bluuebunny/crossref_metadata_2025 huggingface dataset:
Fully Automatic Quantitative Measurement of 18F-FDG PET/CT in Thymic Epithelial Tumors Using a Convolutional Neural Network
Authors: Han Sangwon , Oh Jungsu S. , Kim Yong-il , Seo Seung Yeon , Lee Geun Dong , Park Min-Jae , Choi Sehoon , Kim Hyeong Ryul , Kim Yong-Hee , Kim Dong Kwan , Park Seung-Il , Ryu Jin-Sook
Published: April 2022

Objectives

The aim of this study was to develop a deep learning (DL)–based segmentation algorithm for automatic measurement of metabolic parameters of18F-FDG PET/CT in thymic epithelial tumors (TETs), comparable performance to manual volumes of interest.

Patients and Methods

A total of 186 consecutive patients with resectable TETs and preoperative18F-FDG PET/CT were retrospectively enrolled (145 thymomas, 41 thymic carcinomas). A quasi-3D U-net architecture was trained to resemble ground-truth volumes of interest. Segmentation performance was assessed using the Dice similarity coefficient. Agreements between manual and DL-based automated extraction of SUVmax, metabolic tumor volume (MTV), total lesion glycolysis (TLG), and 63 radiomics features were evaluated via concordance correlation coefficients (CCCs) and linear regression slopes. Diagnostic and prognostic values were compared in terms of area under the receiver operating characteristics curve (AUC) for thymic carcinoma and hazards ratios (HRs) for freedom from recurrence.

Results

The mean Dice similarity coefficient was 0.83 ± 0.34. Automatically measured SUVmax(slope, 0.97; CCC, 0.92), MTV (slope, 0.94; CCC, 0.96), and TLG (slope, 0.96; CCC, 0.96) were in good agreement with manual measurements. The mean CCC and slopes were 0.88 ± 0.06 and 0.89 ± 0.05, respectively, for the radiomics parameters. Automatically measured SUVmax, MTV, and TLG showed good diagnostic accuracy for thymic carcinoma (AUCs: SUVmax, 0.95; MTV, 0.85; TLG, 0.87) and significant prognostic value (HRs: SUVmax, 1.31 [95% confidence interval, 1.16–1.48]; MTV, 2.11 [1.09–4.06]; TLG, 1.90 [1.12–3.23]). No significant differences in the AUCs or HRs were found between automatic and manual measurements for any of the metabolic parameters.

Conclusions

Our DL-based model provides comparable segmentation performance and metabolic parameter values to manual measurements in TETs.
Metastasis From Clear Cell Renal Cell Carcinoma Mimicking Well-Differentiated Pancreatic Neuroendocrine Tumor at 18F-FDG and 68Ga-DOTATOC PET/CT
Authors: Guglielmo Priscilla , Pesella Fiammetta , Sartorello Alida , El Khouzai Badr , Berti Sara , Muccioli Simona , Gregianin Michele
Published: April 2022

Dual-tracer PET/CT with both 18F-FDG and 68Ga-DOTA–conjugated peptides is currently used in clinical routine for characterizing pNET (pancreatic masses suspicious for neuroendocrine tumor). We describe here the case of a 81-year-old man with a pancreatic lesion showing high 68Ga-DOTATOC uptake and mild 18F-FDG avidity, thus suggesting a well-differentiated pNET, which resulted at endoscopic ultrasound-guided fine-needle aspiration to be a clear cell renal cell carcinoma metastasis. In fact, the patient had right nephrectomy for clear cell renal cell carcinoma 27 years earlier. This case puts light on the role of PET/CT with 68Ga-DOTATOC in imaging RCC, a field which deserves to be further explored.
Perirenal Infiltration of Signet Ring Cell Colon Carcinoma Shown by 68Ga-FAPI PET/CT
Authors: Güzel Yunus , Kaplan İhsan , Kepenek Ferat , Söğütçü Nilgün , Kömek Halil
Published: April 2022

A soft tissue lesion surrounding the left kidney was detected in 18F-FDG PET/CT performed with suspicion of recurrence in a patient who was operated for descending colon cancer and showed mild FDG uptake. Intense fibroblast activation protein-specific inhibitor (FAPI) uptake in the perirenal soft tissue was observed in 68Ga-FAPI-04 PET/CT. Tru-cut biopsy of the left perirenal lesion revealed signet ring cell colon carcinoma metastasis. This case demonstrated that 68Ga-FAPI-04 PET/CT could be a promising radiopharmaceutical for the evaluation of signet ring cell colon carcinomas.
18F-FES PET/CT for Characterization of Brain and Leptomeningeal Metastasis in Double Primary Cancer Patient
Authors: Lee Yeongjoo , Yoo Ie Ryung , Ha Seunggyun
Published: April 2022

The clinical value of 16α-18F-fluoro-17 β-estradiol (18F-FES) PET in breast cancer has been widely investigated because it can visualize estrogen receptor–expressing lesions. This relatively new radiotracer adds clinical values by characterization of metastasis in double primary cancer. It also has advantage in finding small brain lesions, which has no background brain activity. Here, we present 18F-FES PET findings of brain and leptomeningeal metastases in a patient with breast and lung malignancy.
Prognostic Significance of Small Pulmonary Vessel Alteration Measured by Chest Computed Tomography in Connective Tissue Diseases With Pulmonary Arterial Hypertension
Authors: Zhang Yue , Zhang Ning , Sun Xiaoxuan , Liu Qingwen , Yuan Xiaohan , Wang Qiang , Zhou Lei
Published: April 2022

Background:

Pulmonary arterial hypertension (PAH) is characterized by structural alterations of pulmonary vessels. Few studies have explored the clinical significance of quantitative assessment of pulmonary small vessels by chest computed tomography (CT). Our aim was to assess whether the prognosis of connective tissue diseases (CTD)-PAH patients could be assessed through pulmonary small vessels measured by chest CT.

