bluuebunny/crossref_metadata_2025 huggingface dataset:
Mechanical Response of Industrial Concrete with SFRC and PFRC
Authors: Ortíz-Lozano José Ángel , Rodríguez-Narciso Silvia , Carrillo Julián , Hernández-Andrade Juan Antonio , Pacheco-Martínez Jesús , Hernández-Marín Martín , de la Fuente-Antequera Albert
Published: November 2022

Concrete is one of the most commonly used construction materials in the world due to its versatility. There are different types of concrete according to the required mechanical responses, and these will depend on the composition of the elements. Therefore, additional elements have been developed to improve the properties and conditions of concrete. One of these elements is reinforcing fibers made of steel, polypropylene, glass, and so on, which, according to the base material, geometry, and dosage, improve the mechanical and workability properties and decrease and/or prevent the generation of cracks, which are some of the most common problems in industrial slabs. This study performs an analysis of the changes in the mechanical properties of concrete (compressive strength, rupture modulus, modulus of elasticity, Poisson’s ratio, and residual stress) due to the addition of fiber-reinforced concrete (FRC) to determine the physical and mechanical conditions of the fibers that improve the concrete and its application in industrial concrete. Due to the large number of samples and variables, advanced statistical methods (analysis of variance and comparative index) were used in the numerical study, which allowed to analyze and compare several results at the same time. This research is divided into two stages. In the first stage, six steel fibers (with a dosage of 2.7, 6, and 11 and three of 28 kg/m3) and five polypropylene fibers (with a dosage of 0.6, 2.15, and 2.7 and two of 3 kg/m3) were used in the study, and compression and bending tests (ASTM C39 and C78, respectively) were performed on 35 cylinders and 45 beams. Improvements were identified in several fiber-reinforced concrete samples in terms of compressive strength: 67% of the steel fiber samples and 100% of the polypropylene fiber samples had values above the average value of the simple concrete; in terms of the modulus of rupture, 83% of the steel fiber samples and 80% of the polypropylene fiber samples had values above the average value of the simple concrete. In the second stage, one type of steel fiber and one type of polypropylene fiber were selected for a second mechanical analysis (64 cylinders, 72 beams, and 15 slabs) with dosages of 20, 30, and 40 kg/m3 and 2.13, 4.25, and 6.38 kg/m3, respectively. In the second stage, statistical analysis and modeling with nonlinear analysis were used to evaluate the results, where residual strength improved but Poisson’s ratio decreased when the dosage of fibers was increased.
The Utility of Sodium Channel Provocation in Unexplained Cardiac Arrest Survivors and Electrocardiographic Predictors of Ventricular Fibrillation Recurrence
Authors: Ensam Bode , Cheung Christopher C. , Almehmadi Fahad , Gregers Winkel Bo , Scrocco Chiara , Brennan Paul , Leong Kevin , Muir Alison , Vanarva Amanda , Tfelt-Hansen Jacob , Roberts Jason D. , Krahn Andrew D. , Behr Elijah R.
Published: November 2022

Background:

The implications of a drug-induced type 1 Brugada ECG pattern following sodium channel blocker provocation (SCBP) are not fully understood.

Methods:

Baseline clinical and ECG data were obtained from consecutive unexplained cardiac arrest survivors undergoing SCBP at 3 centers. A further 15 SCBP positive (SCBP+) unexplained cardiac arrest survivors were recruited from 3 additional centers to explore ventricular fibrillation recurrence.

Results:

A total of 121 consecutive unexplained cardiac arrest survivors underwent SCBP. The yield of the drug-induced type 1 Brugada ECG pattern was 17%. A baseline type 2/3 Brugada pattern (T2/3BP) (adjusted odds ratio, 19.36 [2.74–136.61];
P
=0.003) and PR interval (odds ratio, 1.03 [1.01–1.05] per ms;
P
=0.017) were independent predictors of SCBP+ response. A pathogenic
SCN5A
variant was identified in 36% of the SCBP+ group versus 0% in the SCBP− group (
P
<0.001). Amongst SCBP+ patients, a spontaneous type 1 Brugada pattern was identified in 19% during follow up and in 24% a type 1 Brugada pattern was identified in a relative. Prior syncope (adjusted hazard ratio, 3.83 [1.36–10.78];
P
=0.011) and the presence of global early repolarization (hazard ratio, 7.91 [3.22–19.44];
P
<0.001) were independent predictors of 5-year ventricular fibrillation recurrence. There was a nonsignificant trend toward greater 5-year ventricular fibrillation recurrence in the SCBP− group (23/95 [24%] versus 3/34 [9%];
P
=0.055).

