2018

Background:

Cardiovascular disease is one of the leading causes of death, yet most evidence is collected from small clinical trials or individual hospital providers. Achieving scalable data to enable quality improvements (QIs) remains a challenge. We investigate whether a registry that is shared by multiple providers and integrates data longitudinally could help drive QIs across a large rural geographic region.

Methods:

We describe a case study involving the development of an informatics infrastructure across the entire state of Wyoming. This rural, regional, community-based cardiovascular system of care involved all interventional hospitals in the state as well as all surrounding states. Data exchange was initiated between 36 hospitals, and 56 ambulance agencies, to a centralized registry for clinical analytics and QI for patients with acute myocardial infarction.

Results:

After 3 years, the registry maintained all documented acute myocardial infarctions across Wyoming. Median total ischemic time (time from patient's symptom onset to definitive treatment) had a 36.7% improvement during the program. Changes in quality for the rural community included reduction in overall treatment times, as well as enhanced training, standardized protocols, and community awareness. We also share key lessons learned.

Conclusions:

Collaborative data registries for emergency cardiovascular care can help providers and communities measure and improve the quality of the care across regions.
68Ga–Prostate-Specific Membrane Antigen PET/CT and 18F-FDG PET/CT of Primary Signet Ring Cell Breast Adenocarcinoma
Authors: Parihar Ashwin Singh , Mittal Bhagwant Rai , Sood Apurva , Basher Rajender Kumar , Singh Gurpreet
Published: September 2018

Primary signet ring cell adenocarcinoma of the breast is a rare neoplasm. Similar to other mucinous neoplasms, it has low FDG avidity and poor prognosis compared with the traditional ductal/lobular carcinomas. We present a case of a 40-year-old woman with signet ring cell adenocarcinoma and skeletal fluorosis showing higher uptake of 68Ga–prostate-specific membrane antigen in the primary lesion and the metastatic sites compared with 18F-FDG on PET/CT imaging. Additionally, diffuse increased prostate-specific membrane antigen uptake was noticed in the entire skeleton, likely due to skeletal fluorosis.
Bone Flare to Androgen Deprivation Therapy in Metastatic, Hormone-Sensitive Prostate Cancer on 68Ga-Prostate-Specific Membrane Antigen PET/CT
Authors: Zacho Helle D. , Petersen Lars J.
Published: September 2018

A 69-year-old man with newly diagnosed prostate cancer PSA 274 ng/mL, Gleason 4+3, T-stage 3b) underwent 68Ga-PSMA PET/CT for staging with follow-up scans 6 and 13 weeks after androgen deprivation therapy (ADT) initiation. Six weeks after ADT initiation, lymph node metastases observed at staging showed metabolic and radiological regression, whereas the skeleton showed increased PSMA uptake in existing bone metastases and several new PSMA-avid lesions. Skeletal PSMA uptake decreased after 13 weeks of ADT, and prostate-specific antigen decreased to 16 ng/mL. These findings suggest the presence of the flare phenomenon to ADT in bone metastases seen on PSMA PET/CT.
FDG PET/CT Findings in TAFRO Syndrome
Authors: Hotta Masatoshi , Minamimoto Ryogo , Yashima Arisa , Nakano Masahiro , Yamashita Hiroyuki
Published: September 2018

A 67-year-old woman with prolonged fever, thrombocytopenia, and renal dysfunction underwent FDG PET/CT to evaluate underlying causes, including malignancy. PET/CT showed FDG uptake in ascites, subcutaneous edema, lymph nodes, spleen, and bone marrow. Subsequent bone marrow biopsy revealed myelofibrosis, and laboratory testing showed elevated concentrations of interleukin 6 in serum and ascites. These findings led to the diagnosis of TAFRO syndrome, a variant of multicentric Castleman disease, characterized by thrombocytopenia, anasarca, fever, reticulin myelofibrosis, and organomegaly. Because TAFRO syndrome is potentially fatal, accurate diagnosis is crucial. Characteristic FDG PET/CT findings facilitate the diagnosis of TAFRO syndrome, which is generally challenging.
A Case of Liver Injury Mimicking Metastasis After Gamma Knife Therapy for Lung Cancer
Authors: Tang Kun , Zheng Xiangwu , Lin Jie , Yin Weiwei
Published: September 2018

A 52-year-old man presented a mixed low-density lesion with high FDG uptake in hepatic segment VIII after gamma knife therapy for lung cancer, which was easily misdiagnosed as hepatic metastasis. Follow-up PET/CT assessment demonstrated that the hepatic lesion was barely observed and without FDG accumulation 5 months after radiotherapy. This case suggests that a new FDG-avid lesion at PET/CT after radiotherapy for lung cancer can be caused by radiation-induced liver injury. Knowledge of its imaging characteristics and nature course evaluated by follow-up PET/CT is critical to avoid misinterpretation of this lesion as metastases.
Botulinum Toxin Injection for Lower Face and Oral Cavity Raynaud Phenomenon After Mandibulectomy, Free Fibula Reconstruction, and Radiation Therapy
Authors: Boukovalas Stefanos , Mays Ashley C. , Selber Jesse C.
Published: September 2018