Methods:

In all, 42 CTD-PAH patients diagnosed based on right heart catheterization were retrospectively investigated. All patients underwent a chest CT within 1 month before and after right heart catheterization examination. Main pulmonary artery (MPA) and the cross-sectional area of small pulmonary vessels <5 mm2as a percentage of total lung area (%CSA<5) were measured. The primary endpoint was a composite clinical worsening endpoint.

Results:

After a median follow-up time of 30.5 (interquartile range, 8.5 to 45.25) months, endpoint events occurred in 16 (38.1%) patients after 19.5 (interquartile range, 10.0 to 45.5) months. Cox univariate proportional hazard analysis showed that pulmonary vascular resistance, MPA diameter, and %CSA<5were associated with the end point. A combination of MPA diameter and %CSA< 5was the independent risk factor for the prognosis (hazard ratio, 2.180 [95% confidence interval, 1.405-3.383],P=0.001). Kaplan-Meier analysis showed that CTD-PAH patients satisfying %CSA< 5of <0.382 and MPA >36.75 mm had the highest risk of experiencing the endpoint.

Conclusion:

Among the pulmonary vascular indicators measured by chest CT, in addition to MPA, %CSA< 5may be a potential independent risk factor for poor long-term prognosis in Chinese CTD-PAH patients.
Computed Tomography Pulmonary Angiography Utilization in the Emergency Department During the COVID-19 Pandemic
Authors: Schulz Kathryn , Mao Lu , Kanne Jeffrey
Published: April 2022

Purpose:

To determine if computed tomography pulmonary angiography (CTPA) ordering increased significantly during the COVID-19 pandemic in an emergency department (ED) setting; if positive findings for pulmonary embolism (PE) increased to the same degree; and whether COVID-positive patients have a higher incidence of PE than COVID-negative patients at ED presentation.

Materials and Methods:

We conducted a retrospective review of CTPA performed in our ED between June and December in 2019 and 2020. We collected data on patient demographics, symptoms, COVID-19 status, lab and imaging results, and risk factors for PE. We used a Wilcoxon rank sum to analyze quantitative variables and χ2 or Fisher test for categorical variables. We used logistic regression to identify predictive factors for PE.

Results:

CTPA ordering increased from 432 studies in 2019 to 699 in 2020 (+61.8%, P<0.0001), but detection rates for PE remained stable (11.3% vs. 10.2%, P=0.61). In 2020, 10 of 91 COVID-positive patients undergoing CTPA had positive studies. On regression analysis, COVID-19 was not a significant predictor of PE at ED presentation (odds ratio 1.029, 95% confidence interval: 0.959-1.103). COVID-positive patients were more likely to have nondiagnostic imaging (7.7% vs. 2.5% [COVID-negative] and 0.8% [not tested], P=0.007).

Conclusions:

While CTPA ordering increased significantly during the pandemic, our positivity rate remained stable, suggesting that this increase was appropriate. COVID-positive patients who underwent CTPA in the ED did not have a higher incidence of PE than other patients. Clinicians should use clinical judgment to weigh the likelihood of PE against the risk of nondiagnostic results when determining whether to expose COVID-positive patients to high-dose radiation and contrast with CTPA on initial presentation.
Mortality of adolescents with isolated traumatic brain injury does not vary with type of level I trauma center
Authors: Sheff Zachary T. , Engbrecht Brett W. , Rodgers Richard , Jacobson Lewis E. , Smith Jodi L.
Published: April 2022

BACKGROUND

Pediatric patients with isolated severe traumatic brain injury (TBI) treated at pediatric trauma centers (PTCs) have lower mortality than those treated at adult trauma centers (ATCs) or mixed trauma centers (MTCs). The primary objective of this study was to determine if adolescent patients (15–17 years) with isolated severe TBI also benefited from treatment at PTCs.

METHODS

This was a cross-sectional analysis using a national sample of adolescent trauma patients obtained from the American College of Surgeons' Trauma Quality Program Participant Use Files for 2013 to 2017 (n = 3,524). Mortality, the primary outcome variable, was compared between Level I PTCs, ATCs, and MTCs using multiple logistic regression controlling for patient characteristics and injury severity. Secondary outcomes included discharge disposition, utilization of craniotomy, intensive care unit (ICU) utilization, ICU length of stay (LOS), and hospital LOS.

RESULTS

Prior to adjustment, patients treated at ATCs (odds ratio [OR], 2.76; p = 0.032) and MTCs (OR, 2.36; p = 0.070) appeared to be at greater risk of mortality than those treated at PTCs. However, after adjustment, this difference disappeared (ATC OR, 1.21; p = 0.733; MTC OR, 0.95; p = 0.919). Patients treated at ATCs and MTCs were more severely injured than those treated at PTCs and more likely to be admitted to an ICU (ATC OR, 2.12; p < 0.001; MTC OR, 1.91; p < 0.001). No other secondary outcome differed between center types.

CONCLUSION

Adolescent patients with isolated severe TBI treated at ATCs and MTCs had similar mortality risk as those treated at PTCs. The difference in injury severity across center types warrants additional research.