Conclusions:

The yield of the drug-induced type 1 Brugada ECG pattern in consecutive unexplained cardiac arrest survivors undergoing SCBP is 17%. A baseline T2/3BP and PR interval were independent predictors of the drug-induced type 1 Brugada ECG pattern. Greater heritability of BrS phenotype in this group was evidenced by a greater prevalence of pathogenic
SCN5A
variants and relatives with a type 1 Brugada pattern. A history of prior syncope and the presence of global early repolarization were independent predictors of ventricular fibrillation recurrence.
Noninvasive Plaque Imaging to Accelerate Coronary Artery Disease Drug Development
Authors: Figtree Gemma A. , Adamson Philip D. , Antoniades Charalambos , Blumenthal Roger S. , Blaha Michael , Budoff Matthew , Celermajer David S. , Chan Mark Y. , Chow Clara K. , Dey Damini , Dwivedi Girish , Giannotti Nicola , Grieve Stuart M. , Hamilton-Craig Christian , Kingwell Bronwyn A. , Kovacic Jason C. , Min James K. , Newby David E. , Patel Sanjay , Peter Karlheinz , Psaltis Peter J. , Vernon Stephen T. , Wong Dennis T. , Nicholls Stephen J.
Published: November 2022

Coronary artery disease (CAD) remains the leading cause of adult mortality globally. Targeting known modifiable risk factors has had substantial benefit, but there remains a need for new approaches. Improvements in invasive and noninvasive imaging techniques have enabled an increasing recognition of distinct quantitative phenotypes of coronary atherosclerosis that are prognostically relevant. There are marked differences in plaque phenotype, from the high-risk, lipid-rich, thin-capped atheroma to the low-risk, quiescent, eccentric, nonobstructive calcified plaque. Such distinct phenotypes reflect different pathophysiologic pathways and are associated with different risks for acute ischemic events. Noninvasive coronary imaging techniques, such as computed tomography, positron emission tomography, and coronary magnetic resonance imaging, have major potential to accelerate cardiovascular drug development, which has been affected by the high costs and protracted timelines of cardiovascular outcome trials. This may be achieved through enrichment of high-risk phenotypes with higher event rates or as primary end points of drug efficacy, at least in phase 2 trials, in a manner historically performed through intravascular coronary imaging studies. Herein, we provide a comprehensive review of the current technology available and its application in clinical trials, including implications for sample size requirements, as well as potential limitations. In its effort to accelerate drug development, the US Food and Drug Administration has approved surrogate end points for 120 conditions, but not for CAD. There are robust data showing the beneficial effects of drugs, including statins, on CAD progression and plaque stabilization in a manner that correlates with established clinical end points of mortality and major adverse cardiovascular events. This, together with a clear mechanistic rationale for using imaging as a surrogate CAD end point, makes it timely for CAD imaging end points to be considered. We discuss the importance of global consensus on these imaging end points and protocols and partnership with regulatory bodies to build a more informed, sustainable staged pathway for novel therapies.
A Unique Twelfth- to Fourteenth-Century AD Iron Nail Assemblage from Kanem, Chad
Authors: Magnavita Carlos
Published: November 2022

Iron nails are still a poorly researched group of African archaeological artefacts. Probably because of preservation issues and their ordinary nature, archaeologists have in general not dealt analytically with such objects. A brief survey of the published evidence shows that, compared to North Africa and the Middle Nile Valley, iron nails are late occurrences in sites south of the Sahara, dating to the late first and the second millennia AD. This paper presents the first trait analysis of an iron nail assemblage from sub-Saharan Africa. Based on a collection of recently excavated and well-preserved samples from 12th to 14th century Kanem, the analysis distinguishes four main nail types being used east of Lake Chad at that time. It is concluded that, as any other archaeological artefacts, nails should be properly illustrated and analyzed as a means of warranting the retrieval of relatable data for future comparative studies.
Eukoenenia mocororo (Palpigradi: Eukoeneniidae): a new troglobitic palpigrade from a Brazilian ferruginous cave
Authors: SOUZA MAYSA FERNANDA VILLELA REZENDE , FERREIRA RODRIGO LOPES
Published: November 2022

A new troglobitic palpigrade from Southeastern Brazil is described based on nine specimens (including males, females and immatures of all stages) collected in an iron ore cave named “Mocororô”. The most peculiar trait of Eukoenenia mocororo sp. nov. that readily distinguishes it from other Eukoenenia species described worldwide is the presence of fourteen pairs of setae (including the fusules) on first lobe of male genitalia. Although other palpigrades have been reported from Brazilian iron ore caves, this record is remarkable because Mocororô cave is inserted in Peixe Bravo River Valley (Northern Minas Gerais state)—a ferruginous system with dozens of caves that have been targeted for biospeleological studies only a few times. Therefore, the description of this new species, besides contributing to the conservation of Mocororô cave, constitutes an example of the high potential for discoveries in this region.
Twenty Years of Progress in Congenital Diaphragmatic Hernia at the University of Florida
Authors: Langham Max R. , Kays David W. , Beierle Elizabeth A. , Chen Mike K. , Mullet Timothy C. , Rieger Karen , Wood Charles E. , Talbert James L.
Published: November 2022