Isolated lingual and lower face Raynaud phenomenon without primary Raynaud of the digits is a very rare condition associated with chemoradiation therapy (RT) in previous reports. The condition, which more commonly presents in patients with a history of Raynaud disease, is often self-limiting, but vasodilating agents and steroids have been suggested as possible treatment options. Spasmodic torticollis is a different, more common entity, also associated with history of RT or previous head and neck surgery. We present a rare case of a patient who developed Raynaud phenomenon of the lower face and tongue in the presence of spasmodic torticollis after mandibulectomy and free fibula reconstruction followed by RT to the oral cavity and neck. Possible causes, pathophysiologic mechanisms and treatment options are discussed. This is the first report of botulinum toxin treatment of isolated secondary Raynaud phenomenon of the lower face and tongue.
Provider Characteristics Associated With Outpatient Opioid Prescribing After Surgery
Authors: Cron David C. , Lee Jay S. , Dupree James M. , Syrjamaki John D. , Hu Hsou Mei , Palazzolo William C. , Englesbe Michael J. , Brummett Chad M. , Waljee Jennifer F.
Published: September 2018

Objective:

To characterize differences in postoperative opioid prescribing across surgical, nonsurgical, and advanced practice providers.

Background:

There is a critical need to identify best practices around perioperative opioid prescribing. To date, differences in postoperative prescribing among providers are poorly understood.

Methods:

This is a retrospective multicenter analysis of commercial insurance claims from a statewide quality collaborative. We identified 15,657 opioid-naïve patients who underwent a range of surgical procedures between January 2012 and October 2015 and filled an opioid prescription within 30 days postoperatively. Our primary outcome was total amount of opioid filled per prescription within 30 days postoperatively [in oral morphine equivalents (OME)]. Hierarchical linear regression was used to determine the association between provider characteristics [specialty, advanced practice providers (nurse practitioners and physician assistants) vs. physician, and gender] and outcome while adjusting for patient factors.

Results:

Average postoperative opioid prescription amount was 326 ± 285 OME (equivalent: 65 tablets of 5 mg hydrocodone). Advanced practice providers accounted for 19% of all prescriptions, and amount per prescription was 18% larger in this group compared with physicians (315 vs. 268, P < 0.001). Primary care providers accounted for 13% of all prescriptions and prescribed on average 279 OME per prescription. The amount of opioid prescribed varied by surgical specialty and ranged from 178 OME (urology) to 454 OME (neurosurgery).

Conclusions:

Advanced practice providers account for 1-in-5 postoperative opioid prescriptions and prescribe larger amounts per prescription relative to surgeons. Engaging all providers involved in postoperative care is necessary to understand prescribing practices, identify barriers to reducing prescribing, and tailor interventions accordingly.
Surgical Outcomes of Hepatocellular Carcinoma With Bile Duct Tumor Thrombus
Authors: Kim Dong-Sik , Kim Bong-Wan , Hatano Etsuro , Hwang Shin , Hasegawa Kiyoshi , Kudo Atsushi , Ariizumi Shunichi , Kaibori Masaki , Fukumoto Takumi , Baba Hideo , Kim Seong Hoon , Kubo Shoji , Kim Jong Man , Ahn Keun Soo , Choi Sae Byeol , Jeong Chi-Young , Shima Yasuo , Nagano Hiroaki , Yamasaki Osamu , Yu Hee Chul , Han Dai Hoon , Seo Hyung-Il , Park Il-Young , Yang Kyung-Sook , Yamamoto Masakazu , Wang Hee-Jung
Published: September 2018

Objective:

To identify optimal surgical methods and the risk factors for long-term survival in patients with hepatocellular carcinoma accompanied by macroscopic bile duct tumor thrombus (BDTT).

Summary Background Data:

Prognoses of patients with hepatocellular carcinoma accompanied by BDTT have been known to be poor. There have been significant controversies regarding optimal surgical approaches and risk factors because of the low incidence and small number of cases in previous reports.

Methods:

Records of 257 patients from 32 centers in Korea and Japan (1992-2014) were analyzed for overall survival and recurrence rate using the Cox proportional hazard model.

