bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of CPR in High-Risk Donation after Circulatory Death Donors and Extended Criteria Donors for Kidney Transplantation
Authors: Buggs Jacentha , Rogers Ebonie , Bowers Victor
Published: June 2020

The demand for organs for kidney transplantation (KTX) compels the use of high-risk donation after circulatory death donors (DCDs) and extended criteria donors (ECDs). Many deceased donors receive prehospital CPR, but the literature does not address CPR as a benefit to graft survival. We hypothesized that donor prehospital CPR correlates with improved graft survival with high-risk DCD/ECD kidneys. We retrospectively analyzed KTX recipients and their donor data from 2008 to 2013. A total of 646 cadaveric donors (498 SCDs, 55 DCDs, and 93 ECDs) facilitated 910 KTX. There were 223 KTX performed from 148 high-risk DCDs/ECDs (31 with CPR and 117 without CPR). The mean age of high-risk DCDs/ECDs with CPR was 44.94 versus 53.45 years without CPR (P = 0.005). The recipients of high-risk DCDs/ECDs revealed no significant difference in body mass index, length of stay, discharge Cr, CIT, or DGF with and without CPR. Graft survival at three years was significant with 0/50 failures from high-risk DCDs/ECDs with CPR versus 16/173 without CPR (P = 0.026). Our findings are limited as a single-center retrospective study; however, the result of significant three-year graft survival in high-risk DCDs/ECDs with CPR suggests that prehospital donor CPR should be further investigated for its contribution to the relative quality of the donor.
Predicting Mortality in the Surgical Intensive Care Unit Using Artificial Intelligence and Natural Language Processing of Physician Documentation
Authors: Parreco Joshua , Hidalgo Antonio , Kozol Robert , Namias Nicholas , Rattan Rishi
Published: June 2020

The purpose of this study was to use natural language processing of physician documentation to predict mortality in patients admitted to the surgical intensive care unit (SICU). The Multiparameter Intelligent Monitoring in Intensive Care III database was used to obtain SICU stays with six different severity of illness scores. Natural language processing was performed on the physician notes. Classifiers for predicting mortality were created. One classifier used only the physician notes, one used only the severity of illness scores, and one used the physician notes with severity of injury scores. There were 3838 SICU stays identified during the study period and 5.4 per cent ended with mortality. The classifier trained with physician notes with severity of injury scores performed with the highest area under the curve (0.88 ± 0.05) and accuracy (94.6 ± 1.1%). The most important variable was the Oxford Acute Severity of Illness Score (16.0%). The most important terms were “dilated” (4.3%) and “hemorrhage” (3.7%). This study demonstrates the novel use of artificial intelligence to process physician documentation to predict mortality in the SICU. The classifiers were able to detect the subtle nuances in physician vernacular that predict mortality. These nuances provided improved performance in predicting mortality over physiologic parameters alone.
Factors Predicting Thyroid Malignancy in Fine Needle Aspiration Biopsy Specimens Classified as Atypia of Uncertain Significance/Follicular Lesion of Uncertain Significance
Authors: Brown Ciara , Mangano William , Thompson Stephanie , Richmond Bryan
Published: June 2020

The atypia of uncertain significance/follicular lesion of uncertain significance (AUS/FLUS) category of the Bethesda system for reporting thyroid cytopathology for fine needle aspiration biopsy (FNAB) has a predicted incidence of malignancy from 5 to 15 per cent. The literature has reported that suspicious ultrasound (SUS) characteristics can assist in predicting malignancy in thyroid biopsies. Some research suggests further subdivision of AUS/FLUS into nuclear atypia predominant or follicular predominant. We hypothesized that the rate of malignancy would be higher in AUS/FLUS biopsies with SUS characteristics and in the AUS/FLUS subset classified as nuclear atypia predominant. We performed a four-year retrospective analysis of patients who underwent FNAB classified as AUS/FLUS and who subsequently underwent thyroidectomy from October 2008–October 2012. A total of 3839 thyroid FNAB were performed over the four-year period, of which 342 received AUS/FLUS classification. Of these, we identified 119 patients who underwent thyroidectomy, of which 27 (23%) malignancies were identified. Reported cytology (nuclear atypia vs follicular predominant) did not differ between patients with and without carcinomas (P = 0.33). Suspicious ultrasound appearance failed to be significantly associated with an underlying carcinoma (P = 0.14); although, nearly 70 per cent of malignancies displayed SUS compared with 50 per cent within the benign group. Ultrasound seems to have no additional value in predicting malignancy in the AUS/FLUS categorization. Further subcategorization did not aid in risk stratification of this indeterminate category. This may suggest an expanded role for ancillary technologies such as molecular markers in this challenging Bethesda system for reporting thyroid cytopathology class. Further study of these findings is warranted.
The Impact of Trauma Center Volume on Observed/Expected Mortality: Does Size Matter?
Authors: Elkbuli Adel , Eily Alyssa , Hai Shaikh , McKenney Mark , Morejon Orlando
Published: June 2020