LEVEL OF EVIDENCE

Prognostic/Epidemiological; Level III.
Infection Risk in the First Year After ABO-incompatible Kidney Transplantation: A Nationwide Prospective Cohort Study
Authors: Hirzel Cédric , Projer Lea , Atkinson Andrew , Surial Bernard , Mueller Nicolas J. , Manuel Oriol , Mombelli Matteo , van Delden Christian , Hirsch Hans H. , Boggian Katia , Walti Laura N. , Sidler Daniel , Hadaya Karine , Dickenmann Michael , Müller Thomas F. , Binet Isabelle , Golshayan Déla , Huynh-Do Uyen ,   Swiss Transplant Cohort Study (STCS)
Published: April 2022

Background.

ABO-incompatible (ABOi) kidney transplantation (KT) expands the kidney donor pool and may help to overcome organ shortage. Nonetheless, concerns about infectious complications associated with ABOi-KT have been raised.

Methods.

In a nationwide cohort (Swiss Transplant Cohort Study), we compared the risk for infectious complications among ABOi and ABO-compatible (ABOc) renal transplant recipients. Infections needed to fulfill rigorous, prespecified criteria to be classified as clinically relevant. Unadjusted and adjusted competing risk regression models were used to compare the time to the first clinically relevant infection among ABOi-KT and ABOc-KT recipients. Inverse probability weighted generalized mixed-effects Poisson regression was used to estimate incidence rate ratios for infection.

Results.

We included 757 living-donor KT recipients (639 ABOc; 118 ABOi) and identified 717 infection episodes. The spectrum of causative pathogens and the anatomical sites affected by infections were similar between ABOi-KT and ABOc-KT recipients. There was no significant difference in time to first posttransplant infection between ABOi-KT and ABOc-KT recipients (subhazard ratio, 1.24; 95% confidence interval [CI], 0.93-1.66; P = 0.142). At 1 y, the crude infection rate was 1.11 (95% CI, 0.93-1.33) episodes per patient-year for ABOi patients and 0.94 (95% CI, 0.86-1.01) for ABOc-KT recipients. Inverse probability weighted infection rates were similar between groups (adjusted incidence rate ratio, 1.12; 95% CI, 0.83-1.52; P = 0.461).

Conclusions.

The burden of infections during the first year posttransplant was high but not relevantly different in ABOi-KT and ABOc-KT recipients. Our results highlight that concerns regarding infectious complications should not affect the implementation of ABOi-KT programs.
Malignancies in Deceased Organ Donors: The Spanish Experience
Authors: Mahíllo Beatriz , Martín Silvia , Molano Esteban , Navarro Aurora , Castro Pablo , Pont Teresa , Andrés Amado , Galán Juan , López Montserrat , Oliver Eva , Martínez Adolfo , Mosteiro Fernando , Roque Rebeca , Pérez-Redondo Marina , Cid-Cumplido Manuela , Ballesteros María A. , Daga Domingo , Quindós Brígida , Sancho Micaela , Royo-Villanova Mario , Bernabé Esther , Muñoz Raúl , Chacón José Ignacio , Coll Elisabeth , Domínguez-Gil Beatriz
Published: April 2022

Background.

To better define the risk of malignancy transmission through organ transplantation, we review the Spanish experience on donor malignancies.

Methods.

We analyzed the outcomes of recipients of organs obtained from deceased donors diagnosed with a malignancy during 2013–2018. The risk of malignancy transmission was classified as proposed by the Council of Europe.

Results.

Of 10 076 utilized deceased donors, 349 (3.5%) were diagnosed with a malignancy. Of those, 275 had a past (n = 168) or current (n = 107) history of malignancy known before the transplantation of organs into 651 recipients. Ten malignancies met high-risk criteria. No donor-transmitted cancer (DTC) was reported after a median follow-up of 24 (interquartile range [IQR]: 19–25) mo. The other 74 donors were diagnosed with a malignancy after transplantation. Within this group, 64 donors (22 with malignancies of high or unacceptable risk) whose organs were transplanted into 126 recipients did not result in a DTC after a median follow-up of 26 (IQR: 22–37) mo, though a prophylactic transplantectomy was performed in 5 patients. The remaining 10 donors transmitted an occult malignancy to 16 of 25 recipients, consisting of lung cancer (n = 9), duodenal adenocarcinoma (n = 2), renal cell carcinoma (n = 2), extrahepatic cholangiocarcinoma (n = 1), prostate cancer (n = 1), and undifferentiated cancer (n = 1). After a median follow-up of 14 (IQR: 11–24) mo following diagnosis, the evolution was fatal in 9 recipients. In total, of 802 recipients at risk, 16 (2%) developed a DTC, which corresponds to 6 cases per 10 000 organ transplants.

Conclusions.

Current standards may overestimate the risk of malignancy transmission. DTC is an infrequent but difficult to eliminate complication.
A Fourth Dose of COVID-19 Vaccine Does Not Induce Neutralization of the Omicron Variant Among Solid Organ Transplant Recipients With Suboptimal Vaccine Response
Authors: Karaba Andrew H. , Johnston Trevor S. , Aytenfisu Tihitina Y. , Akinde Olivia , Eby Yolanda , Ruff Jessica E. , Abedon Aura T. , Alejo Jennifer L. , Blankson Joel N. , Cox Andrea L. , Bailey Justin R. , Klein Sabra L. , Pekosz Andrew , Segev Dorry L. , Tobian Aaron A.R. , Werbel William A.
Published: April 2022

Background.

