bluuebunny/crossref_metadata_2025 huggingface dataset:
Várzeas construídas como Soluções Baseadas na Natureza (SbN) para readequação de rios e córregos urbanos
Authors: Belini João Pedro Coelho , Gonçalves Filipe Chaves , Garcia Joaquin Ignacio Bonnecarrère
Published: November 2022

A abordagem adaptativa do planejamento urbano busca construir uma capacidade de resiliência como etapa prévia para sustentabilidade. Em sintonia, o estudo adotou as Soluções Baseadas na Natureza (SbN) para propor a Readequação de rios e córregos urbanos, aliando interesses ambientais e socioeconômicos. Propôs-se assim a utilização de Sistemas de Tratamento por Várzeas Construídas (STVC). Estes congregam as funções das várzeas naturais, elementos da geomorfologia fluvial que são desconsiderados na drenagem urbana convencional, sendo otimizadas por elementos da Engenharia. Assim, como hipótese de pesquisa, considerou-se que os STVC atuariam no tratamento das águas pluviais, diminuindo a carga de poluição difusa carreada até os corpos hídricos pelo sistema convencional de drenagem. Além disso, que sua utilização também corroboraria com a retenção temporária de parte do volume escoado na bacia urbana, favorecendo sua infiltração. Logo, a proposição teve como objetivo aliar tanto o controle quantitativo como, principalmente, o qualitativo das águas urbanas, atuando como barreira protetora do ecossistema aquático. A concepção dos STVC se alinha ainda com o que propõe os Objetivos do Desenvolvimento Sustentável, ODS, propostos pela ONU. E, para verificação da hipótese inicial de atuação combinada quali-quantitativa, realizou-se revisão bibliográfica sobre as potencialidades da implantação de tais sistemas e a consideração do estudo de cenários. As conclusões do estudo permitem destacar o potencial, em termos da drenagem urbana sustentável, que os STVC conferem. Logo, acredita-se que um melhor detalhamento técnico, obtido pela implantação dos sistemas em escala real, pode gerar resultados que validem sua aplicação.
Advances in Cardiac Electrophysiology
Authors: Piccini Jonathan P. , Russo Andrea M. , Sharma Parikshit S. , Kron Jordana , Tzou Wendy , Sauer William , Park David S. , Birgersdotter-Green Ulrika , Frankel David S. , Healey Jeff S. , Hummel John , Koruth Jacob , Linz Dominik , Mittal Suneet , Nair Devi G. , Nattel Stanley , Noseworthy Peter A. , Steinberg Benjamin A. , Trayanova Natalia A. , Wan Elaine Y. , Wissner Erik , Zeitler Emily P. , Wang Paul J.
Published: November 2022

Despite the global COVID-19 pandemic, during the past 2 years, there have been numerous advances in our understanding of arrhythmia mechanisms and diagnosis and in new therapies. We increased our understanding of risk factors and mechanisms of atrial arrhythmias, the prediction of atrial arrhythmias, response to treatment, and outcomes using machine learning and artificial intelligence. There have been new technologies and techniques for atrial fibrillation ablation, including pulsed field ablation. There have been new randomized trials in atrial fibrillation ablation, giving insight about rhythm control, and long-term outcomes. There have been advances in our understanding of treatment of inherited disorders such as catecholaminergic polymorphic ventricular tachycardia. We have gained new insights into the recurrence of ventricular arrhythmias in the setting of various conditions such as myocarditis and inherited cardiomyopathic disorders. Novel computational approaches may help predict occurrence of ventricular arrhythmias and localize arrhythmias to guide ablation. There are further advances in our understanding of noninvasive radiotherapy. We have increased our understanding of the role of His bundle pacing and left bundle branch area pacing to maintain synchronous ventricular activation. There have also been significant advances in the defibrillators, cardiac resynchronization therapy, remote monitoring, and infection prevention. There have been advances in our understanding of the pathways and mechanisms involved in atrial and ventricular arrhythmogenesis.
First Randomized, Multicenter, Placebo-Controlled Study of Self-Administered Intranasal Etripamil for Acute Conversion of Spontaneous Paroxysmal Supraventricular Tachycardia (NODE-301)
Authors: Stambler Bruce S. , Plat Francis , Sager Philip T. , Shardonofsky Silvia , Wight Douglas , Potvin Diane , Pandey A. Shekhar , Ip James E. , Coutu Benoit , Mondésert Blandine , Sterns Laurence D. , Bennett Matthew , Anderson Jeffrey L. , Damle Roger , Haberman Ronald , Camm A. John
Published: November 2022

Background:

Pharmacologic termination of paroxysmal supraventricular tachycardia (PSVT) often requires medically supervised intervention. Intranasal etripamil, is an investigational fast-acting, nondihydropyridine, L-type calcium channel blocker, designed for unsupervised self-administration to terminate atrioventricular nodal–dependent PSVT. Phase 2 results showed potential safety and efficacy of etripamil in 104 patients with PSVT.

Methods:

NODE-301, a phase 3, multicenter, double-blind, placebo-controlled study evaluated the efficacy and safety of etripamil nasal spray administered, unsupervised in patients with symptomatic sustained PSVT. After a medically supervised etripamil test dose while in sinus rhythm, patients were randomized 2:1 to receive etripamil 70 mg or placebo. When PSVT symptoms developed, patients applied a cardiac monitor and attempted a vagal maneuver; if symptoms persisted, they self-administered blinded treatment. An independent Adjudication Committee reviewed continuous electrocardiogram recordings. The primary efficacy endpoint was termination of adjudicated PSVT within 5 hours after study drug administration.