Relationship between trauma center patient volume (TCV) and mortality remains inconclusive. Our aim was to determine the relationship between TCVs and observed/expected (O/E) all-cause mortality. This is the first study to evaluate the relationship between trauma center (TC) volumes and O/E all-cause mortality with no exclusion. Review of prospectively collected data from 94 TCs using the National Sample Program from the National Trauma Data Bank 2013. TCs were stratified into five groups based on TCV: <701, 701 to 1200, 1201 to 1700, 1701 to 2200, and >2200 yearly patient encounters. Chi-square and coefficient of determination were used for data analysis with a statistical significance defined as P-value < 0.05. A total of 139,324 trauma patients with blunt and penetrating injuries were evaluated from the National Sample Program. Of which, 63.6 per cent were male, 70.6 per cent white, and the average age was 41 years. The data were stratified by TCV into five groups with average O/Es ranging from 0.69 to 0.86 (P > 0.05). The coefficient of determination between TCV and O/E was r = 0.14 and r2 = 0.02. When controlling for Injury Severity Score, the correlation between mechanism of injury (blunt vs penetrating) and O/E mortality was r = 20.025. The group with the lowest average volumes had statistically significantly worse outcomes than the group with next higher volumes and also worse than the group with the highest volumes (Group 5, P = 0.04). Higher TC volumes correlated with higher injury severity and lower O/E mortality.
A 12-Year Single-Institution Experience with Accelerated Partial Breast Irradiation
Authors: Scott Anthony M. , Callier Matthew C. , Lashley Madison , Cole David A. , Dale Paul S.
Published: June 2020

Accelerated partial breast irradiation (APBI) using the implanted brachytherapy device MammoSite® was approved for routine use by the Food and Drug Administration in 2002. The American Society of Breast Surgeons MammoSite® Breast Brachytherapy Registry served as a guideline for our institution to begin offering this treatment in 2005. This report reviews our available data to provide an analysis of patient outcomes over 12 years of use at a single institution. A retrospective review was conducted of records of 150 patients who underwent APBI or attempted APBI after breast-sparing surgeries between 2006 and 2017. These charts were analyzed for documentation of patient age, cancer stage, incidence of recurrence, and posttreatment complications. Of the patients evaluated, 99 per cent (149/150) completed treatment. The median time since treatment completion is now 8.9 years. One hundred eleven patients (74%) are now greater than five years posttreatment. Ipsilateral breast recurrence was found in 2.7 per cent of patients (4/149), and 1.3 per cent of patients (2/149) developed new primary breast tumors. Acute complications, mostly skin erythema (21%), were uncommon and self-limited. Subacute effects were generally fibrosis (13%) and mild local pain (9.4%). APBI for breast cancer after breast-conserving surgery continues to be used at our institution for select patients with good outcomes. Local control and toxicity are similar to that reported in the literature. Five-year local recurrence rates compare favorably with national trials. Occasional complications included fibrosis, persistent pain, and skin irritation.
Negative Sestamibi Scans Predict Lower Likelihood of Surgical Referral in Patients with Primary Hyperparathyroidism
Authors: Lloyd Jacob Q. , Holcombe Jenny M. , Rackley Allyssa A. , Tanner Richard M. , Giles W. Heath
Published: June 2020

99mTechnetium sestamibi scans (MIBI) can provide negative or inaccurate results in patients with biochemical primary hyperparathyroidism. Reliance on MIBI as a diagnostic modality rather than as a localization tool leads to misdiagnosis and inappropriate care. The aim of this study was to determine the impact of negative MIBI scans on referral patterns and surgical intervention. Adults with MIBI scans at our institution from January 1, 2011, to May 31, 2017, were retrospectively reviewed. Data collected include demographics, study date and results, ordering physician specialty, pre/postoperative laboratories, and operative and final pathology. Statistical analysis was performed with SPSS v24 (IBM Corp., Armonk, NY). Three hundred fifty-seven patients had a MIBI scan; 10 were excluded for incomplete data or incorrect diagnosis. One hundred eighty-six were interpreted as positive (53.6%) and 161 were interpreted as negative (46.4%). Of the 186 positive MIBI scans, 135 (72.6%) were seen by an endocrine surgeon (ES). Of these 135 patients, 111 (82.2%) underwent parathyroidectomy. Of the 161 negative MIBI scans, 69 (42.9%) were seen by an ES. Of these, 53 (76.8%) underwent parathyroidectomy. In all, 90/92 (97.8%) with a negative MIBI scan who were not seen by an ES did not have surgery. Nonendocrine surgeon physicians are more likely to use MIBI scans as diagnostic tools to assist with clinical decision-making. Patients with a negative MIBI scan not seen by an ES were significantly less likely to undergo para-thyroidectomy. Patients with primary hyperparathyroidism should be referred to an experienced parathyroid surgeon for evaluation, regardless of the MIBI result.
Imaging-Associated Radiation Trends in a Puerto Rican Pediatric Surgical Population: Is Over-Radiation an Issue in Our Emergency Departments?
Authors: Diaz Keila , Marcano Sofia , Ortiz Victor , Sanchez Carlos , Santiago Elvis , Zequeira Jorge J.
Published: June 2020