Results:

Curative surgery was performed in 244 (94.9%) patients with an operative mortality of 5.1%. Overall survival and recurrence rate at 5 years was 43.6% and 74.2%, respectively. TNM Stage (P < 0.001) and the presence of fibrosis/cirrhosis (P = 0.002) were independent predictors of long-term survival in the Cox proportional hazards regression model. Both performing liver resection equal to or greater than hemihepatectomy and combined bile duct resection significantly increased overall survival [hazard ratio, HR = 0.61 (0.38-0.99); P = 0.044 and HR = 0.51 (0.31-0.84); P = 0.008, respectively] and decreased recurrence rate [HR = 0.59 (0.38-0.91); P = 0.018 and HR = 0.61 (0.42-0.89); P = 0.009, respectively].

Conclusions:

Clinical outcomes were mostly influenced by tumor stage and underlying liver function, and the impact of BDTT to survival seemed less prominent than vascular invasion. Therefore, an aggressive surgical approach, including major liver resection combined with bile duct resection, to increase the chance of R0 resection is strongly recommended.
Disease-free Survival and Local Recurrence After Laparoscopic-assisted Resection or Open Resection for Rectal Cancer
Authors: Stevenson Andrew R. L. , Solomon Michael J. , Brown Christopher S. B. , Lumley John W. , Hewett Peter , Clouston Andrew D. , Gebski Val J. , Wilson Kate , Hague Wendy , Simes John
Published: September 2018

Objective:

The aim of the study was to determine the efficacy of laparoscopic rectal resection (Lap) versus open laparotomy and rectal resection (Open) for rectal cancer on locoregional recurrence (LRR) and disease-free survival (DFS) at 2 years.

Summary background data:

Although a Lap approach to colon cancer surgery may offer similar oncological outcomes to Open with potentially less morbidity, this remains to be clearly established for the treatment of rectal cancer.

Methods:

A randomized, multicenter noninferiority phase 3 trial of 475 patients with T1 to T3 rectal adenocarcinoma <15 cm from anal verge, given Lap or Open and followed for a minimum 2 years to assess LRR, DFS, and overall survival (OS).

Results:

Secondary endpoint analyses included 450 patients (95%) without metastases at baseline (mean age 64; 34% women) who received Lap (n = 225) or Open (n = 225). Median follow-up was 3.2 years (range: 0.1–5.4 yrs). LRR cumulative incidence at 2 years: Lap 5.4%; Open 3.1% [difference, 2.3%; 95% confidence interval (CI), −1.5% to 6.1%; hazard ratio (HR) 1.7; 95% CI, 0.74–3.9]. DFS at 2 years: Lap 80%; Open 82% (difference, 2.0%; 95% CI, −9.3% to 5.4%; HR for recurrence or death, 1.17; 95% CI, 0.81–1.68; P = 0.41). After adjustment for baseline factors HR = 1.07 (95% CI, 0.7–1.6). OS at 2 years: Lap 94%; Open 93% (difference 0.9%; 95% CI, −3.6% to 5.4%).

Conclusions:

Laparoscopic surgery for rectal cancer did not differ significantly from open surgery in effects on 2-year recurrence or DFS and OS. Confidence intervals included potentially clinically important differences favoring open resection, so that the combination of primary and secondary study endpoints may not support laparoscopic resection of rectal cancer as a routine standard of care and further follow-up is required.
Workload, Recurrence, Quality of Life and Long-term Efficacy of Endoscopic Therapy for High-grade Dysplasia and Intramucosal Esophageal Adenocarcinoma
Authors: Schwameis Katrin , Zehetner Jörg , Green Kyle M. , DeMeester Steven R.
Published: September 2018

Objective:

To review the workload, type and frequency of recurrence, long-term quality of life (QOL), and late oncologic outcomes with endoscopic therapy.

Background:

The short-term oncologic efficacy of endoscopic resection (ER) and ablation for patients with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) is well-established in the literature.

Methods:

A retrospective chart review was performed of the initial 40 patients who had endoscopic therapy from 2001 to 2010 at 1 center by 1 physician.

Results:

Initial pathology was HGD in 22 and IMC in 18 patients, but 9 patients (41%) with HGD progressed to invasive cancer during endotherapy. The median follow-up was 82 months. Four patients had an esophagectomy, and in the remaining 36 patients, 70 ERs and 111 ablations were performed. The median number of endoscopic sessions was 4 in patients with short segment compared with 7 in patients with long-segment Barrett's. Complete resolution of intestinal metaplasia (CRIM) was achieved in 30 patients (83%) at a median of 21 months. In 18 patients (60%), CRIM was maintained, whereas 12 patients developed recurrence at a median of 14 months. Additional endotherapy (n = 11) led to CRIM again in 10 patients (83%). There were no cancer deaths when CRIM was achieved. Overall survival with endotherapy was 73% at 5 years and 67% at 10 years. Quality of life (QOL) was below population means in 4 of 8 areas, but alimentary satisfaction was good after endotherapy.