Results:

NODE-301 accrued 156 positively adjudicated PSVT events treated with etripamil (n=107) or placebo (n=49). The hazard ratio for the primary endpoint, time-to-conversion to sinus rhythm during the 5-hour observation period, was 1.086 (95% CI, 0.726–1.623;
P
=0.12). In predefined sensitivity analyses, etripamil effects (compared with placebo) occurred at 3, 5, 10, 20, and 30 minutes (
P
<0.05). For example, at 30 minutes, there was a 53.7% of SVT conversion in the treatment arm compared to 34.7% in the placebo arm (hazard ratio, 1.87 [95% CI, 1.09–3.22];
P
=0.02). Etripamil was well tolerated; adverse events were mainly related to transient nasal discomfort and congestion (19.6% and 8.0%, respectively, of randomized treatment-emergent adverse events.

Conclusions:

Although the primary 5-hour efficacy endpoint was not met, analyses at earlier time points indicated an etripamil treatment effect in terminating PSVT. Etripamil self-administration during PSVT was safe and well tolerated. These results support continued clinical development of etripamil nasal spray for self-administration during PSVT in a medically unsupervised setting.

Registration:

URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT03464019.
The Influence of the Dimensions of Perceived Value on Keepers’ Satisfaction and Intention to Abandon
Authors: Luna-Cortés Gonzalo
Published: November 2022

This research examines the effect of dimensions of keepers’ perceived value (utilitarian, emotional, social) of their dogs on the dogs’ behavioral problems, keepers’ satisfaction, and intent to abandon their dogs, using confirmatory factor analysis (CFA) and structural equation modeling (SEM). A questionnaire was administered to 330 keepers walking their dogs in a national park in Bogotá, Colombia, which examined their perceptions of and attitudes toward their dogs. Keepers who placed a higher utilitarian value on their dog were more satisfied with their dog. Positive feelings toward their dogs (emotional value) negatively affected the keepers’ intention to abandon their dogs. Contrary to prior findings, the social value of dogs did not influence dogs’ behavioral problems. Finally, as expected, dogs’ behavioral problems negatively influenced keepers’ satisfaction, which affected keepers’ intention to abandon their dogs. Theoretical and practical implications of the dimensions of perceived value in the field of dogs’ welfare are discussed.
Description and molecular characterisation of Ditylenchus pedrami n. sp. (Rhabditida: Anguinidae) from Iran
Authors: Azimi Sedighe , Abdolkhani Abbas
Published: November 2022

Ditylenchus pedrami n. sp., recovered from the rhizospheric soil of date palm in Khuzestan province, southwest Iran, is described and illustrated based upon morphological and molecular data. The new species is characterised by having six lines in the lateral field, lip region smooth and continuous with body contour, stylet 9-11 μm long, median pharyngeal bulb oval with small valve, pharyngeal bulb offset from the intestine, V = 83.9 (80.2-88.1), conoid tail with a pointed, dull or rounded tip and males with 20.1 (17-24) μm long spicules. Morphologically, the new species comes close to D. africanus, D. anchilisposomus, D. australiae, D. clarus, D. clavicaudatus and D. parcevivens, mainly by having shared features like six lines in the lateral fields, stylet length and somewhat similar tail tip. The new species was also compared with D. stenurus and D. sarvarae, two species with close phylogenetic affinities to it. The phylogenetic relationships of the new species with representatives of the family Anguinidae were reconstructed and discussed using partial sequences of the small subunit, D2-D3 expansion segments of the large subunit, and internal transcribed spacer regions of ribosomal DNA (SSU, LSU D2-D3 and ITS rDNA) based on Bayesian inference (BI).
Of Men and Dogs
Authors: Minov Sergey
Published: November 2022

This article contains the unpublished Syriac text of the Story of the Dog Who Talked. Put down in writing by the West Syrian monk ʿAzīz bar Ṣlīḇā bar Bassūs in the year 1503, the Story is, arguably, the earliest datable specimen of the fairy tale genre of folklore attested in the Syriac language. The text of the Story, published on the basis of manuscript Mardin, Church of the Forty Martyrs, 350, is accompanied by an English translation and discussion.
The Epistemic Responsibilities of Voters: Towards an Assertion-Based Account
Authors: Giavazzi Michele
Published: November 2022

It is often claimed that democratic voters have epistemic responsibilities. However, it is not often specified why voters have such epistemic responsibilities.

In this paper, I contend that voters have epistemic responsibilities because voting is best understood as an act that bears assertoric force. More precisely, voters perform what I call an act of political advocacy whereby, like an asserter who states or affirms that something is the case, they state or affirm that a certain course of political action is the one that should be followed or enacted.