The increased use of CT scans has raised concerns regarding the risks of early radiation exposure in the Puerto Rico pediatric population. Available literature sustains that repeated exposure to imaging-related radiation in the pediatric population is associated with a 3-fold increase in the risk of developing pediatric hematogenous and central nervous system malignancies. It is for this reason that an international effort known as the Image Gently Campaign was created, mostly based on the “As Low As Reasonably Achievable” (ALARA) principle described by the Center for Disease Control. With this in mind, our aim was to identify whether there are any discrepancies in imaging tendencies outside our pediatric academic center in Puerto Rico and to determine whether our patients are at increased risk of over-radiation. There were 181 patients; five were excluded because of incomplete data. Our results show that children with appendicitis who are evaluated at nontertiary centers are more likely to have a CT scan performed (93%, OR: 4.054; 95% confidence interval: 2.6–6.4), as opposed to a nonradiating imaging study. In the Pediatric University Hospital, a CT scan was performed as the initial study in 23 per cent of the patients (OR: 0.09; 95% confidence interval: 0.05–0.18), favoring ultrasound as the diagnostic modality of choice. Our concern is that if this trend does not change, our pediatric population might have an increased risk of developing associated malignancies. We believe a local effort toward educational strategies should be implemented to prevent radiation overexposure in our pediatric patients.
Moderate Sedation or Monitored Anesthesia Care for Colonoscopies: Is There a Difference?
Authors: Ng Matthew , Dhanani Rahim , Galadima Hadiza , Burgess Jessica
Published: June 2020

To determine whether monitored anesthesia care (MAC) results in shorter colonoscopy time. A retrospective chart review from electronic medical records at Sentara Norfolk General Hospital was performed of all patients seen by the Eastern Virginia Medical School Department of Surgery who underwent a screening or diagnostic colonoscopy from December 2015 to July 2017. The primary end point is procedure time, with secondary end point of sedation time. There is a statistically significant difference in time to cecum between moderate sedation (MOD) and MAC (P = 0.002). Operator perceived difficulty is statistically associated with increased time to cecum (P < 0.0001). Time to cecum between MOD and MAC over the levels of difficulty was not significant (P = 0.403). A subanalysis looking at time to cecum between MOD and MAC for each level of difficulty showed a significant effect when difficulty was described as no difficulty. There is a statistically significant difference in time to scope insertion between MOD and MAC (P < 0.0001). Our data show that, taken as a conglomerate, the procedure and sedation time is shorter in MAC than in MOD. The use of MAC is associated with decrease time to scope insertion and overall time to cecum.
Is the Face an Air Bag for the Brain and Torso?—The Potential Protective Effects of Severe Midface Fractures
Authors: Woriax Hannah E. , Hamill Mark E. , Gilbert Carol M. , Reed Christopher M. , Faulks Emily R. , Love Katie M. , Lollar Daniel I. , Nussbaum Michael S. , Collier Bryan R.
Published: June 2020

We investigated the patterns of injury associated with major midface trauma. Our hypothesis is that midface injuries are associated with a decrease in certain traumatic brain injuries as well as major torso injuries. The registry of our Level I trauma center was queried for all adult patients treated over 25 years from 1989 to 2013. Patients with midface fractures were identified based on the ICD-9 code. Associated injuries were defined based both on individual ICD-9 codes as well as the Barell Injury Matrix. Injury etiology was defined based on e-codes. Univariate analysis was performed using chi-squared test, Fisher's exact test, and Wilcoxon test. A total of 29,152 patients were identified. Excluding pediatric patients, those with exclusively penetrating trauma, and patients with incomplete data, 20,971 patients were included for subsequent analysis. Midface fractures were identified in 752 patients. Patients with Le Fort fractures were more likely to be male, have a higher Injury Severity Score, a lower arrival Glasgow Coma Scale, and more likely to require intensive care unit admission and mechanical ventilation, with a longer hospital length of stay. Patients with midface fractures had significantly fewer subdural hematomas, subarachnoid hemorrhages, spine fractures, and were less likely to have associated abdominal and pelvic injuries. Patients with midface fractures were more likely to require facial reconstruction procedures and craniotomy. Patients presenting with midface fractures after blunt trauma have a distinctly different pattern of injuries. One potential mechanism for this is a deceleration effect, where midface impact and resulting fractures dissipate some of the energy.
Posterior Thoracic Stab Wounds: Evaluating the Value of Commonly Used Radiologic Modalities
Authors: Brigode William M. , Masteller Michael , Chaudhuri Rishi , Sullivan Ryan , Vafa Amir
Published: June 2020