Over the past 20 years the clinical paradigms underlying the care of children with congenital diaphragmatic hernia (CDH) have undergone profound changes. The purpose of this work is to provide an historic review of research and clinical studies related to CDH at the University of Florida (UF) and Shands Children's Hospital during the chairmanship of Edward M. Copeland, III, M.D. and to present our current clinical results. During Dr Copeland's tenure survival for newborns symptomatic with CDH treated at UF/Shands Children's Hospital has improved from less than 20 per cent to 85 per cent. Clinical observations have suggested and research studies at UF using a fetal lamb model have confirmed that fetal distress can occur late in gestation, which may predispose infants with CDH to pulmonary hypertension. However, our patient experience has confirmed that the most significant cause of mortality in human infants is not pulmonary hypertension but iatrogenic injury to their hypoplastic lungs. Strict avoidance of barotrauma in these babies has been the most important clinical advance during these two decades. Significant clinical and research problems remain including defining optimal prenatal care, management of complications during the first few weeks of life, and development of strategies to accelerate lung growth. Dramatic improvements in survival have resulted in children who manifest a number of clinical problems that were not evident when most of these patients died early in infancy. Our experience at Shand's Children's Hospital/UF indicates that feeding problems, respiratory infections, and management of subtle or overt neurologic complications may become major issues for some of these survivors and their families.
Does Fibrin Sealant Reduce Drain Output and Allow Earlier Removal of Drainage Catheters in Women Undergoing Operation for Breast Cancer?
Authors: Langer Samantha , Guenther J. Michael , Difronzo L. Andrew
Published: November 2022

Serosanguinous drainage after mastectomy and axillary lymph node dissection has traditionally been treated with the temporary use of closed suction drainage catheters. Use of drainage catheters is associated with wound infection, discomfort, nerve injury, and impaired arm movement. Commercially produced fibrin sealant has been proposed to reduce postoperative serosanguinous collections. We hypothesized that the intraoperative application of low-dose (2–5 cm3) fibrin sealant would reduce serosanguinous drainage and allow earlier removal of closed suction drainage catheters after operation for breast cancer. Fifty-five women with known breast cancer underwent either total mastectomy, modified radical mastectomy, or isolated level I and II axillary lymph node dissection. Twenty-six patients were treated with fibrin sealant and 29 served as control subjects. The application of fibrin sealant resulted in a significant reduction in overall duration catheters were needed (7 vs 8.3 days; P = 0.05). More importantly fibrin sealant reduced the time until 24-hour drain output was less than 30 cm3 (4.9 vs 6.2 days). Additionally fibrin sealant application resulted in a 60 per cent reduction in overall drainage amount after total mastectomy and a 32 per cent reduction after modified radical mastectomy. The application of fibrin sealant after axillary lymph node dissection did not decrease overall drainage amount. In conclusion fibrin sealant reduces serosanguinous drainage after total mastectomy and modified radical mastectomy and may allow earlier removal of closed suction drainage catheters.
Intraperitoneal Underlay Ventral Hernia Repair Utilizing Bilayer Expanded Polytetrafluoroethylene and Polypropylene Mesh
Authors: Millikan Keith W. , Baptista Michael , Amin Beejal , Deziel Daniel J. , Doolas Alexander
Published: November 2022

A prospective study of patients with ventral hernias was undertaken to study the experience with an open intraperitoneal underlay technique utilizing a bilayer prosthetic mesh. From September 1998 to March 2001, 102 patients underwent repair with a bilayer expanded polytetrafluoroethylene (ePTFE) and polypropylene mesh placed intraperitoneally and fixed in place with full-thickness abdominal muscle wall sutures to achieve a 5-cm underlay of the fascial defect circumferentially. There were 67 females and 35 males ranging in age from 29 to 76 years (mean 53 years). Average patient weight was 207 lb with 64 patients in the obese category. Forty patients presented with recurrent hernias. Mean operative time was 103 minutes with an average diameter hernia defect size of 15 cm. Median hospital stay was 3 days. There was no surgical mortality, and major morbidity occurred in six patients (2 wound infections, one deep vein thrombosis, one myocardial infarction, one pneumonia, and one pulmonary embolus). Mean follow-up is 28 months (range 12–42 months). No recurrence has been found with 100 per cent follow-up to date. No bowel obstruction or enteric fistulas have occurred during the follow-up period. The open intraperitoneal underlay mesh technique can be performed with a zero per cent early recurrence rate. Bilayer prosthetic mesh composed of ePTFE and polypropylene can be safely placed intraperitoneally without causing intestinal obstruction or enteric fistula.
The Extent of Cryosurgery Increases the Complication Rate after Hepatic Cryoablation
Authors: Sohn Richard L. , Carlin Arthur M. , Steffes Christopher , Tyburski James G. , Wilson Robert F. , Littrup Peter J. , Weaver Donald W.
Published: November 2022

Although there have been many reports on the use of cryosurgery to ablate hepatic malignancies none have specifically examined the relationship of complication rates to the extent of cryoablation. A retrospective review from January 1997 to May 2002 identified 98 patients treated with hepatic cryotherapy. The extent of the cryosurgery was determined by the total number of lesions (TNL) and total estimated area (TEA) of the lesions from preoperative evaluation by CT scan and intraoperative evaluation by ultrasound. The major complication rate was 11 per cent. The 30-day mortality was 0 per cent, but the late procedure-related mortality was 2 per cent. Increasing the extent of cryotherapy measured by intraoperative ultrasound demonstrated significant increases in the complication rate and length of stay (LOS). With cryoablation of TEA ≥30 cm2 there was a significant increase in the overall complication rate (56% vs 23%; P = 0.003) and LOS (8.8 ± 6.9 vs 6.1 ± 4.2; P = 0.022) compared with TEA <30 cm2. Performance of concurrent procedures also led to a significant increase in complications (69% vs 29%; P = 0.010) and LOS (8.6 ± 6.8 vs 6.0 ± 4.0; P = 0.019). Multivariate analysis, however, showed intraoperative TEA ≥30 cm2 to be the most significant independent predictor of increased complications and prolonged LOS.
Gastrointestinal Complications after Ruptured Aortic Aneurysm Repair
Authors: Durrani Noreen K. , Trisal Vijay , Mittal Vijay , Hans S.S.
Published: November 2022