Consequently, the performance of acts of political advocacy such as voting should be understood as bounded by epistemic norms mirroring those binding the act of assertion and yield epistemic responsibilities mirroring the ones required to satisfy these norms.
The Biography of Muḥammad b. Ibrāhīm al-Nuʿmānī
Authors: Rezaei Azadeh
Published: November 2022

Muḥammad b. Ibrāhīm al-Nuʿmānī, al-Kātib, (d. before 360/971) is a venerable Imāmī traditionist for his celebrated work the Kitāb al-ghayba—a compilation of nearly 445 traditions to demonstrate the occultation of the twelfth Imam and his parousia in the last days of history. Although some monographical studies have been done on this author and his work, the biographical questions about the Imāmī community that he came from, the first places from where he started his Ḥadīth study, and the connection between his being kātib by profession and his learning traditions remained unanswered. The present article is an endeavor to present a more complete biography of al-Nuʿmānī. It consists of an examination of the socioreligious milieu of his hometown al-Nuʿmāniyya, the different places that he visited to his teachers, some fragmentary information about his grandson Abū l-Qāsim al-Maghribī, his stay in Aleppo, his works and pupils, and a more plausible date of his death in Aleppo.
Advances in the Diagnosis and Excision of Breast Cancer
Authors: Klimberg V. Suzanne
Published: November 2022

Until recently little advance in the diagnosis and excision of breast cancer has been made since the inception of needle localization breast biopsy (NLBB). Stereotactic core needle breast biopsy (SCNBB) can avoid most NLBB especially for calcifications. However, when open biopsy is necessary NLBB has been the standard of care. As many as 50 per cent of nonpalpable lesions can be seen by ultrasound (US) to avoid the unpleasantness and complications associated with NLBB. Further SCNBB leaves a blood-filled cavity that can be easily seen by US. Intraoperative US can be used to direct the excision while improving margin negativity. MRI has improved sensitivity in detecting suspicious breast lesions and techniques such as hematoma-directed US-guided breast biopsy can facilitate excision of such masses. Clearly new technologies have improved the ability to diagnosis and excise breast cancer. The onus on the surgeon is to incorporate them into standard practice to improve outcomes.
The Future of Clinical Cancer Management: One Tumor, One Chip
Authors: Yeatman Timothy J.
Published: November 2022

Recent advances in gene expression profiling technology have now made it feasible to consider using microarray technology in the routine management of the cancer patient. Microarray chips are now capable of interrogating up to 48,000 or more different genes in a single experiment using multiple platforms. Sophisticated data analysis has already demonstrated that multiple tumor types can be distinguished on the basis of their gene expression patterns. These analyses have led to the detection of new tumor markers and markers of tumor progression. Gene expression arrays have also been demonstrated to be capable of predicting the survival of patients with breast cancer, lung cancer, brain cancer, and acute lymphocytic leukemia. The future holds great promise for the rapid development of molecular medicine with diagnosis, prognosis, and even therapy being based on a single microarray chip. These developments signal a significant paradigm shift in the clinical management of human cancer.
Two Decades of Student Career Choice at the University of Florida: Increasingly a Lifestyle Decision
Authors: Lind D. Scott , Cendan Juan C.
Published: November 2022

Recently, there has been a decrease in the number of graduating U.S. medical students entering surgical residency. Therefore the purpose of this study was to examine student career choice over the last two decades (1982–2002) at the University of Florida. Residency match and academic performance data for the University of Florida medical school graduates from 1982 through 2002 were obtained from the College of Medicine's Offices of Student Affairs and Education. The percentage of medical students pursuing a career in surgery rose slightly in the 1980s to peak at 22 per cent of the graduating class in 1991 and then steadily declined in the 1990s to 15 per cent in the graduating class of 2002. The percentage of women entering surgical residency has remained relatively constant (20-year mean = 6.41 ± 0.77) despite a significant increase percentage of women in the graduating class (Class of 1983, 24%; Class of 2002, 55%). The percentage of graduating students entering a primary care residency has remained relatively constant (54.4 ± 1.24), whereas the number of students pursuing a “lifestyle-friendly” specialty has increased substantially over the last two decades (Class of 1983, 9%; Class of 2002, 22%). In addition the mean overall grade point average of female students entering ‘lifestyle-friendly’ specialty residencies is significantly higher than the mean overall grade point average of all students entering a surgical residency (3.61 ± 0.38 versus 3.48 ± 0.35; P < 0.05). Similar to national trends the percentage of senior medical students entering surgical residency at the University of Florida is gradually declining. Although the percentage of graduating medical students entering primary care has remained relatively constant the number of students following a lifestyle-friendly specialty has steadily increased. A disproportionately low number of graduating female medical students are entering surgical residency. By one measure of academic performance the quality of female graduates entering lifestyle-friendly specialty residencies is superior to that of students entering surgical residency. Lifestyle issues are increasingly important in student career choice decisions.
Retrograde Intussusception of the Efferent Limb after a Pancreaticojejunostomy
Authors: Whipple Oliver C. , Stringer E.F. , Senkowski Christopher K. , Hartley Michael
Published: November 2022

Retrograde intussusception is exceedingly rare and has not been reported after a pancreaticojejunostomy. Recurrent retrograde intussusception has been reported only once before. In adults retrograde intussusception has been associated with gastric resection, gastrojejunostomy, Roux- en-Y gastric bypass, and gastrostomy tube placement. We report a case of retrograde intussusception of the efferent limb into the anastomosis of a revised Roux- en-Y bypass of the pancreas. Two long side-to-side anastomoses with plication were performed to prevent a third episode of intussusception involving this patient's Roux- en-Y.
A Prospective Evaluation of a Bedside Technique for Placement of Inferior Vena Cava Filters: Accuracy and Limitations of Intravascular Ultrasound
Authors: Gamblin T. Clark , Ashley Dennis W. , Burch Shelia , Solis Maurice
Published: November 2022