This study was performed to assess our institution's experience with stab injuries to the posterior mediastinal box. We examine the value of performing CT of the chest and esophagram in conjunction with a chest X-ray (CXR) over performing CXR(s) alone in evaluating this group of patients. We performed a retrospective study covering a 10-year period consisting of patients with stab wounds to the posterior mediastinal box. Age, gender, and injury severity score as demographic data points were collected. CXR, CT, and esophagram results; identified injuries; and subsequent interventions were analyzed. Of 78 patients who met the inclusion criteria, a total of 55 patients underwent esophagram, one had a false-positive result, and zero had their course altered by the study. Sixty-six patients underwent CT imaging, and there were nine missed findings on initial CXR. Five of these were clinically insignificant and the remaining four were managed with a chest tube alone. There were no tracheobronchial, esophageal, cardiac, or great vessel injuries. Hemodynamically stable, asymptomatic patients with stab wounds to the posterior mediastinal box do not require routine CT and esophagram in the absence of CXR and cardiac ultrasonographic abnormalities.
The Price of Always Saying Yes: A Cost Analysis of Secondary Overtriage to an Urban Level I Trauma Center
Authors: Bukur Marko , Teurel Candace , Catino Joseph , Kurek Stanley
Published: June 2020

Level I trauma centers serve as a community resource, with most centers using an inclusive transfer policy that may result in overtriage. The financial burden this imparts on an urban trauma system has not been well examined. We sought to examine the incidence of secondary overtriage (SOT) at an urban Level I trauma center. This was a retrospective study from an urban Level I trauma center examining patients admitted as trauma transfers (TT) from 2010 to 2014. SOT was defined as patients not meeting the “Orange Book” transfer criteria and who had a length of stay of <48 hours. Average ED and transport charges were calculated for total transfer charges. A total of 2397 TT were treated. The number of TT increased over the study interval. The mean age of TT was 59.7 years (SD ± 26.4 years); patients were predominantly male (59.2%), white (83.2%), with at least one comorbidity (71.5%). Blunt trauma accounted for 96.8 per cent of admissions with a median Injury Severity Score of nine (IQR: 5–16). Predominant injuries were isolated closed head trauma (61.4%), skin/soft tissue injury (18.9%), and spinal injury (17.6%). SOT was 48.2 per cent and increased yearly (P < 0.001). The median trauma center charge for SOT was ($27,072; IQR: $20,089–34,087), whereas ED charges were ($40,440; IQR: $26,150–65,125), resulting in a total cost of $67,512/patient. A liberal TT policy results in a high SOT rate adding significant unnecessary costs to the health-care system. Efforts to establish transfer guidelines may allow for significant cost savings without compromising care.
Hurricane Irma Impact on the Inpatient Population at a Tertiary Children's Hospital in Florida
Authors: Hoffman Amber , Fagan Heather , Casas-Melley Adela , Wei Julie , Hebra AndrÉ
Published: June 2020

Hurricane Irma resulted in the evacuation of 6.3 million people in Florida in September, 2017. Our tertiary Children's Hospital activated our incident command center (ICC) 24 hours before storm landfall, and preparations were made to accommodate vulnerable pediatric patients (VPP) or children with medical complexity. Our ICC was active for 92 hours and the hospital was staffed with 467 associates and 40 physicians. Urgent operative and interventional radiology procedures were performed during the storm. Thirteen patients were transferred to our facility and 13 VPP were sheltered. During the lockdown period, our facility operated at 90 per cent capacity inclusive of VPP. Personnel were used in critical areas in the hospital, independent of their base units. There were no adverse outcomes or complications. Timely activation of ICC and deployment of Team A 24 hours before storm hit allowed for safe hospital operations. Planning for the inflow of patients is imperative to allow for preemptive deployment of staff and resources for inpatients, transfers, emergency room admissions, and VPP. VPP should be monitored regionally as they will consume hospital resources during natural disasters and must be accounted for to allow for safe and effective care delivery for all patients.
Flail Chest: Influence on Length of Stay and Mortality in Blunt Chest Injury
Authors: Udekwu Pascal , Roy Sara , McIntyre Sarah , Farrell Meagan
Published: June 2020

Flail chest is used as one of the indicators for rib fixation, which is being performed more frequently. Radiologic and clinical flail chest are not clearly differentiated in published studies and the relationship between radiologic flail chest (RFC) and outcomes are not clearly established. Our study was designed to evaluate the relationship of RFC to outcomes in patients with severe blunt chest injury. Adult patients with severe blunt chest injury admitted between January 1, 2014, and June 30, 2016, were identified retrospectively. Three hundred and eighty-three patients were studied and mortality rate was not significantly different in patients with an RFC diagnosis (5.88%) compared with patients without RFC (3.83%), P = 0.50. Length of stay (LOS) in patients with and without RFC were compared and patients with RFC were found to have a statistically significant increase in both hospital and intensive care unit LOS (P = 0.0178, P < 0.0017). Multivariate analysis confirmed RFC as an independent predictor of increased LOS when compared with the number of rib fractures and displacements. Our study suggests that RFC may drive inappropriate use of rib fixation. This questions the justification of liberal rib fixation based on the perceived high mortality rate of modern flail chest diagnoses.
Trauma Patients’ Attitudes toward Organ Donation at an Urban Level I Trauma Center
Authors: Cull John D. , Ivkovic Katarina , Manning Benjamin , Chan Edie Y.
Published: June 2020