Gastrointestinal complications after ruptured aortic abdominal aneurysm (AAA) repair are not well defined and are limited to descriptions of ischemic colitis. We sought to delineate risk factors predicting gastrointestinal complications after ruptured AAA repair. Data from 100 consecutive patients after ruptured AAA repair between July 1980 and June 2000 were gathered for multiple preoperative, intraoperative, and postoperative factors. These variables were analyzed relative to postoperative gastrointestinal complications and resulting mortality. Overall mortality was 48 per cent. Gastrointestinal complications were encountered 29 times in 27 patients of 100 total patients (27%). Complications included prolonged adynamic ileus (three), acute pancreatitis (four) and cholecystitis (two), perforated duodenal ulcer (one), bowel obstruction (three), antibiotic-associated colitis (six), ischemic colitis (three), bowel infarction (four), and liver failure (three). Comparison of patients with and without gastrointestinal complications showed no predictive preoperative or intraoperative variables. Gastrointestinal complications are common in ruptured aortic aneurysm repair and carry increased mortality and morbidity. Surgeons must maintain a high level of suspicion to anticipate possible gastrointestinal complications.
Hepatic Radio frequency Ablation of Metastatic Ovarian Granulosa Cell Tumors
Authors: Jacobs Ira A. , Chang C.K. , Salti George
Published: November 2022

Intrahepatic recurrences of a granulosa cell tumor of the ovary after primary resection has traditionally been considered a relative contraindication to surgical management. Improvements in ablative technologies such as radiofrequency ablation (RFA) offer the surgeon additional alternatives in the management of selected intrahepatic tumors. We present a case report of an intrahepatic recurrence of a metastatic ovarian granulosa cell tumor 6 months after primary resection. The patient received RFA of the intrahepatic lesions and the patient remains free of detectable disease 14 months later. A review of the literature is presented. This is the first known report of the use of RFA for intrahepatic recurrence of a metastatic ovarian granulosa cell tumor. In selected cases of metastatic ovarian granulosa cell tumors to the liver RFA may increase the percentage of patients considered surgically treatable.
LaparoscopicVersusOpen Sigmoid Colectomy for Diverticulitis
Authors: Lawrence David M. , Pasquale Michael D. , Wasser Thomas E.
Published: November 2022

This study compared laparoscopic with open sigmoid colectomy for patients with a diagnosis of diverticulitis. Increased use of less invasive techniques makes it vitally important to evaluate outcomes of these techniques as compared with standard open procedures. Patients undergoing sigmoid colectomy for diverticulitis without hemorrhage (code 56211) between January 1997 and December 2001 were reviewed. Two groups were identified: those undergoing open sigmoid colectomy and those undergoing laparoscopic sigmoid colectomy; American Society of Anesthesiologists (ASA) scores, operative time, intensive care unit (ICU) and hospital length of stay, morbidity/mortality, and hospital charges were compared. During the study period 271 sigmoid colectomies were performed for diverticulitis without hemorrhage: 56 laparoscopically and 215 with the standard open technique. Four patients required conversion from laparoscopic to open colectomy. Mean ASA scores were: open group 2.4; laparoscopic group, 1.9 ( P < 0.001). Mean operative times were: laparoscopic group, 170 ± 45 minutes; open group, 140 ± 49 minutes ( P < 0.001). In the open group 39 patients required transfer to the ICU; one patient in the laparoscopic group required transfer to the ICU. Average hospital lengths of stay for the open and laparoscopic groups were 9.06 and 4.12 days, respectively ( P < 0.001). Complications were recorded in 57 (27%) of 215 patients who underwent an open procedure versus 5 (9%) of 56 patients who underwent laparoscopic sigmoid colectomy ( P < 0.01). There were three deaths in the open group and none in laparoscopic group. Average total hospital charges were $25,700 for open sigmoid colectomy and $17,414 for laparoscopic colectomy. Laparoscopic sigmoid colectomy compares favorably with open sigmoid colectomy for patients with a diagnosis of diverticulitis.
Multimodality Treatment for Esophageal Cancer: The Role of Surgery and Neoadjuvant Therapy
Authors: Makary Martin A. , Kiernan Paul D. , Sheridan Michael J. , Tonnesen Glen , Hetrick Vivian , Vaughan Betty , Graling Paula , Elster Eric
Published: November 2022