Our objective was to evaluate the safety and accuracy of a bedside technique for placing vena cava filters with intravascular ultrasonography. We conducted a prospective case series of 36 patients requiring prophylactic vena cava filter placement. Intravascular ultrasound (IVUS) was used to assess the best location for inferior vena cava filter placement. Location of best filter placement was compared with a bedside technique using a fluoroscopic examination. Thirty-six patients underwent an IVUS examination. The 21 men and 15 women had a mean age of 51 years. Our bedside placement technique was successfully performed in 34 patients. Two patients did not undergo a bedside technique because of inadequate imaging. The difference between best filter placement and bedside technique was 1.22 ± 1.24 cm. In three patients our bedside technique differed from best filter placement by more than 3 cm. Excluding these three patients the difference between best filter placement and bedside technique was 0.92 ± 0.79 cm. This bedside IVUS technique for placement of inferior vena cava filters is established as safe and accurate; however, knowledge of the limitations involving the technique is important.
Impact of Hypercalcemia and Parathyroid Hormone Level on the Sensitivity of Preoperative Sestamibi Scanning for Primary Hyperparathyroidism
Authors: Parikshak Manesh , Castillo Eduardo D. , Conrad Mark F. , Talpos Gary B.
Published: November 2022

Technetium 99m sestamibi scanning (MIBI) can direct unilateral parathyroidectomy. However, the clinical application remains variable with sensitivities ranging from 55 to 100 per cent. We examined whether patient factors including serum calcium (Ca) and parathyroid hormone (PTH) levels impact the sensitivity of MIBI. We completed a retrospective review of 102 patients with primary hyperparathyroidism and mild hypercalcemia who underwent preoperative MIBI. All patients underwent bilateral neck explorations with abnormalities confirmed by histopathology. MIBI sensitivity was correlated with preoperative Ca and PTH levels using univariate and logistic regression analysis. The mean preoperative Ca was 11.0 mg/dL and the mean PTH was 158 pg/mL. More than 95 per cent of patients with Ca greater than 11.3 mg/dL had a positive scan as compared with 60 per cent of those with lesser values ( P = 0.0024). Similarly a serum PTH level greater than 160 pg/mL correlated with positive scans in 93 per cent as opposed to 57 per cent in those with lower levels ( P = 0.006). Using a scan-directed approach 65 of 74 patients would have undergone unilateral exploration; this would yield a 7.7 per cent operative failure rate because of contralateral multigland disease. Lower Ca and PTH levels seem to correlate with reduced sensitivity of MIBI. Increasing acceptance of surgery for hyperparathyroidism with minimal hypercalcemia may make MIBI less attractive without ancillary diagnostic measures such as rapid parathormone assays.
Presentation and Treatment of Venomous Snakebites at a Northern Academic Medical Center
Authors: Cowles Robert A. , Colletti Lisa M.
Published: November 2022

Poisonous snakebites are relatively rare in the United States. The incidence of venomous snakebites is comparatively high in the southern states compared with the northern states and reports of these accidents from northern states is particularly uncommon. We report the experience with treatment of venomous snakebites at the University of Michigan over a 25-year period from 1976 to 2001. Six cases were identified and are described in detail. All patients were male and all were bitten in the upper extremity by pit vipers. One patient suffered a moderate envenomation and was treated with antivenin. Four other cases of mild envenomation occurred and two of these cases required antivenin therapy. One case was considered to represent a “dry” bite and required only 24-hour observation. There were no severe envenomations and no mortalities. On short-term follow-up all patients recovered without sequelae. This report demonstrates that venomous snakebites can be treated effectively at low-volume centers.
The Impact of Pelvic and Lower Extremity Fractures on the Incidence of Lower Extremity Deep Vein Thrombosis in High-Risk Trauma Patients
Authors: Britt Stephen L. , Barker Donald E. , Maxwell Robert A. , Ciraulo David L. , Richart Charles M. , Burns R. Phillip
Published: November 2022