Many health-care workers (HCWs) surveyed at a trauma center believed their patients distrusted the organ allocation system. This study compares urban trauma patients’ (TPs) attitudes toward organ donation with attitudes from the 2012 National Survey of Organ Donation Attitudes (NSODA). TPs presenting to the trauma clinic between September 2014 and August 2015 were surveyed. Patient responses were compared with the 2012 NSODA. One hundred and thirty-three TPs (95.0%) responded to the survey. Compared with the 2012 NSODA, groups were similar with regard to a patient's desire for OD after death (Trauma: 62.4% [Confidence interval [CI]: 53.6–70.7] vs NSODA: 59.3% [CI: 56.6–61.8]) and the belief that doctors are less likely to save their life if they are an organ donor (24.8% [CI: 17.7–33.0] vs 19.6% [CI: 18.3–21.0]). Approximately, 30 per cent of patients believed discrimination prevented minority patients from receiving transplants (27.1 [CI: 19.7–35.5] vs 30.3 [CI: 28.8–31.9]). TPs were less likely than the NSODA group to donate a family members’ organs, if they did not know the family members’ wishes (56.4% [CI: 47.5–65.0] vs 75.6% [CI: 68.7–71.8]); TPs were less likely to believe the United States transplant system uses a fair approach to distribute organs (47.4% [38.7–56.2] vs 64.6% [CI: 63.0–66.2]). Adjusting for race, both groups were similar in their willingness to donate a family members’ organs; black TPs were less likely to believe the United States transplant system, which follows a fair approach in distributing organs (43.0% [CI: 32.4–54.2] vs 63.7% [59.7–67.6]). Despite HCWs perceptions, TPs had a positive view of OD. Educating HCWs on patient attitudes toward OD may decrease institutional barriers to OD.
Preoperative Educational Intervention Decreases Unplanned Gastrostomy-Related Health Care Utilization
Authors: Barry Wesley E. , Barin Erica N. , Marshall Lori C. , Doherty Majella , Nguyen Eugene , Mclaughlin Cory , Kaplan Lucas , Stein James E. , Jensen Aaron R.
Published: June 2020

Apprehension in taking independent care of children with medical devices may lead to unnecessary visits to the ED and/or acute clinic (AC). To address these concerns, our institution implemented a gastrostomy tube (GT) class in 2011 for caretakers. We hypothesized that inappropriate GT-related ED/AC visits would be lower in preoperatively educated caregivers. We performed a retrospective cohort study of all patients aged 0 to 18 who received GT (surgical or percutaneous) at our institution between 2006 and 2015 (n = 1340). Class attendance (trained vs untrained) and unscheduled GT-related ED/AC visits one year after GT placement were reviewed. Gastrostomy-related ED/AC visits were classified as appropriate (hospital-based intervention) or inappropriate (site care and education/reassurance). Occurrence of ED/AC visits was compared between trained and untrained cohorts. We found that 59 per cent of patients had an unscheduled GT-related ED/AC visit within one year of placement. The trained cohort had 27 per cent less unplanned ED/AC visits within one year (mean 1.21 (SD 1.82) vs untrained 1.65 (2.24), P < 0.001). On multivariate analysis, GT education independently decreased one-year GT-related health care utilization (Odds Ratio 0.75, 95% Confidence Interval 0.59–0.95). Formal education seems to decrease GT-related health care utilization within one year of placement and should be integrated into a comprehensive care plan to improve caregiver self-efficacy.
Can Selective Image-Guided Intraoperative Margin Resection Improve Re-Excision Rates after Lumpectomy in Ductal Carcinoma In Situ of the Breast?
Authors: Gray Kelsey , Ayabe Reed , Shover Andrew , Moazzez Ashkan , Ozao-Choy Junko , Dauphine Christine
Published: June 2020

The rate of positive margins after breast conserving surgery (BCS) can be as high as 50 per cent, and optimal techniques for reducing rates of positive margins are presently debated. Our institution has previously demonstrated low rates of margin re-excision using a standardized approach to intraoperative selective margin excision for patients undergoing BCS. We hypothesized that this approach can be used for patients with ductal carcinoma in situ (DCIS) and can yield similar rates when compared with invasive cancer. We performed a retrospective analysis of women with breast cancer who underwent BCS from January 2012 through July 2016 using our institution's standardized approach to selective margin resection. Of the 152 patients who underwent BCS, there were 30 (20%) with DCIS and 122 (80%) with invasive cancer. There was no statistically significant difference in re-excision rates for DCIS (13.3%) and invasive cancer (13.1%). Notably, the DCIS group had a larger mean lesion size ( P = 0.00009); however, the lesion was visible on ultrasound more often in the invasive cancer group ( P = 0.007). This standardized approach to intraoperative selective margin excision can produce similar rates of margin re-excision for DCIS and invasive cancer and may be a viable option for lowering re-excision rates for patients with DCIS.
Outcomes of Combined Hernia Repair and Peritoneal Dialysis Catheter Placement: A NSQIP Analysis
Authors: Tom Cynthia M. , Dubina Emily D. , Simms Eric R. , De Virgilio Christian , Moazzez Ashkan
Published: June 2020