Humoral responses to coronavirus disease 2019 (COVID-19) vaccines are attenuated in solid organ transplant recipients (SOTRs), necessitating additional booster vaccinations. The Omicron variant demonstrates substantial immune evasion, and it is unknown whether additional vaccine doses increase neutralizing capacity versus this variant of concern (VOC) among SOTRs.

Methods.

Within an observational cohort, 25 SOTRs with low seroresponse underwent anti–severe acute respiratory syndrome coronavirus 2 spike and receptor-binding domain immunoglobulin (Ig)G testing using a commercially available multiplex ELISA before and after a fourth COVID-19 vaccine dose (D4). Surrogate neutralization (percent angiotensin-converting enzyme 2 inhibition [%ACE2i], range 0%–100% with >20% correlating with live virus neutralization) was measured against full-length spike proteins of the vaccine strain and 5 VOCs including Delta and Omicron. Changes in IgG level and %ACE2i were compared using the paired Wilcoxon signed-rank test.

Results.

Anti–receptor-binding domain and anti-spike seropositivity increased post-D4 from 56% to 84% and 68% to 88%, respectively. Median (interquartile range) anti-spike antibody significantly increased post-D4 from 42.3 (4.9–134.2) to 228.9 (1115.4–655.8) World Health Organization binding antibody units. %ACE2i (median [interquartile range]) also significantly increased against the vaccine strain (5.8% [0%–16.8%] to 20.6% [5.8%–45.9%]) and the Delta variant (9.1% [4.9%–12.8%] to 17.1% [10.3%–31.7%]), yet neutralization versus Omicron was poor, did not increase post-D4 (4.1% [0%–6.9%] to 0.5% [0%–5.7%]), and was significantly lower than boosted healthy controls.

Conclusions.

Although a fourth vaccine dose increases anti-spike IgG and neutralizing capacity against many VOCs, some SOTRs may remain at high risk for Omicron infection despite boosting. Thus, additional protective interventions or alternative vaccination strategies should be urgently explored.
Dementia and Related Comorbidity
Authors: Zuliani Giovanni , Gallerani Massimo , Maietti Elisa , Reverberi Roberto , Romagnoli Tommaso , Cervellati Carlo , Brombo Gloria
Published: April 2022

Background:

The aim of the present study was to examine the prevalence of dementia, related comorbidities, and mortality rates in hospitalized elderly patients in Italy.

Methods:

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged 65 years or above admitted to acute Internal Medicine during 2 years (n=3,695,278 admissions). Discharge diagnoses were re-classified into 24 clusters, each including homogeneous diseases by the ICD-9-CM code classification. Dementia was identified by the presence of ICD-9-CM codes 290, 294, or 331 series.

Results:

Patients with dementia represented 7.5% of the sample; compared with those without dementia, they were older and more often female, had a greater length of hospital stay and higher mortality rate. Besides delirium [odds ratio (OR): 54.20], enthesopaties (OR: 2.19), diseases of fluids and electrolytes (OR:1.96), diseases of arteries (OR: 1.69), skin diseases (OR: 1.64), and pneumonia and pleurisy (OR: 1.53) were the diseases more strongly associated with the diagnosis of dementia, independent of other clusters, age, sex, and length of stay.

Conclusions:

Some comorbidities are specifically associated with the diagnosis of dementia among hospitalized elderly patients. Overall, these comorbidities describe the typical clinical profile of the patient with advanced dementia and could be treated in the context of the primary care, since they do not require specific skills belonging to hospital settings.
The predictive value of local to remote functional connectivity changes in comitant exotropia patients
Authors: Chen Ri-Bo , Zhong Yu-Lin , Huang Xin
Published: April 2022

Background

Comitant exotropia (CE) is a common eye disease with abnormal eye movement, whereas altered synchronous neural activity in CE patients is poorly understood. The purpose of our study was to investigate local to remote functional connectivity of blood oxygen level-dependent (BOLD) signals changes in CE patients.

Material and Methods

Thirty-four patients and thirty-four healthy controls (HCs) underwent resting-state MRI scans. The ReHo and FC method was applied to investigate the local to remote functional connectivity changes in CE patients.

Results

Compared to the HC group, CE patients showed significant increased ReHo values in the left cerebellar_crus2 and left middle frontal gyrus. Meanwhile, CE patients showed significant decreased ReHo values in the right middle temporal gyrus, left postcentral gyrus and right angular. Moreover, CE patients showed an increased FC between the cerebellar network, sensorimotor network (SMN) and default-mode network (DMN). The support vector machine (SVM) classification was up to a total accuracy of 94.12%. The AUC of the classification model was 0.99 on the basis of ReHo map.

Conclusion

Our result highlights that CE patients had abnormal local to remote functional connectivity in the cerebellar network, SMN, DMN, which might indicate the neural mechanism of eye movements and stereo vision dysfunction in CE patients. Moreover, the SVM algorithm reveals ReHo maps as a potential biomarker for predicting clinical outcomes in CE patients.
Impact of Medicaid Expansion on the Diagnosis, Treatment, and Outcomes of Stage II and III Rectal Cancer Patients
Authors: Lin Mayin , O’Guinn Makayla , Zipprer Elizabeth , Hsieh John C , Dardon Arturo Torices , Raman Shankar , Foglia Christopher M , Chao Steven Y
Published: April 2022

BACKGROUND:

Insurance status has been associated with disparities in stage at cancer diagnosis. We examined how Medicaid expansion (ME) impacted diagnoses, surgical treatment, use of neoadjuvant therapies (NCRT), and outcomes for Stage II and III rectal cancer.