Lower extremity fractures (LEFx) and pelvic fractures (PFx) are believed to increase the risk of lower extremity deep vein thrombosis (LEDVT). We studied trauma patients at high risk for LEDVT to determine whether an increased incidence of LEDVT was associated with LEFx and/or PFx. From January 1995 through December 1997 4163 trauma patients were admitted to our Level I trauma center. One thousand ninety-three patients at high risk for LEDVT were screened with serial lower extremity venous duplex ultrasound. Their medical records were retrospectively reviewed for demographics, mechanism of injury, and fracture data. The occurrence of LEDVT, pulmonary embolus, and LEDVT prophylaxis and treatment were noted. The incidence of LEDVT in the fracture group (Fx) was compared with that in the nonfracture group (NFx) using chi-square analysis and logistic regression. Statistical significance was set at ≤0.05. Complete data were available for 1059 of 1093 patients. Five hundred sixty-nine (53.73%) patients had PFx and/or LEFx, 151 (14.26%) patients had PFx only, 317 (29.3%) patients had LEFx only, and 101 (9.54%) patients had both PFx and LEFx. Four hundred ninety (46.27%) patients had NFx. In 1059 patients LEDVT was detected in 125 (11.8%). Sixty-three patients in the Fx groups developed LEDVT (50.4%): 19 (15.2%) PFx patients, 15 (12.0%) PFx/LEFx patients, and 29 (23.2%) LEFx patients. Sixty-two (49.6%) NFx patients developed LEDVT. LEDVT incidence was not significantly different between the Fx and NFx groups or among the PFx, LEFx, and PFx/LEFx groups ( P = 0.317). Nine patients developed pulmonary embolism: four NFx patients, two LEFx patients, two PFx patients, and one PFx/LEFx patient. Significant predictors of LEDVT were age and hospital length of stay. Mean age in patients with LEDVT was 47.58 years and in patients without LEDVT it was 40.89 years ( P < 0.001). Mean hospital length of stay in patients with LEDVT was 29.81 days and in patients without LEDVT it was 16.84 days. The power of this study to detect differences representing medium effect sizes was greater than 90 per cent. We conclude that LEFx and/or PFx was not associated with an increased incidence of LEDVT in trauma patients at high risk for LEDVT. Lower extremity venous duplex ultrasound needs to be performed in both Fx and NFx groups to detect LEDVTs.
Clinical Characteristics and Outcomes of Surgical Patients with Vancomycin-Resistant Enterococcal Infections
Authors: Joels Charles S. , Matthews Brent D. , Sigmon Lee B. , Hasan Reem , Lohr Charles E. , Kercher Kent W. , Norton James , Sing Ronald F. , Heniford B. Todd
Published: November 2022

The purpose of this study is to determine risk factors associated with mortality in surgical patients with vancomycin-resistant enterococcus (VRE) infections. The hospitalizations of surgical patients with VRE infections from January 1998 to December 2001 were reviewed. Statistical analysis was performed using the Student's t test, chi square, and Fisher's exact test. Thirty-one surgical patients (male:female, 14:17) with a mean age of 51.9 years (range, 21–83 years) developed VRE infection. Infections included bacteremia (12), urinary tract (11), surgical site (seven), and soft tissue (five) infections and intra-abdominal abscess (one). Nine (29.0 per cent) patients received recent outpatient antibiotics and 20 (64.5 per cent) were on steroids. Fifteen (48.4 per cent) patients were treated with intravenous vancomycin before infection. Twelve (38.1 per cent) patients died with a trend toward advanced age (60.7 vs 46.5 years; P = 0.06). The incidence of VRE infection in kidney transplant patients was 1.8 per cent. Six transplant patients (five kidney and one kidney/pancreas) developed VRE infections with four deaths. Hypertension ( P = 0.04), coronary artery disease ( P = 0.02), and the need for intra-arterial pressure monitoring ( P = 0.04) were associated with mortality. Isolate location, gender, diabetes, renal dysfunction, respiratory disease, liver disease, and serum albumin were not associated with mortality. Kidney transplant patients have a high incidence of VRE infection. Surgical patients with VRE infections have a high mortality rate. Hypertension and coronary artery disease are risk factors for mortality.
Effect of Massage Technique on Sentinel Lymph Node Mapping for Cancer of the Breast
Authors: Haynes Georgia , Garske Diane , Case Doug , Shen Perry , Levine Edward A. , Perrier Nancy D.
Published: November 2022

Sentinel lymph node (SLN) mapping has substantially changed the nature of surgery for cancer of the breast. Variables such as tracer type, volume, injection site, timing, and surgical experience have all been extensively evaluated. However, little attention has been paid to the technique of massage for SLN procedures. We sought to evaluate the effects of three different massage techniques on mapping success or accuracy of SLN mapping for breast cancer. All lymphatic mapping procedures for breast cancer at our tertiary-care center were performed by three experienced surgeons using both colloid and dye followed by a 5-minute massage. All data pertaining to SLN identification, histopathology, tumor characteristics, and patient demographics were entered into the Breast Care Center database. Consistent and uniquely differing massage techniques classified as resuscitative, buffer, or knead-like were each used by a specific surgeon. The last 25 consecutive cases performed by two surgeons and the last 24 by one surgeon were evaluated. The overall rate of SLN identification was 97 per cent, and the overall accuracy was 98.7 per cent. There was no statistically significant difference in the rate of SLN identification or accuracy between techniques. The proportions of blue-stained SLNs were similar, but the resuscitative technique yielded fewer hot SLNs (Fisher's exact test, P = 0.02). This method also yielded one false negative case. The three different massage techniques yielded a similar number of blue-stained SLNs. The resuscitative technique yielded fewer hot SLNs than the kneading and buffer methods. Our results failed to demonstrate a superior breast massage technique for identifying sentinel nodes. A larger randomized trial is needed to confirm these findings.
Traumatic Pseudoaneurysm of the Brachiocephalic Artery following Medianoscopy: Initial Endovascular Repair Followed by Open Surgery—A Case Report
Authors: Biebl Matthias , Neuhauser B. , Perkmann R. , Tauscher T. , Waldenberger P. , Fraedrich G.
Published: November 2022