Treatment of esophageal cancer has traditionally included surgery as the initial modality. Neoadjuvant chemoradiation therapy has been introduced with the goal of downstaging tumors before surgical resection; however, its role in esophageal cancer remains controversial. We report 116 patients who underwent esophagogastrectomy with reconstruction for carcinoma of the esophagus or esophagogastric junction over a 10-year period (January 1, 1990 to June 1, 2001). Forty patients underwent neoadjuvant radiation and chemotherapy followed by surgery. Hospital mortality in this group was 7.5 per cent, complete pathologic response (CPR) was 37.5 per cent, and overall 3– and 5-year survival rates were 47 and 38 per cent. Five-year survival in the 15 patients with CPR was 85 per cent. Five patients underwent neoadjuvant single-agent therapy (four chemotherapy and one radiation) followed by surgery, and none survived to 3 years. Seventy-one patients underwent surgery without neoadjuvant therapy. Hospital mortality in this group was 1.4 per cent, with 3- and 5-year survival of 21 and 17 per cent—a decreased long-term survival compared with the neoadjuvant therapy group despite the observation that patients who underwent neoadjuvant therapy had a larger tumor size on presentation (5.5 ± 0.4 cm vs 3.8 ± 0.2 cm; P = 0.002). Squamous cell carcinomas seemed to be more responsive to neoadjuvant radiation and chemotherapy followed by surgery than were adenocarcinomas, with a CPR of 44.4 versus 35.5 per cent; however, 5-year survival rates in these complete responders were not significantly different (100% and 78%, respectively; P = 0.97). We report that esophagogastrectomy in conjunction with neoadjuvant therapy results in increased survival compared with surgery without neoadjuvant therapy ( P < 0.01), although there may be an increased perioperative mortality associated with neoadjuvant therapy. Further studies are needed to evaluate the role of preoperative chemoradiation and to better identify the pretreatment characteristics of patients with a complete pathological response.
Cystosarcoma Phyllodes Tumors in Men
Authors: Konstantakos Anastasios K. , Graham Debra J.
Published: November 2022

Cystosarcoma phyllodes (CSP) tumors of the breast are rare, comprising less than 1 per cent of all mammary neoplasms. CSP tumors have typically been regarded as predominantly benign, unilateral lesions of the female breast. However, sporadic cases of CSP have been reported in males. We present the first case of CSP in a man occurring in bilateral axillae and review the literature on CSP in males.
Interval Jejunoileal Bypass Reduces the Morbidity and Mortality of Roux-en-Y Gastric Bypass in the Super-Obese
Authors: Arteaga James R. , Huerta Sergio , Basa Nicole R. , Livingston Edward H.
Published: November 2022

Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6–24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 ± 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.
Factitious Oxygen Desaturation after Isosulfan Blue Injection
Authors: Heinle Erin , Burdumy Theodore , Recabaren James
Published: November 2022

Profound pulse oximetery desaturations are observed following isosulfan blue dye injection during breast sentinel node biopsy. The objective of this study was to examine the effect isosulfan dye has on oxygenation status and the reliability of pulse oximetery in evaluating this parameter. After study design, institutional review board approval was obtained. A prospective 5-month study was performed between January and April 2002. Twenty-one women with invasive breast cancer were monitored during breast sentinel node biopsies. Twenty-two operative cases were analyzed by pulse oximetry and arterial catheterization to record oxygen saturation. Time intervals of analysis were 0, 5, 10, 20, 30, and 40 minutes following injection of isosulfan blue dye. Simultaneous pulse oximetry and arterial blood gas analysis allowed comparison of indirect oximetry oxygen saturation (SpO2) to actual arterial oxygen saturation (SaO2). SpO2 values were decreased from baseline values at 10, 20, and 30 minutes without decrease in SaO2 saturation ( P < 0.001). The mean oximetry SpO2 desaturation was 5.6 per cent, with a range to 9 per cent. After injection with isosulfan blue dye, a significant SpO2 desaturation occurs. Clinicians must be aware of the factitious effect isosulfan blue dye has on SpO2 monitoring, to assess accurately the oxygenation status of the anesthetized patient.
Analysis of Causes and Prevention of Early Readmission to Surgical Intensive Care
Authors: Nishi Gregg K. , Suh Richard H. , Wilson Matthew T. , Cunneen Scott A. , Margulies Daniel R. , Shabot M. Michael
Published: November 2022

The purpose of this study was to analyze causes of early readmission to the surgical intensive care unit (SICU), to determine whether readmission can be predicted or prevented, and to compare outcomes of patients readmitted to the SICU with patients not requiring readmission. All patients admitted to the Cedars-Sinai SICU from January 1, 1996, to December 31, 2001, were included. Clinical data was prospectively collected in an on-line computer system. The charts of all early readmission patients were retrospectively reviewed. SICU and hospital outcomes were abstracted from a computerized data warehouse. During the study period, 10,840 patients were admitted to the SICU including 97 (0.89%) early readmissions. SICU admission APACHE II and SAPS I scores, SICU and hospital length of stay, and mortality were significantly higher in readmitted patients compared to patients not requiring readmission. The majority of early SICU readmissions were due to respiratory and neurologic deterioration. Upon review, 62 per cent of all readmissions met appropriate SICU discharge criteria and were not predictable while only 5 per cent of SICU discharge were felt to have been premature. Patient outcomes are adversely affected by early readmission to the SICU. Careful neurologic assessment, meticulous attention to respiratory care transfer orders, and prompt respiratory therapy on floor care may significantly decrease the need for early readmission to the SICU.
Relapsing Secondary Hyperparathyroidism Due to Multiple Nodular Formations after Total Parathyroidectomy with Autograft
Authors: Falvo Laura , Catania Antonio , Sorrenti Salvatore , D'Andrea Vito , Santulli Maria , Antoni Enrico De
Published: November 2022