STUDY DESIGN:

We used 2010-2017 American College of Surgeons National Cancer Database (NCDB) to identify patients ages 18-65, with Medicaid as primary form of payment, and were diagnosed with Stage II or III rectal cancer. Patients were stratified based on Census bureau division’s ME adoption rates of High, Medium, Low. Overall trends were examined, and patient characteristics and outcomes were compared before and after ME date of 1/1/2014.

RESULTS:

Over 8 years of NCDB data examined, there was an increasing trend of Stage II and III rectal cancer diagnoses, surgical resection, and use of NCRT for Medicaid patients. We observed an increase in age, proportion of White Medicaid patients in Low ME divisions, and proportion of fourth income quartile patients in High ME divisions. Univariate analysis showed decreased use of open surgery for all 3 categories after ME, but adjusted odds ratios (aOR) were not significant based on multivariate analysis. NCRT utilization increased after ME for all 3 ME adoption categories and aOR significantly increased for Low and High ME divisions. ME significantly decreased 90-day mortality.

CONCLUSIONS:

Medicaid expansion had important impacts on increasing Stage II and III rectal cancer diagnoses, use of NCRT, and decreased 90-day mortality for patients with Medicaid. Our study supports increasing health insurance coverage to improve Medicaid patient outcomes in rectal cancer care.
Field Trauma Triage among Older Adults: A Cost-Effectiveness Analysis
Authors: Maughan Brandon C , Lin Amber , Caughey Aaron B , Bulger Eileen M , McConnell K John , Malveau Susan , Griffiths Denise , Newgard Craig D
Published: April 2022

BACKGROUND:

National guidelines for prehospital trauma triage aim to identify seriously injured patients who may benefit from transport to trauma centers. These guidelines have poor sensitivity for serious injury among older adults. We evaluated the cost-effectiveness of a high-sensitivity triage strategy for older adults.

STUDY DESIGN:

We developed a Markov chain Monte Carlo microsimulation model to estimate the cost-effectiveness of high-sensitivity field triage criteria among older adults compared with current practice. The model used a retrospective cohort of 3621 community-dwelling Medicare beneficiaries who were transported by emergency medical services after an acute injury in 7 counties in the northwestern US during January to December 2011. These data informed model estimates of emergency medical services triage assessment, hospital transport patterns, and outcomes from index hospitalization up to 1 year after discharge. Outcomes beyond 1 year were modeled using published literature. Differences in cost and quality-adjusted life years (QALYs) were calculated for both strategies using a lifetime analytical horizon. We calculated the incremental cost-effectiveness ratio (cost per QALY gained) to assess cost-effectiveness, which we defined using a threshold of less than $100,000 per QALY.

RESULTS:

High-sensitivity trauma field triage for older adults would produce a small incremental benefit in average trauma system effectiveness (0.0003 QALY) per patient at a cost of $1,236,295 per QALY. Sensitivity analysis indicates that the cost of initial hospitalization and emergency medical services adherence to triage status (ie transporting triage-positive patients to a trauma center) had the largest influence on overall cost-effectiveness.

CONCLUSIONS:

High-sensitivity trauma field triage is not cost-effective among older adults.
Prediction of Posthepatectomy Liver Failure with a Combination of Albumin-Bilirubin Score and Liver Resection Percentage
Authors: Takahashi Kazuhiro , Gosho Masahiko , Kim Jaejeong , Shimomura Osamu , Miyazaki Yoshihiro , Furuya Kinji , Akashi Yoshimasa , Enomoto Tsuyoshi , Hashimoto Shinji , Oda Tatsuya
Published: April 2022

BACKGROUND:

Posthepatectomy liver failure (PHLF) is a main cause of death after partial hepatectomy. The aim of this study was to develop a practical stratification system using the albumin-bilirubin (ALBI) score and liver resection percentage to predict severe PHLF and conduct safe hepatectomy.

METHODS:

Between January 2002 and March 2021, 361 hepatocellular carcinoma (HCC) patients who underwent partial hepatectomy were enrolled. Medical image analysis software was applied postoperatively to accurately simulate hepatectomy. The liver resection percentage was calculated as follows: (postoperatively reconstructed resected specimen volume [ml] – tumor volume [ml])/total functional liver volume (ml) × 100. Multivariate analysis was performed to identify risk factors for PHLF grade B/C. A heatmap for predicting grade B/C PHLF was generated by combining the ALBI score and liver resection percentage.

RESULTS:

Thirty-nine patients developed grade B/C PHLF; 2 of these patients (5.1%) died. Multivariate analysis demonstrated that a high ALBI score and high liver resection percentage were independent predictors of severe PHLF (odds ratio [OR], 8.68, p < 0.001; OR, 1.10, p < 0.001). With a threshold PHLF probability of 50% for the heatmap, hepatectomy was performed for 346 patients meeting our criteria (95.8%) and 325 patients meeting the Makuuchi criteria (90.0%). The positive predictive value and negative predictive value for severe PHLF were 91.6% and 66.7% for our system and 91.7% and 33.3% for the Makuuchi criteria.