Endovascular stent graft repair of traumatic vessel injuries is gaining worldwide acceptance as a minimally invasive alternative to open surgical repair. However, effective endovascular repair fails if the aneurysm is not completely excluded. Conversion to open surgery may be unavoidable in such cases. Herein we describe the case of a 45-year-old man who was referred to our hospital with a pseudoaneurysm of the proximal brachiocephalic artery caused by biopsy during diagnostic medianoscopy. The pseudoaneurysm was primarily treated by stent-graft implantation into the proximal brachiocephalic artery. As a result of the unfavorable location of the lesion exclusion of the aneurysm failed and the initial therapy had to be extended to open reconstruction of the brachiocephalic artery. A bypass procedure from the aortic arch to the right common carotid artery was performed with reinsertion of the right subclavian artery to exclude the pseudoaneurysm.
Inferior Vena Cava Filter Placement: Preinsertion Inferior Vena Cava Imaging
Authors: Matthews Brent D. , Joels Charles S. , Lequire Mark H.
Published: November 2022

Imaging of the vena vava prior to the insertion of an inferior vena vava (IVC) filter is mandatory to assess IVC diameter and patency, delineate anatomy and venous anomalies, and to direct filter placement for appropriate deployment and avoidance of complications. The standard imaging technique is vena cavography, although alternative methods to evaluate the inferior vena cava include carbon dioxide venography, transabdominal duplex ultrasound, and intravascular ultrasound. This manuscript will review the anatomical features, technique, and complications of pre-insertion inferior vena cava imaging and discuss alternative methods to evaluate the inferior vena cave prior to filter insertion.
Complications of Inferior Vena Cava Filters
Authors: Joels Charles S. , Sing Ronald F. , Heniford B. Todd
Published: November 2022

Inferior vena cava (IVC) filters offer a safe and effective means of preventing pulmonary embolus and have reduced complications when compared to earlier techniques of caval interruption. However, despite continued improvement in filters and insertion methods, complications still occur. Pneumothorax, hemorrhage, and vessel injury may result while obtaining vascular access. Filter misplacement, excessive tilt, and vascular injury have been reported with insertion, but preinsertion cavography is helpful in preventing these insertion-related complications. Attention to detail, proper use of guidewires, and preinsertion imaging are vital in preventing insertion-related complications as well. Long-term complications occur in a minority of patients and include recurrent pulmonary embolus, caval occlusion, and filter migration. Overall, the benefits of preventing pulmonary embolism far exceed the risks related to filter placement in properly selected patients.
Analyzing Prophylactic Antibiotic Administration in Procedures Lasting More than Pour Hours: Are Published Guidelines Being Followed?
Authors: Gupta Naren , Kaul-Gupta Rina , Carstens Miki M. , Franga Dion , Martindale Robert G.
Published: November 2022

Published guidelines for surgical antibiotic prophylaxis recommend that an appropriately selected and administered antibiotic should be repeated in a timely manner in lengthy procedures. To assess concordance with published guidelines we reviewed the prophylactic antibiotic usage in procedures lasting more than 4 hours at a 500-bed university hospital. The records of 300 procedures longer than 4 hours in duration from the gastrointestinal, neurosurgery, and vascular surgery services were retrospectively reviewed. Analysis was confined to the usage of antibiotics in a prophylactic setting. Using a liberal interpretation of the American College of Surgeons, Centers for Disease Control and Prevention, Surgical Infection Society, and Medical Letter Guidelines each case was evaluated for the appropriateness of the antibiotic selection, the interval between the first dose and the skin incision, and the timeliness of repeat dosing. Twenty-five patients (8.3%) did not receive any antibiotic coverage at all. One hundred ninety cases (63.3%) received the correct antibiotic, but only 96 (32%) received it in a timely manner before surgery. Nine patients (3%) in 300 cases received repeat doses at the correct time for the entire duration of the surgery in complete compliance with the published guidelines. We conclude that antibiotic prophylaxis of lengthy procedures is rarely in accordance with published guidelines.
Parathyroid Cancer, a Continued Diagnostic and Therapeutic Dilemma: Report of Four Cases and Review of the Literature
Authors: Snell Sarah B. , Gaar Earl E. , Stevens Scott P. , Flynn Michael B.
Published: November 2022

Parathyroid cancer presents a diagnostic challenge as a rare endocrine malignancy usually not recognized preoperatively and often not conclusively identified intraoperatively. We examined a cluster of parathyroid cancers treated at University of Louisville-affiliated hospitals during a 5-year interval. Clinical and histologic data from patient records at University Surgical Associates, the University of Louisville Hospital, Norton Hospital, and the Louisville Veterans Administration Medical Center in Louisville, KY were retrospectively reviewed. During the study interval surgical exploration of the neck was undertaken on 175 patients with primary hyperparathyroidism; four parathyroid malignancies (2%) were identified. Three of the four patients exhibited symptomatic hyperparathyroidism with very high diagnostic calcium and parathormone levels. All patients had multiple coexisting diseases and two had undergone previous parathyroid surgery. Sestamibi scan localized the lesion in two patients, ultrasound was used in one patient, and a positron emission tomography scan was needed to identify the lesion in the fourth. Intraoperative findings varied from multiple nodules involving the thyroid and paratracheal nodules to otherwise normal-appearing enlarged parathyroid gland. External pathologic review was needed to conclusively establish the diagnosis in all cases, even though initial histologic analysis was suggestive of malignancy. All patients are alive, well, and free of disease. This rarely occurring malignancy may be suggested by very high preoperative calcium parathormone levels. Intraoperative and histologic findings are often inconclusive resulting in therapeutic decisions made by the operating surgeon on the basis of limited or incomplete information.
Massive Benign Thymic Hyperplasia in a Six-Month-Old Girl: Case Report
Authors: Gow Kenneth W. , Kobrynski Lisa , Abramowsky Carlos , Lloyd David
Published: November 2022