Historically, hernias were repaired before peritoneal dialysis (PD) catheter placement to obviate hernia complications, or after PD catheter placement once hernias became symptomatic or complicated. The aim of this study was to evaluate the outcomes and safety of combined hernia repair and PD catheter placement (HPD) compared with PD catheter placement alone. Within the NSQIP databases (2005–2014), 4406 patients who underwent PD catheter placement alone and 330 patients who underwent HPD were identified. Thirty-day outcomes were compared. Overall, HPD patients were older (61 vs 57 years, P < 0.001), male (72.4% vs 56.1%, P < 0.001), and more likely to have ascites (3.6% vs 1.0%, P < 0.001). Umbilical hernias (87.9%) were most commonly repaired. There was no significant difference in mortality, morbidity, superficial surgical site infection, deep SSI, organ/space SSI, readmission, or reoperation rates. HPD was associated with shorter length of stay (1.1 vs 1.7 days, P = 0.010) and longer mean operative time (66.1 vs 43.7 minutes, P < 0.001). On multivariate analyses, HPD was not an independent predictor of morbidity or mortality. In conclusion, HPD can be safely performed to prevent future complications and additional operations.
Supermassive Transfusion: A 15-Year Single Center Experience and Outcomes
Authors: Yu Alison J. , Inaba Kenji , Biswas Subarna , De Leon Luis Alejandro , Wong Monica , Benjamin Elizabeth , Lam Lydia , Demetriades Demetrios
Published: June 2020

The objective of this study was to determine the survival outcome associated with large-volume blood transfusion after trauma. This was a retrospective study at a Level I trauma center from January 2000 to December 2014 that included trauma patients who received ≥25 units packed red blood cell (pRBC) within the first 24 hours of hospital admission. Univariate and multivariable logistic regressions identified risk factors for mortality. Receiver operating characteristic curve analysis evaluated the ability of pRBC volume to predict mortality. Among 74,065 adults (‡18 years old), 178 patients (0.24%) received ≥25 units of pRBC in the first 24 hours, of which 142 (79.8%) received 25 to 49 units, 28 (15.7%) received 50 to 74 units, and 8 (4.5%) received ≥75 units. Overall, 92.2 per cent were male, mean age 33.9 (614.0), mean Injury Severity Score 28.9 (614.3), and median Glasgow Coma Scale score 12 (3–15). The overall mortality was 65.2 per cent and 64.1 per cent for those receiving 25 to 49 units, 64.3 per cent for 50 to 74 units, and 87.5 per cent for ≥75 units. In univariate analysis, female gender was associated with lower mortality [odds ratio (OR) 0.24, P = 0.025]. Decreasing Glasgow Coma Scale (OR 0.82, P < 0.001), increasing Injury Severity Score (OR 1.07, P < 0.001), and thoracotomy (OR 3.91, P < 0.001) were associated with higher mortality. There was no transfusion cutoff that was significantly associated with higher mortality.
Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: A Case Series Report of a Natural Orifice Surgical Technique
Authors: Basam Motahar , Tsay Anna , Attaluri Vikram , Mclemore Elisabeth C.
Published: June 2020

In the treatment of colorectal cancer, total mesorectal excision (TME) has risen as the gold standard in the surgical treatment of this disease in order to obtain negative distal and circumferential radial margins. Since introduction in 2010, transanal TME has aimed to decrease the rate of positive margins and improve the quality of the dissection while decreasing the complications associated with a transabdominal low pelvic dissection. We retrospectively reviewed 25 cases of transanal TME completed between December 2014 and August 2017. Most of the patients in our case series were male (60%) with an average age of 57.1 years, BMI of 28.4 kg/m2, and with an American Society of Anesthesiologists score of II. The average tumor was midrectal (about 5.9 cm from the anal verge), clinically T3-T4 (92%), and had undergone neoadjuvant therapy (96%). The average operation was about six hours and 44 minutes with ileostomy placed most of the time (92%). In all the cases where the TME quality was graded, the specimens were reported to have been complete (grade I). There were no positive distal, radial, or proximal margins. The average hospital stay was about 5.9 days. The rate of minor complications was about 48 per cent and major complications occurred about 16 per cent of the time.
Readmissions after Ileostomy Creation Using a Nationwide Database
Authors: Seo Young-Ji , Bailey Katherine , Aguayo Esteban , Juo Yen-Yi , Sanaiha Yas , Dobaria Vishal , Benharash Peyman , Lin Anne
Published: June 2020