CONCLUSION:

Our stratification system could increase the number of hepatectomy candidates and is practical for deciding the surgical indications and determining the upper limit of the liver resection percentage corresponding to each patient’s liver function reserve, which could prevent PHLF and yield better postoperative outcomes.
Novel Way to Improve Satisfaction, Comprehension, and Anxiety in Caregivers: A Randomized Trial Exploring the Use of Comprehensive, Illustrated Children’s Books for Pediatric Surgical Populations
Authors: Baimas-George Maria , Watson Michael , Paton B Lauren , Cosper Graham , Schmelzer Thomas , Schulman Andrew , Bambini Daniel , Matthews Brent
Published: April 2022

BACKGROUND

Surgery generates anxiety and stress, which can negatively impact informed consent and postoperative outcomes. This study assessed whether educational, illustrated children’s books improve comprehension, satisfaction, and anxiety of caregivers in pediatric surgical populations.

METHODS

A prospective randomized trial was initiated at a tertiary care children’s hospital. All patients ≤ 18 years old with caregiver and diagnosis of 1) uncomplicated appendicitis (English or Spanish speaking); 2) ruptured appendicitis; 3) pyloric stenosis; 4) need for gastrostomy tube; or 5) umbilical hernia were eligible. Conventional consent was obtained followed by completion of 17 validated survey questions addressing apprehension, satisfaction, and comprehension. Randomization (2:1) occurred after consent and before operative intervention with the experimental group (EG) receiving an illustrated comprehensive children’s book outlining anatomy, pathophysiology, hospital course, and postoperative care. A second identical survey was completed before discharge. Primary outcomes were caregiver apprehension, satisfaction, and comprehension.

RESULTS

Eighty caregivers were included (55: EG, 25: control group [CG]). There were no significant differences in patient or caregiver demographics between groups. The baseline survey demonstrated no difference in comprehension, satisfaction, or apprehension between groups (all p values NS). After intervention, EG had significant improvement in 14 of 17 questions compared with CG (all p < 0.05). When tabulated by content, there was significant improvement in comprehension (p = 0.0009), satisfaction (p < 0.0001), and apprehension (p < 0.0001).

CONCLUSION

The use of illustrated educational children’s books to explain pathophysiology and surgical care is a novel method to improve comprehension, satisfaction, and anxiety of caregivers. This could benefit informed consent, understanding, and postoperative outcomes.
Impact of the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients: A Randomized Clinical Trial
Authors: Park Shin-Hoo , Huh Hyub , Choi Sung Il , Kim Jong-Han , Jang You-Jin , Park Joong-Min , Kwon Oh Kyoung , Jung Mi Ran , Jeong Oh , Lee Chang Min , Min Jae Seok , Kim Jin-Jo , An Liang , Yang Kyung Sook , Park Sungsoo , Lee Il Ok ,   the Deep Neuromuscular Block on Oncologic Quality of Laparoscopic Surgery in Obese Gastric Cancer Patients (DEBLOQS_GC) Study Group
Published: April 2022

BACKGROUND:

Obesity can hinder laparoscopic procedures and impede oncological safety during laparoscopic cancer surgery. Deep neuromuscular block (NMB) reportedly improves laparoscopic surgical conditions, but its oncological benefits are unclear. We aimed to evaluate whether deep NMB improves the oncologic quality of laparoscopic cancer surgery in obese patients.

STUDY DESIGN:

We conducted a double-blinded, parallel-group, randomized, phase 3 trial at 9 institutions in Korea. Clinical stage I and II gastric cancer patients with a BMI at or above 25 kg m –2 were eligible and randomized 1:1 ratio to the deep or moderate NMB groups, with continuous infusion of rocuronium (0.5–1.0 and 0.1–0.5 mg kg –1 h –1, respectively). The primary endpoint was the number of retrieved lymph nodes (LNs). The secondary endpoints included the surgeon’s surgical rating score (SRS) and interrupted events.

RESULTS:

Between August 2017 and July 2020, 196 patients were enrolled. Fifteen patients were excluded, and 181 patients were finally included in the study. There was no significant difference in the number of retrieved LNs between the deep (N = 88) and moderate NMB groups (N = 93; 44.6 ± 17.5 vs 41.5 ± 16.9, p = 0.239). However, deep NMB enabled retrieving more LNs in patients with a BMI at or above 28 kg/m2 than moderate NMB (49.2 ± 18.6 vs 39.2 ± 13.3, p = 0.026). Interrupted events during surgery were lower in the deep NMB group than in the moderate NMB group (21.6% vs 36.6%; p = 0.034). The SRS was not influenced by NMB depth.

CONCLUSION:

Deep NMB provides potential oncologic benefits by retrieving more LNs in patients with BMI at or above 28 kg/m2 during laparoscopic gastrectomy.
Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury
Authors: Zambetti Benjamin R , Stuber Jacqueline D , Patel Devanshi D , Lewis Richard H , Huang Dih-Dih , Zickler William P , Fischer Peter E , Magnotti Arianna L , Croce Martin A , Magnotti Louis J
Published: April 2022

BACKGROUND:

Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI.

STUDY DESIGN:

Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality.

RESULTS:

Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02).

CONCLUSIONS:

SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.
Gender Disparity in the Citation of Surgical Research
Authors: Kane William J , Hedrick Traci L , Schroen Anneke T
Published: April 2022

BACKGROUND:

Women surgeons face numerous barriers to career advancement. Inequitable citation of surgical literature may represent a contributing factor to gender disparities in academic surgery.

STUDY DESIGN:

This was a cross-sectional analysis of publications from 50 top-ranking surgery journals in 2017 and 2018, as defined by the 2019 InCites Journal Citation Reports. The citation rate of publications by women vs men first authors was compared. Similarly, the citation rate of publications by men vs women last authors was also compared. Adjusted regression analyses of citation rates accounted for the time interval since publication as well as the journal within which the article was published, among other potential confounding factors.