A 6-month-old girl presented with respiratory symptoms with a large right-sided mediastinal mass noted on diagnostic imaging. Percutaneous biopsy revealed normal thymic tissue. Steroids were administered with no response. Right thoracotomy and complete thymectomy were performed. The specimen weighed approximately eight to ten times normal weight, and histology and flow cytometry revealed normal thymic tissue consistent with benign hyperplasia. The child has remained tumor free for a year since surgery. The rare nature of this tumor leads us to report this case and review the current literature.
Optimization of the Gamma Probe-Guided Parathyroidectomy
Authors: Bozkurt M. Fani , Ugur Omer , Hamaloglu Erhan , Sayek Iskender , Gulec Seza A.
Published: November 2022

The objective of this study was to determine the patient-specific optimal time to surgery preoperatively to improve operative success in gamma probe-guided parathyroid localization. Fifteen patients with hyperparathyroidism underwent a double-phase Tc99m-MIBI (15–20 mCi) parathyroid scintigraphy to study the Tc99m-MIBI clearance kinetics from parathyroid and thyroid glands and to determine the time point at which the optimal target-to-background ratio was achieved. Optimal time to surgery was determined on the basis of the time at which the target-to-background ratio was maximal. On the day of surgery the patients received the same dose of Tc99m-MIBI and were taken to the operating room at the time of optimal target-to-background ratio. A four-gland exploration was performed with identification and excision of hot lesions using a gamma probe. Ex vivo lesion-to-background ratios were determined. Histopathologic confirmation of a successful parathyroidectomy was obtained intraoperatively by frozen section. The total operative time and the time to localize and excise the parathyroid glands were recorded. The mean surgery time was compared with that of previous parathyroidectomies performed by the same surgical team without use of preoperative scintigraphy and intraoperative gamma probe. Scintigraphy correctly localized parathyroid pathology in 12 of 15 (80%) patients. Intraoperative gamma probe was successful in 15 of 15 (100%). The optimal time to surgery was found to be different for each patient, and the mean time was calculated as 136 ± 43 minutes. Mean surgery time for the excision of parathyroid gland was 91 ± 46 minutes, which was significantly shorter than previous four-gland exploration without use of scintigraphy and gamma probe (160 ± 61 minutes; t = 3.021, P = 0.007). The mean ex vivo lesion-to-background gamma probe count ratio of abnormal parathyroid glands (77.35) was found to be significantly higher than that of all other lesions with abnormal Tc99m-MIBI uptake (5.05) ( U = 10.5, P < 0.0001). Optimal target-to-background ratio is essential for the success of gamma probe-guided parathyroidectomy. This ratio was highly variable among the patients in this study. Individualization of the best surgical exploration time after Tc99m-MIBI injection will improve the surgical success of this operation.
The “Open-Book” Variation of Component Separation for Repair of Massive Midline Abdominal Wall Hernia
Authors: Ennis L. Scott , Young Jeffrey S. , Gampper Thomas J. , Drake David B.
Published: November 2022

The reconstruction of massive midline abdominal wall defects as a result of intra-abdominal catastrophes has long challenged the reconstructive surgeon. Previously, the lack of autogenous tissue often forced the surgeon to resort to synthetic materials, which may be complicated by adhesions, enterocutaneous fistulas, and infection. The introduction of the “components of anatomic separation” technique by Ramirez et al. in 1990 allowed for autogenous reconstruction using bipedicle rectus flaps. This technique was far superior to any previous option, but it had its limitations. The authors report a modification to the component separation technique which may allow larger defects to be closed as well as diminish the weakness left below the arcuate line found in some of the previously reported techniques. Ten patients are discussed for which this modified technique of component separation was employed. The follow-up ranges from 5 weeks to 53 months.
An Analysis of Standard Open and Endovascular Surgical Repair of Abdominal Aortic Aneurysms in Octogenarians
Authors: Patel Ajay P. , Langan Eugene M. , Taylor Spence M. , Gray Bruce H. , Carsten Christopher G. , Cull David L. , Snyder Bruce A. , Stanbro Marcus D. , Youkey Jerry R. , Sullivan Timothy M.
Published: November 2022

While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. There were 11 females in the open group and 1 female in the endovascular group. There were no statistically significant differences in preoperative patient comorbidities between groups. Total mortality for the entire series was 11.8 per cent but this included 5 ruptured AAAs, all of which patients died, and 11 additional AAAs that were symptomatic, of which 1 patient died. Total nonruptured mortality for the entire series was 2.2 per cent (0% for the endo-group and 3.3% for the open group). There were statistically significant differences between the endovascular versus the open groups when comparing aneurysm diameter (5.6 cm vs. 6.2 cm; P = 0.016), estimated blood loss (225 cc vs. 2100 cc; P < 0.001), ICU days (0 vs. 3; P < 0.001), length of hospital stay (2 days vs. 12 days; P < 0.001), and patients with blood transfusions (1 vs. 27; P < 0.001). When comparing postoperative morbidities, 4 of the endovascular patients (25%) and 25 of the open patients (68.6%) had a complication ( P = 0.006). In conclusion, endovascular stent graft treatment of nonruptured infrarenal AAAs in octogenarians led to significantly better outcomes and should probably be considered the preferred treatment whenever anatomically appropriate. Endovascular exclusion of ruptured AAAs may potentially improve future outcomes in this high-risk group.
The Cost of Trauma
Authors: Lanzarotti Stephen , Cook Craig S. , Porter John M. , Judkins Daniel G. , Williams Mark D.
Published: November 2022