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0–7, 8–30, 31–90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions were because of renal failure (17% vs 9%, P < 0.001). In the Late group, the most common reason for readmission was renal failure (14%), followed by anastomotic complications (11%), and stoma reversal (8%). In this nationwide study, all-cause 90-day non-elective readmissions after ileostomy procedures occurred in nearly 30 per cent of patients. Although early rehospitalizations were mainly because of surgical complications and gastrointestinal complications, late readmissions were because of ileostomy reversal.
Same-Day versus Conventional Different-Day Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: A Multi-Center Retrospective Study
Authors: Al-Temimi Mohammed H. , Trujillo Charles , Shah Mital , Rangarajan Sriram , Kim Edwin , Chandrasekaran Bindupryia , Handman David , Johna Samir
Published: June 2020

Same-day endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (LC) could potentially reduce hospital length of stay (HLOS). Patients undergoing same-day procedures (N = 164) between 2012 and 2014 were compared with different-day procedures performed in the second half of 2014 (N = 276), in the Kaiser Permanente Southern California database. Both groups had comparable baseline characteristics. ERCP success rate (97.5% vs 93.5%), overall postoperative morbidity (3.66% vs 3.99%), and retained stones (2.5% vs 5.8%) were not different between groups ( P > 0.05); however, HLOS was shorter in the same-day group (2.99 ± 2.34 vs 3.84 ± 2.52 days, P < 0.001). Morbidity, procedure success, and HLOS were not different in the same-day group, whether ERCP was performed before or after LC ( P > 0.05). In the same-day group, those undergoing single anesthesia had higher BMI (40.1 ± 10.8 vs 30.3 ± 6.6) and were more likely to have gastric bypass (30% vs 0%) than those undergoing separate anesthesia sessions ( P < 0.01). Longer HLOS (4.8 ± 3.5 vs 2.9 ± 2.2 days) and higher estimated blood loss (65 ± 90 mL vs 20 ± 29 mL) were also associated with the single-anesthetic session ( P < 0.01). ERCP performed on the same day of LC reduces HLOS without increasing morbidity. This approach does not affect postoperative morbidity and ERCP success rate, whether ERCP was performed before or after LC.
Short-Term Outcomes with Robotic Right Colectomy
Authors: Kelley Scott R. , Duchalais Emilie , Larson David W.
Published: June 2020

Few series have reported on the impact of robotic right colectomy compared with conventional laparoscopy. Even fewer have reported on the outcomes of intracorporeal anastomoses. The aim of our study was to determine the impact of robotic surgery on short-term operative outcomes in patients undergoing right colectomy with intracorporeal anastomosis. One hundred and fourteen consecutive patients who underwent a right colectomy by two colorectal surgeons between 2012 and 2017 were included. Patients were separated into two groups: laparoscopic technique with extracorporeal anastomosis (n = 87) and robotic technique with intracorporeal anastomosis (n = 27). Univariate analysis was performed to determine differences in outcomes. Differences between cohorts were only identified with regard to gender (62 vs 37%, P = 0.022) and year of surgery. In comparison with laparoscopy, robotic colectomy resulted in a shorter time of GI recovery (1.3 ± 0.6 vs 3 ± 1.1, P < 0.0001), lower rates of postoperative ileus (4 vs 28%, P = 0.007), lower overall morbidity (26 vs 52%, P = 0.019), less blood loss ( P = 0.001), 50 per cent lower narcotic use, and longer operative time (255 ± 66 vs 139 ± 49, P < 0.001). Despite longer operative time, robotic surgery improved GI recovery, significantly lowered oral morphine equivalent usage, and decreased short-term complications.
Efficacy of Wound Coverage Techniques in Extremity Necrotizing Soft Tissue Infections
Authors: Lauerman Margaret H. , Scalea Thomas M. , Eglseder W. Andrew , Pensy Raymond , Stein Deborah M. , Henry Sharon
Published: June 2020

Little data exist about management of wounds created by debridement in necrotizing soft tissue infections (NSTIs). Multiple wound coverage techniques exist, including complete primary wound closure, split-thickness skin grafting, secondary intention, and flap creation. We hypothesized that all wound coverage techniques would be associated with high rates of successful wound coverage and low crossover rates to other wound coverage techniques. NSTIs over a three-year period were retrospectively reviewed. Both the initial and secondary wound coverage techniques (if necessary) were recorded. The primary outcome was the ability to achieve complete wound coverage. Overall, 46 patients with NSTIs had long-term data available. Of the patients undergoing split-thickness skin grafting as the initial wound coverage technique, 8/8 (100%) achieved complete wound coverage; and of those undergoing flap creation, 1/1 (100%) achieved complete wound coverage; and of those undergoing complete primary wound closure, 4/4 (100%) achieved complete wound coverage. Of the patients undergoing secondary intention as the initial wound coverage technique, 5/33 (15.2%) achieved complete wound coverage and 28/33 (84.8%) required a secondary wound coverage technique with split-thickness skin grafting. All 46 patients achieved long-term successful wound coverage. Time to wound coverage did not vary with initial wound coverage technique ( P = 0.44). Split-thickness skin grafting, flap creation, complete primary wound closure, and secondary intention are all reasonable choices for initial wound coverage for NSTIs. Although secondary intention had a low success rate as an initial wound coverage technique, all patients ultimately achieved complete wound coverage without a significant increase in time to coverage.
The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury
Authors: Plaster Andrew L. , Hamill Mark E. , Lollar Daniel I. , Love Katie M. , Faulks Emily R. , Freeman Daniel W. , Benson Andrew D. , Nussbaum Michael S. , Collier Bryan R.
Published: June 2020