Total parathyroidectomy with autograft represents an optimal surgical technique in the treatment of secondary hyperparathyroidism. Relapsing hyperparathyroidism due to miliary-type nodular formations scattered over the autograft site represents a complication that is rarely described in the literature. We examined five case histories of patients relapsing as a result of miliary-type nodular formations in the autograft site; in four cases the relapse was localized in the upper limb and in one case in a pouch of the sternocleidomastoid muscle. The patients underwent removal of the hyperfunctioning parathyroid formations accompanied by demolition of the surrounding muscle tissue. The relapsing hyperparathyroidism caused by multiple miliary-type nodular formations is a rare occurrence, akin to parathyromatosis. The increasingly widespread use of total parathyroidectomy with autograft to treat secondary hyperparathyroidism can lead to an increase in the incidence of this complication. Correct surgical technique and a careful selection of the parathyroid tissue to be autografted can prevent this complication. Furthermore, extensive demolition of the muscle tissue in the autograft site can prevent further relapses. Intraoperative rapid parathormone assay was found to be predictive of the disease's persistence and recurrence.
Duodenal Switch Procedure for Benign Duodenal Disorders
Authors: Theodoropoulos John , Richardson J. David
Published: November 2022

The duodenal switch operation has been found to be a very useful operation for a variety of nonbariatric procedures. A small series of patients operated on for primary bowel reflux, duodenal diverticula, and benign duodenal obstruction have all faired well. This procedure offers a much more physiologic approach to certain duodenal problems than a gastric jejunojejunostomy.
The Metastatic/Examined Lymph Node Ratio is an Important Prognostic Factor after Pancreaticoduodenectomy for Pancreatic Adenocarcinoma
Authors: Berger Adam C. , Watson James C. , Ross Eric A. , Hoffman John P.
Published: November 2022

Survival after curative resection for pancreatic adenocarcinoma remains poor; an important prognostic factor is lymph node (LN) status. Recent reports have established the number of LN examined as a separate prognostic factor in many malignancies. We retrospectively reviewed the charts of 128 patients undergoing pancreaticoduodenectomy (PD) for pancreatic cancer and obtained information such as overall survival (OS), disease-free survival (DFS), tumor characteristics, preoperative carbohydrate antigen (CA) 19–9, sex, and age. The ratio of metastatic to examined LN (LNR) was determined, and OS and DFS were analyzed in relation to the three groups: LNR = 0, LNR < 0.15, and LNR > 0.15. The median number of LN collected was 17. There were 46 NO patients (median = 12) and 83 N1 patients (median = 19). The number of LN harvested had no impact on OS or DFS in the N0 or N1 patient populations. When LNR was examined as a continuous variable, it had a borderline impact on OS ( P = 0.068). Examination of LNR by three groups showed an impact on OS ( P = 0.037) and DFS ( P = 0.013). After curative PD for pancreatic cancer, the ratio of metastatic to examined lymph nodes is an important prognostic factor and should be evaluated in stratification schemes for future clinical trials investigating adjuvant treatments.
Evaluation of Initial Base Deficit as a Prognosticator of Outcome in the Pediatric Trauma Population
Authors: Peterson D.L. , Schinco M.A. , Kerwin A.J. , Griffen M.M. , Pieper P. , Tepas J.J.
Published: November 2022

Although the utility of the base deficit as an indicator of hypoperfusion and physiologic derangement in adults is well established, its value in the assessment of children is not as clear. The purpose of this study was to evaluate this tool with regard to injury severity, infectious morbidity, and outcome in a pediatric trauma population. A retrospective review of a 6-year period of the database of our level 1 pediatric trauma center was performed. One hundred seventeen severely injured children requiring mechanical ventilation were identified. Initial base deficit, Injury Severity Score, time to correction of this abnormality, ventilator days, infectious morbidity, and mortality were obtained and compared. Of the 117 patients included in this study, 30 patients were identified with an initial BD of less than or equal to -8 mEq/L and were placed into group 1. Group 2 consisted of the remaining 87 patients who presented with a base deficit (BD) of greater than -8 mEq/L. An admission base deficit of -8 mEq/L or less corresponded to a probability of mortality of 23 per cent as opposed to only 6 per cent with a BD greater than -8. Patients in group 1 remained on mechanical ventilation 9.4 ± 8.1 days, whereas patients in group 2 remained ventilated 6.5 ± 6.4 days; an increase of nearly 145 per cent. Likewise, the number of infectious complications rose 26 per cent with a worsening initial base deficit from 17 per cent of group 2 patients to 43 per cent of group 1 patients. We conclude that a high initial base deficit in injured children predicts a higher incidence of infectious complications and a less favorable outcome. This readily available laboratory study can identify those children most at risk of potentially preventable complications.
Age, Blood Transfusion, and Survival after Trauma
Authors: Mostafa Gamal , Gunter Oliver L. , Norton H. James , Mcelhiney Barbara M. , Bailey Donna F. , Jacobs David G.
Published: November 2022