Trauma is a financial burden. For the 2634 trauma patients seen in 1999, the percentage of their hospital bill reimbursed and cost coverage (CC), whether that reimbursement covered their hospital costs, were analyzed. Student t tests to compare the mean percentage reimbursements (mPR) and logistic regression with CC (yes/no) as dependent variable with results as odds ratio (OR) were done. The overall mPR was 36 per cent. Among the 947 patients admitted (36%), there was no association between injury severity and mPR. For penetrating trauma, the mPR (25%) was lower than for blunt trauma (37%, P = 0.05). The assault mPR (21%) was lower than for motor vehicle crash (39%, P < 0.001). The mPR for patients transferred in (26%) was lower than for all others (37%, P < 0.001). Male sex (OR = 0.76), Hispanic ethnicity (OR = 0.46), admission (OR = 0.69), severe brain injury (OR = 0.58), abdominal injury (OR = 0.65), and extremity injury (OR = 0.69) were significant predictors for no CC. Reimbursement is better for blunt trauma. That transfers had a significantly lower mPR may represent “dumping” of patients. There is an association between anatomic regions injured and CC. No reimbursement was obtained for 26 per cent of the patients, and in 56 per cent the reimbursement did not cover costs. A change in financing for trauma is needed.
Institutioning a Clinical Practice Guideline to Decrease the Rate of Normal Appendectomies
Authors: Blisard Deanna , Rosenfeld Joel C. , Estrada Fernando , Reed James F.
Published: November 2022

With the advent of laparoscopic appendectomy, the rate of normal appendectomies increased at our institution. To decrease our rate of normal appendectomies, we instituted a clinical practice guideline in January 1999 for the preoperative evaluation and treatment of patients with possible acute appendicitis. The medical records of 464 consecutive patients who underwent either open or laparoscopic appendectomy with a preoperative diagnosis of acute appendicitis between January 1, 1997, and December 31, 2000, were reviewed. The decision of open versus laparoscopic appendectomy was made at the time of surgery by the attending surgeon. Two hundred twelve patients (116 females, 96 males) underwent an appendectomy for acute appendicitis (142 open, 70 laparoscopic) from January 1, 1997 through December 31, 1998, prior to the institution of the guideline. Two hundred fifty-two patients (117 females, 135 males) underwent an appendectomy for acute appendicitis (193 open, 59 laparoscopic) from January 1, 1999, through December 31, 2000 (after the guideline was instituted). Prior to the guideline, the normal appendectomy rate was 21.7 per cent (18.3% open, 28.6% laparoscopic). After the guideline was instituted, the normal appendectomy rate was 16.7 per cent (14.5% open, 23.7% laparoscopic). In females, the normal appendectomy rate prior to the guideline was 31.0 per cent (26.6% open, 36.5% laparoscopic) while the normal appendectomy rate after the guideline was 23.1 per cent (19.0% open, 31.6% laparoscopic), P = 0.172. In males, the normal appendectomy rate prior to the guideline was 10.4 per cent (11.5% open, 5.6% laparoscopic) while the normal appendectomy rate after the guideline was 11.1 per cent (11.4% open, 9.5% laparoscopic), P = 0.861. By instituting a guideline for the diagnosis and treatment of possible acute appendicitis, we were able to decrease our rate of normal appendectomies. Although statistical significance was not reached, there is a trend toward decreasing the rate of normal appendectomies in females after the guideline was instituted.
Disability and Chronic Pain after Open Mesh and Laparoscopic Inguinal Hernia Repair
Authors: Bozuk Michael , Schuster Rob , Stewart David , Hicks Kathrin , Greaney Gregory , Waxman Kenneth
Published: November 2022

Proponents of laparoscopic inguinal hernia repair maintain that the associated costs and risks are offset by faster recovery and less postoperative pain. It was our hypothesis that the incidence of chronic pain in both groups of our patients was not as high as reported in the literature. Patients for the study were identified from a community hospital medical record database. A total of 229 patients were available and agreed to participate in the study. Data collected included the patient's current pain level at the hernia site, pain medication currently used, narcotics currently used, return to normal work, and return to normal activity. Overall, 19.7 per cent of patients complained of mild pain, but only 2.2 per cent classified this as moderate or severe. Mild pain was noted more often in the open repair patients compared with the laparoscopic group. However, there was no difference in the frequency of moderate or severe pain. The time to return to work was longer in the open repair group than the laparoscopic repair group, but there were large ranges in both groups. The inability to return to full preoperative activity was infrequent and equivalent in both open and laparoscopic hernia repair groups. In our study of 229 patients undergoing elective open or laparoscopic inguinal hernia repair at a community hospital, we have found a low incidence of moderate or severe chronic pain. In addition, we found that this procedure did not interfere with return to work at 6 months or return to daily activities in either the laparoscopic or open repair group.