Conclusions:

Endotherapy is successful in most patients, but multiple sessions are usually required and disease progression can occur. Once CRIM is achieved, recurrence is common and mandates continued endoscopic follow-up. QOL is impaired with endotherapy, but alimentary satisfaction and oncologic outcomes support esophageal preservation with endotherapy for patients with HGD or IMC.
Variation in Surgical Treatment of Abdominal Aortic Aneurysms With Small Aortic Diameters in the Netherlands
Authors: Karthaus Eleonora G. , Vahl Anco , van der Werf Leonie R. , Elsman Bernard H. P. , Van Herwaarden Joost A. , Wouters Michel W. J. M. , Hamming Jaap F.
Published: September 2018

Objective:

To evaluate reasons to deviate from aneurysm diameter thresholds, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation.

Background:

Guidelines recommend surgical treatment for asymptomatic abdominal aortic aneurysms (AAAs) with a diameter of at least 55 mm for men and 50 mm for women. We evaluate reasons to deviate from these guidelines, and focus on the difference in how Dutch vascular surgical units (VSUs) perceive their deviation and their actual deviation.

Methods:

All patients undergoing elective AAA repair between 2013 and 2016 registered in the Dutch Surgical Aneurysm Audit (DSAA) were included. Surgery at diameters of <55 mm for men and <50 mm for women were considered guideline deviations. National deviation and hospital variation in deviation were evaluated over time. Questionnaires were distributed among all Dutch VSUs, inquiring for acceptable reasons for guideline deviation. VSUs were asked to estimate the guideline deviation percentage in their hospital which was then compared with their DSAA percentage.

Results:

In all, 9039 patients were included. In 15%, we found guideline deviation, varying from 2% to 40% between VSUs. Over time, 21 VSUs were identified with a lower percentage of deviation than the national mean each year and 8 VSUs with a higher percentage. 44/60 VSUs completed the questionnaire. Most commonly reported reasons to deviate were concomitant large iliac diameter (91%) and saccular aneurysm (82%). The majority of the VSUs (77%) estimated their guideline deviation to be <5%. Eleven VSUs (25%) estimated their deviation concordant with their DSAA percentage, but 75% of VSUs underestimated their deviation.

Conclusions:

Dutch VSUs regularly deviate from the guidelines regarding aneurysm diameter, with variation between VSUs. Consensus exists amongst VSUs on acceptable reasons for guideline deviations; however, the majority underestimates their actual deviation percentage.
Somatostatin as Inflow Modulator in Liver-transplant Recipients With Severe Portal Hypertension
Authors: Troisi Roberto Ivan , Vanlander Aude , Giglio Mariano Cesare , Van Limmen Jurgen , Scudeller Luigia , Heyse Bjorn , De Baerdemaeker Luc , Croo Alexander , Voet Dirk , Praet Marleen , Hoorens Anne , Antoniali Giulia , Codarin Erika , Tell Gianluca , Reynaert Hendrik , Colle Isabelle , Sainz-Barriga Mauricio
Published: September 2018

Objective:

To investigate the safety and efficacy of somatostatin as liver inflow modulator in patients with end-stage liver disease (ESLD) and clinically significant portal hypertension (CSPH) undergoing liver transplantation (LT) (ClinicalTrials.gov number,01290172).

Background:

In LT, portal hyperperfusion can severely impair graft function and survival, mainly in cases of partial LT.

Methods:

Thirty-three patients undergoing LT for ESLD and CSPH were randomized double-blindly to receive somatostatin or placebo (2:1). The study drug was administered intraoperatively as 5-mL bolus (somatostatin: 500 μg), followed by a 2.5 mL/h infusion (somatostatin: 250 μg/h) for 5 days. Hepatic and systemic hemodynamics were measured, along with liver function tests and clinical outcomes. The ischemia-reperfusion injury (IRI) was analyzed through histological and protein expression analysis.

Results:

Twenty-nine patients (18 receiving somatostatin, 11 placebo) were included in the final analysis. Ten patients responded to somatostatin bolus, with a significant decrease in hepatic venous portal gradient (HVPG) and portal flow of −28.3% and −29.1%, respectively. At graft reperfusion, HVPG was lower in patients receiving somatostatin (−81.7% vs −58.8%; P = 0.0084), whereas no difference was observed in the portal flow (P = 0.4185). Somatostatin infusion counteracted the decrease in arterial flow (−10% vs −45%; P = 0.0431). There was no difference between the groups in the severity of IRI, incidence of adverse events, long-term complications, graft, and patient survival.

Conclusions:

Somatostatin infusion during LT in patients with CSPH is safe, reduces the HVPG, and preserves the arterial inflow to the graft. This study establishes the efficacy of somatostatin as a liver inflow modulator.