Blood transfusion affects outcomes after trauma, but whether elderly patients are disproportionately affected remains unknown. To determine the possible interaction between age, packed cell transfusion volume (PCTV), and mortality after injury, we designed a 6-year retrospective review (January 1995 through December 2000) of patients ≥16 years of age who received blood transfusion within the first 24 hours after injury. One thousand three hundred twelve patients ≥16 years of age admitted to our trauma center received packed red blood cells in the initial 24 hours after admission. Of the 1312 patients, 1028 (78%) were ≤55 years and 284 (22%) were >55 years of age, and overall mortality was 21.2 per cent. Age, Injury Severity Score (ISS) Glasbow Coma Scale (GCS), and PCTV emerged as independent predictors of mortality. PCTV for elderly survivors (4.6 units) was significantly less than that of younger survivors (6.7 units). Furthermore, mean PCTV for all survivors decreased progressively with advancing age. No patient >75 years with a PCTV > 12 units survived. Age and PCTV act independently, yet synergistically to increase mortality following injury.
Update on the NSABP and ACOSOG Breast Cancer Sentinel Node Trials
Authors: White Richard L. , Wilke Lee G.
Published: November 2022

Sentinel lymph node biopsy in women with breast cancer has become routine in many surgical practices; yet basic questions regarding the procedure remain unanswered. The National Surgical Adjuvant Bowel and Breast Project (NSABP) and the American College of Surgeons Oncology Group (ACOSOG) trials address the issues of morbidity, efficacy, safety, and the significance of low-volume disease. NSABP B-32 randomizes women to sentinel lymph node biopsy followed by a standard level I and II axillary dissection or sentinel lymph node biopsy without dissection unless metastatic disease is noted by H&E examination. Overall survival, disease-free survival, and morbidity serve as end points. Further pathologic evaluation of the lymph nodes with immunohistochemistry will be performed by the study center. This study is nearing its anticipated accrual goal. Patients enrolled in the now-closed ACOSOG Z0010 trial underwent bone marrow aspiration just prior to sentinel node biopsy. Immunocytochemical analysis of the marrow will be compared to sentinel lymph node (SLN) biopsy to determine prognostic accuracy. ACOSOG Z0011 randomizes women undergoing breast-conserving therapy with low-volume axillary disease to completion axillary dissection or observation. Overall survival, disease-free survival, local regional control, and morbidity serve as end points. This trial is currently enrolling patients.
Incurable Colorectal Carcinoma: The Role of Surgical Palliation
Authors: Cummins Erin R. , Vick Kenneth D. , Poole Galen V.
Published: November 2022

About 20 per cent of patients with carcinoma of the colon or rectum present with metastatic disease. Surgeons are frequently asked to consider resection or other operative procedures in these patients for palliation. We performed this review to determine whether patients presenting with known metastatic colorectal cancer derive benefit from surgical intervention. We performed a retrospective review of all patients with Ml carcinoma of the colon or rectum who were identified from the University of Mississippi Medical Center Cancer Registry from April 1985 through February 2003. Patients who underwent hepatic and/or pulmonary resection with curative intent were excluded from analysis, as were patients with metachronous metastases. Eighty patients with Ml colorectal cancer who did not undergo surgery with curative intent were identified, and in 74 of these, complete medical records and follow-up were available. Forty-nine of the 74 patients (66%) underwent an operation, and 25 were managed nonoperatively. Indications for surgery included bowel obstruction, active hemorrhage, severe anemia from gastrointestinal bleeding with requirement for blood transfusions, intractable pain, and perforation of the colon. Average survival was 11.2 months for operative patients versus 6.5 months for nonoperative patients ( P < 0.05). Thirty-six patients who underwent resectional procedures had a postoperative hospitalization of 7.5 days and a median survival of 11.5 months. Thirteen patients who had a nonresectional procedure had an average postoperative stay of 9 days and a median survival of 4 months. Median survival in those who did not undergo an operation was 4.8 months. Although metastatic colorectal carcinoma cannot usually be cured by surgical intervention, many patients who present with metastatic disease will benefit from palliative operations with relatively short hospitalizations and reasonable survival. Those who are not candidates for resection of the primary tumor have shorter survival times. Surgery can alleviate many of the distressing symptoms in patients with metastatic colorectal carcinoma.
Impact of Age on the Outcome of Liver Resections
Authors: Aldrighetti Luca , Arru Marcella , Calori Giliola , Caterini Roberto , Comotti Laura , Torri Giorgio , Ferla Gianfranco
Published: November 2022