RESULTS:

A total of 19,084 publications from 48 surgery journals with a median (interquartile range) of 8 (4 to 15) citations contributing to a median (interquartile range) Journal Impact Factor of 4.0 (3.4 to 4.6) were analyzed. Compared with man-first author publications, woman-first author publications demonstrated a 9% lower citation rate (incidence rate ratio 0.91, p < 0.001). Similarly, compared with publications by man-last authors, woman-last author publications demonstrated a 4% lower citation rate (incidence rate ratio 0.96, p = 0.03). These associations persisted after multivariable adjustment for additional confounding factors, however, not on sensitivity analysis of 24 of the highest-ranking journals.

CONCLUSIONS:

Among top-tier surgical journals, publications by women-first and -last authors were less cited compared with publications by men-first and -last authors, but not among the highest-tier surgical journals. Gender bias may exist in the citation of surgical research, contributing to gender disparities in academic surgery.
Individual and Institutional Factors Associated with PGY5 General Surgery Resident Self-Efficacy: A National Survey
Authors: Kearse LaDonna E , Schmiederer Ingrid S , Dent Daniel L , Anderson Tiffany N , Payne Davis H , Jensen Rachel , Trickey Amber W , Ding Qian , Korndorffer James R
Published: April 2022

BACKGROUND:

Variability in post-graduate year 5 (PGY5) residents’ operative self-efficacy exists; yet the causes of variability have not been explored. Our study aims to determine resident-related and program-dependent factors associated with residents’ perceptions of self-efficacy.

STUDY DESIGN:

Following the 2020 American Board of Surgery In-Training Examination, a national survey of self-efficacy in 10 of the most commonly performed Accreditation Council for Graduate Medical Education case-log procedures was completed.

RESULTS:

A total of 1,145 PGY5 residents completed the survey (response rate 83.8%), representing 296 surgical residency programs. Female sex (odds ratio [OR] 0.46 to 0.67; 95% CI 0.30 to 0.95; p < 0.05) was associated with decreased self-efficacy for 6 procedures. Residents from institutions with emphasis on autonomy were more likely to report higher self-efficacy for 8 of 10 procedures (OR 1.39 to 3.03; 95% CI 1.03 to 4.51; p < 0.05). In addition, increased socialization among residents and faculty also correlated with increased self-efficacy in 3 of 10 procedures (OR 1.41 to 2.37; 95% CI 1.03 to 4.69; p < 0.05). Procedures performed with higher levels of resident responsibility, based on Graduated Levels of Resident Responsibility (GLRR) and Teaching Assistant (TA) scores, were correlated with higher self-efficacy (p < 0.001).

CONCLUSION:

Ensuring that residents receive ample opportunities for GLRR and TA experiences, while implementing programmatic support for resident-dependent factors, may be crucial for building self-efficacy in PGY5 residents. Institutional support of resident “autonomy” and increasing methods of socialization may provide a means of building trust and improving perceptions of self-efficacy. In addition, reevaluating institutional policies that limit opportunities for graduated levels of responsibility, while maintaining patient safety, may lead to increased self-efficacy.
Neoadjuvant Therapy for Pancreatic Cancer: Increased Use and Improved Optimal Outcomes
Authors: Davis Catherine H , Beane Joal D , Gazivoda Victor P , Grandhi Miral S , Greenbaum Alissa A , Kennedy Timothy J , Langan Russell C , August David A , Alexander H Richard , Pitt Henry A
Published: April 2022

BACKGROUND:

The introduction of more effective chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to assess the evolving use of NAT in individuals with PDAC undergoing pancreatoduodenectomy (PD) and to compare their outcomes with patients undergoing upfront operation.

STUDY DESIGN:

The American College of Surgeons NSQIP Procedure Targeted Pancreatectomy database was queried from 2014 to 2019. Patients undergoing pancreatoduodenectomy were evaluated based on the use of NAT versus upfront operation. Multivariable analysis was performed to determine the effect of NAT on postoperative outcomes, including the composite measure optimal pancreatic surgery (OPS). Mann-Kendall trend tests were performed to assess the use of NAT and associated outcomes over time.

RESULTS:

A total of 13,257 patients were identified who underwent PD for PDAC between 2014 and 2019. Overall, 33.6% of patients received NAT. The use of NAT increased steadily from 24.2% in 2014 to 42.7% in 2019 (p < 0.0001). On multivariable analysis, NAT was associated with reduced serious morbidity (odds ratio [OR] 0.83, p < 0.001), clinically relevant pancreatic fistulas (OR 0.52, p < 0.001), organ space infections (OR 0.74, p < 0.001), percutaneous drainage (OR 0.73, p < 0.001), reoperation (OR 0.76, p = 0.005), and prolonged length of stay (OR 0.63, p < 0.001). OPS was achieved more frequently in patients undergoing NAT (OR 1.433, p < 0.001) and improved over time in patients receiving NAT (50.7% to 56.6%, p < 0.001).

CONCLUSION:

NAT before pancreatoduodenectomy increased more than 3-fold over the past decade and was associated with improved optimal operative outcomes.
Using Process Flow Disruption Analysis to Guide Quality Improvement
Authors: Slakey Douglas P , Sargut Gökçe , Glowacki Nicole E , Katoozian Parisa Y , Baylis William J , Anderson Edwin J
Published: April 2022

BACKGROUND:

Process flow describes the efficiency and consistency with which a process functions. Disruptions in surgical flow have been shown to be associated with an increase in error. Despite this, little experience exists in using surgical flow analysis to guide quality improvement (QI).