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.
Patient-Surgeon Relationship Influences Outcomes in Bariatric Patients
Authors: Carmichael Samuel P. , Veasey Elizabeth C. , Davenport Daniel L. , Jay Katie , Bernard Andrew C.
Published: June 2020

Bariatric surgery is an important therapy in weight loss. However, adherence to follow-up is critical and may be influenced by the patient-surgeon relationship. To test this hypothesis, bariatric surgical patients were surveyed from March 2013 to March 2015 via the National Association for Weight Loss Surgery webpage and social media outlets. Surgical outcomes and adherence to follow-up were collected, and aspects of the patient-surgeon relationship were assessed via the Likert scale. Correlations between survey item responses were calculated using Fisher's exact test, Student's t test, and Spearman's rho rank correlation. Three hundred twenty patients responded (n = 287 completed in entirety and n = 33 partially completed); 48 months was the median time to survey from operation (interquartile range, 22–84 months). Eighty-six per cent (n = 276) of patients rated their relationship with their operative surgeon as “average” to “very good.” Thirteen per cent (n = 43) rated their relationship as “poor” to “very poor.” Positive relationship with the operative surgeon and lack of complication were associated with adherence to follow-up ( P = 0.0001 and P = 0.002, respectively). The presence of complication did not affect the overall patient-surgeon relationship ( P = 0.5), although aspects of the patient-surgeon relationship were correlated to complications. There was no association between weight loss at one year and patient-surgeon relationship ( P = 0.6) or presence of complication ( P = 0.1). The findings of this study support the role of a positive patient-surgeon relationship in achieving long-term follow-up in post-bariatric surgical patients.
Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status
Authors: Haines Krista , Rust Clayton , Nguyen Benjamin Pham , Agarwal Suresh
Published: June 2020

Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.
Patients with Psychiatric Disorders Require Greater Health-Care Resources after Injury
Authors: Warnack Elizabeth , Choi Beatrix Hyemin , Dimaggio Charles , Frangos Spiros , Bukur Marko , Marshall Gary
Published: June 2020

The objective of this study was to assess whether patients with comorbid psychiatric conditions admitted after traumatic injury require greater health-care resource utilization. The trauma registry of a Level 1 trauma center was used to identify all adult trauma patients presenting from 2012 to 2015. Patients with psychiatric needs, identified as having either an ICD-9 code corresponding to a psychiatric disorder or requiring inpatient psychiatric consultation, were compared with controls, using propensity score matching. Patients with psychiatric disorders were more than three times more likely to present with penetrating injuries (odds ratio [OR] 3.5, P < 0.005). They had longer length of hospital stay (median 5 [IQR 2.5–11] vs. three days [IQR 1–7], P < 0.01), were approximately 70 per cent more likely to require ICU-level care (OR 1.68, P = 0.08), and were 80 per cent less likely to be discharged home (OR 0.18, P < 0.005). Trauma patients with psychiatric illness or need consume greater health-care resources.
Quantitative Evaluations of the Effects of Noise on Mental Workloads Based on Pupil Dilation during Laparoscopic Surgery
Authors: Gao Jiaqi , Liu Shenglin , Feng Qingmin , Zhang Xutian , Zhang Jianyang , Jiang Mingyin , Wang Linlin , Zhang Qiang
Published: June 2020

Noise can exert undeniable pressure on human minds, especially during tasks that require high precision and attention, such as those performed during surgery. To investigate whether auditory stimuli increases mental loads during laparoscopic surgery, we examined the effects of operating room (OR) noises and music by measuring mean changes in pupil sizes and subjectively assessing performances during surgery. We recruited 24 subjects with varying laparoscopic surgery experience levels to perform complete appendectomy using a laparoscopic simulator. Wearable eye trackers were worn by all subjects to monitor pupil sizes during surgery, and surgical tasks were performed under conditions of silence, background OR noise, and music. National Aeronautics and Space Administration-Task Load Index scores and performance parameters were also recorded during surgical tasks. Noise distractions were associated with significant increases in pupil sizes compared with those observed in silence, and the related increases in mental loads may have affected surgical performance. However, more experienced operators had smaller changes in pupil sizes because of auditory disturbances than moderately experienced surgeons. Noise stimulation in the OR increases surgeon's mental workload and performance. Auditory regulation of the OR may be better standardized using data from studies of the effects of acoustic stimulation in the OR, and mental stresses during surgery could be considered in a more humane manner. Further investigations are necessary to determine the cognitive consequences of various auditory stimuli.