The purpose of this study was to evaluate the influence of age on the outcome of liver resections. One hundred five consecutive hepatic resections were divided into two groups: ≥65 years old [old group (O-group)] and <65 years old [young group (Y-group)]. The two groups were first compared to evaluate the distribution of the variables potentially affecting the postoperative course, including primary diagnosis, concomitant diseases, previous upper abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of hepatic resections in the two groups was comparatively evaluated in terms of postoperative mortality, morbidity, transfusions, and length of postoperative hospitalization. The Y-group included 61 resections in 60 patients, mean age 52 ± 10 years (mean ± SD), range 23–64 years, whereas the O-group included 44 resections in 43 patients, mean age 71 ± 4 years (mean ± SD), range 65–82 years. The O-group included more hepatocellular carcinomas (45.4% vs 18.0%, P = 0.002) and chronic liver diseases (40.9% vs 18.7%, P = 0.017); the median length of operation was slightly higher in the Y-group (300 minutes vs 270 minutes, P = 0.003). Both O-group and Y-group were comparable ( P = n.s.) when evaluated for all other listed variables. As far as concerns the outcome of hepatic resections in the two groups, the length of postoperative hospitalization was identical (median 9 days, 5–60 days), whereas transfusions of packed red cells (O-group vs Y-group: 25.0% vs 16.3%, P = 0.30) or fresh frozen plasma (O-group vs Y-group: 13.6% vs 6.5%, P = 0.053) were not statistically different. Postoperative mortality included one case among young patients whereas no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (31.5% vs 20.5%, P = 0.59). The age factor does not negatively affect the outcome of liver resections.
Use of Percutaneous Drainage to Treat Hepatic Abscess after Radiofrequency Ablation of Metastatic Pancreatic Adenocarcinoma
Authors: Thomas K. Tyson , Bream Peter R. , Berlin Jordan , Meranze Steven G. , Wright J. Kelly , Chari Ravi S.
Published: November 2022

Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases. A known complication of RFA is the development of hepatic abscess. The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described. A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation. Following 6 months’ treatment, a new liver metastasis was identified. It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA. Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA. She remained febrile despite needle aspiration and intravenous antibiotics. A percutaneous drain was placed and the symptoms resolved. Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree. The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula. She remains well without evidence of abscess or disease recurrence. Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma. However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered.
Atypical Etiology of Massive Gastrointestinal Bleeding: Arterio-Enteric Fistula following Enteric Drained Pancreas Transplant
Authors: Lopez Nicholas M. , Jeon Hoonbae , Ranjan Dinesh , Johnston Thomas D.
Published: November 2022

Pancreas transplantation is an established treatment for selected type I insulin-dependent diabetes mellitus (DM). Increasingly, enteric drainage of exocrine secretions has been performed in preference to bladder drainage. We present two cases of massive gastrointestinal hemorrhage (GIH) related to arterial-graft duodenal fistulas, a rare cause of massive bleeding. Case 1 DM is a 49-year-old male who underwent simultaneous kidney pancreas transplantation (SPK) for DM and end-stage renal disease (ESRD). He developed a transplant duodenal stump leak that resolved with drainage. He presented with massive hemorrhage at 2 months. Angiography revealed a fistula between the graft-recipient arterial anastomosis and the stump leak. This was managed by transplant pancreatectomy. Case 2 SB is a 37-year-old male who underwent pancreas-after-kidney transplantation (PAK) for type I DM. At 6 months, the pancreas graft failed due to chronic rejection. He presented 9 months later with massive hemorrhage. Upper and lower endoscopy were inconclusive. Angiography revealed a fistula between the transplant arterial graft and the transplant duodenum. This was initially managed by coil embolization and definitively by transplant pancreatectomy. Patients with functional or nonfunctional pancreas transplants presenting with massive GIH not readily localized by endoscopy should undergo angiography to exclude this unusual etiology.
Dermatofibrosarcoma Protuberans and Breast Cancer: Genetic Link or Coincidental Association?
Authors: Beech Derrick J. , Brown Long Anne , Paul Long William
Published: November 2022

Dermatofibrosarcoma protuberans is a low-grade cutaneous neoplasm originating from the dermis with a high propensity for local recurrence. These malignancies are classified as soft tissue sarcoma although regional or distance metastatic spread is rare. Germ-line mutations of p53 have been described with a rare autosomal dominant syndrome in patients with soft tissue sarcoma and breast adenocarcinoma (Li Fraumeni's syndrome). The described case illustrates the rare occurrence of dermatofibrosarcoma protuberans (DFSP) and breast adenocarcinoma with an emphasis on the possibility of a molecular or genetic association.
Blunt Abdominal Trauma with Ruptured 16-Week Cornual Ectopic Pregnancy
Authors: Vorhies Robert W. , Waswick William A. , Delmore James E. , Dort Jonathan M. , Shaw John W.
Published: November 2022

Trauma is the leading cause of nonobstetric morbidity and mortality in pregnancy. Care of the pregnant trauma patient is well documented in the medical literature; however, little has been written about the management of trauma patients with ectopic or cornual pregnancy. Herein, we report the previously undocumented occurrence of a traumatic rupture of a cornual ectopic pregnancy. The use of trauma ultrasound, computerized tomography, as well as obstetrical evaluation prevented an imminent life-threatening complication of this patient's pregnancy.