STUDY DESIGN:

In a 900-bed teaching hospital with an annual surgical volume of 24,000 cases, a 4-month observational study of process flow was done by experts in complex system evaluation. Identified flow disruptions were used to guide QI. Statistical analysis included descriptive and bivariate techniques.

RESULTS:

More than 200 unique process data points were evaluated. There was a high degree of variability in completion of 79 individual intraoperative data elements. Lack of completion of all elements of the time out was associated with number of times the operating room door opened during case (19, 11–27; p = 0.01). Flow disruptions were used to direct surgical QI. One example was a disruption affecting the use of Sugammadex. Resolving this flow disruption resulted in a 59% reduction in the incidence of postoperative respiratory failure (p < 0.01) and a direct and variable cost savings of $447,200 and $313,160, respectively, in the first 12 months.

CONCLUSIONS:

The use of process flow analysis to direct surgical quality initiatives is a novel approach that emphasizes system-level strategy. Resolving flow disruptions can lead to effective QI that embraces reliability by focusing attention on common processes rather than adverse events that may be unique and therefore difficult to apply broadly.
Machine Learning Refinement of the NSQIP Risk Calculator: Who Survives the “Hail Mary” Case?
Authors: Rogers Michael P , Janjua Haroon , DeSantis Anthony J , Grimsley Emily , Pietrobon Ricardo , Kuo Paul C
Published: April 2022

BACKGROUND:

The American College of Surgeons (ACS) NSQIP risk calculator helps guide operative decision making. In patients with significant surgical risk, it may be unclear whether to proceed with “Hail Mary”–type interventions. To refine predictions, a local interpretable model-agnostic explanations machine (LIME) learning algorithm was explored to determine weighted patient-specific factors’ contribution to mortality.

STUDY DESIGN:

The ACS-NSQIP database was queried for all surgical patients with mortality probability greater than 50% between 2012 and 2019. Preoperative factors (n = 38) were evaluated using stepwise logistic regression; 26 significant factors were used in gradient boosted machine (GBM) modeling. Data were divided into training and testing sets, and model performance was substantiated with 10-fold cross validation. LIME provided individual subject mortality. The GBM-trained model was interpolated to LIME, and predictions were made using the test dataset.

RESULTS:

There were 6,483 deaths (53%) among 12,248 admissions. GBM modeling displayed good performance (area under the curve = 0.65, 95% CI 0.636–0.671). The top 5 factors (% contribution) to mortality included: septic shock (27%), elevated International Normalized Ratio (22%), ventilator-dependence (14%), thrombocytopenia (14%), and elevated serum creatinine (5%). LIME modeling subset personalized patients by factors and weights on survival. In the entire cohort, mortality positive predictive value with 2 factor combinations was 53.5% (specificity 0.713), 3 combinations 64.2% (specificity 0.835), 4 combinations 72.1% (specificity 0.943), and all 5 combinations 77.9% (specificity 0.993). Conversely, mortality positive predictive value fell to 34% in the absence of 4 factors.

CONCLUSIONS:

Through the application of machine learning algorithms (GBM and LIME), our model individualized predicted mortality and contributing factors with substantial ACS-NSQIP predicted mortality. USE of machine learning techniques may better inform operative decisions and family conversations in cases of significant surgical risk.
Disparity in Clinical Trial Participation Among Patients with Gastrointestinal Cancer
Authors: Abbas Alizeh , Diaz Adrian , Obeng-Gyasi Samilia , Cloyd Jordan M , Ejaz Aslam , Stewart John H , Pawlik Timothy M
Published: April 2022

BACKGROUND:

Clinical trial participation among cancer patients remains low. We sought to examine the impact of patient- and system-level factors on clinical trial participation among gastrointestinal (GI) surgical patients.

STUDY DESIGN:

Adult patients with a GI cancer who underwent oncologic surgery who were enrolled in National Cancer Institute (NCI)–funded clinical trials from 2000 through 2019 were compared with trial-eligible adult patients in the National Cancer Database (NCDB) between 2004 and 2017. Multivariable logistic regression was used to identify factors associated with clinical trial participation.

RESULTS:

Participants from 36 NCI-funded clinical trials (n = 10,518) were compared with 2,255,730 trial-eligible nonparticipants from the NCDB. Patients aged 65 years or younger (odds ratio [OR] = 0.5, 95% CI 0.47–0.53), Medicare (OR = 0.46, 95% CI 0.43–0.49) or Medicaid (OR = 0.51, 95% CI 0.46–0.58) insurance, as well as lower levels of education (OR = 0.82, 95% CI 0.75–0.89) were associated with a lower likelihood of clinical trial enrollment. Black (OR = 0.72, 95% CI 0.67–0.78) and Asian/Pacific Islander (OR = 0.96, 95% CI 0.85–1.08) patients were less likely to participate in trials vs White patients. There were interactions between race/ethnicity and income; high-income (OR = 0.67, 95% CI 0.55–0.81) and low-income Black (OR = 0.75, 95% CI 0.66–0.87) patients were less likely, respectively, to participate than high- or low-income White individuals (p < 0.001).

CONCLUSIONS:

Clinical trial participation is low among adult GI cancer patients who undergo surgery in the US. Programs aimed at improving trial participation among vulnerable populations are needed to improve trial participation.