bluuebunny/crossref_metadata_2025 huggingface dataset:
Investigation of the Effects of the Classification of Building Stock Geometries Determined Using Clustering Techniques on the Vulnerability of Galvanized Iron Roof Covers Against Severe Wind Loading
Authors: Tan Liezl Raissa E. , Acosta Timothy John S. , Gumaro Joshua Joseph C. , Agar Joshua C. , Tingatinga Eric Augustus J. , Plamenco Dean Ashton D. , Ereno Mary Nathalie C. , Musico John Kenneth B. , Pacer Jihan S. , Baniqued Julius Rey D. , Hernandez Jaime Y. , Villalba Imee Bren O.
Published: May 2021

In the risk assessment of buildings against severe wind loading, the vulnerability component of risk is highly affected by the geometry of the structure. Parameters such as the height, width, length, aspect ratio, eaves length, and roof slope, affect the pressure distribution around the structure, which in turn affects the response of galvanized iron (GI) roof covers to wind loadings. In developing countries, there is a large variation in the building geometric parameters which poses a challenge in determining the archetypes that would best represent the building population for risk assessment. This paper aims to develop and propose a method in determining the building archetypes based on its geometry. The hierarchy for grouping of geometries started with the roof type. These were gable type roofs, mono-slope type roofs and hip type roofs. The building datasets per roofing type were then clustered using a two-stage approach involving Hierarchical and K-means clustering which were based on the aforementioned geometric parameters. These algorithms will aggregate buildings having similar sets of geometric parameters but the number of clusters must be specified. In order to determine the optimal number of clusters, this study employs various validation tools or measures namely – dendrograms, variation of the variance ratio criterion (VRC) across number of clusters, validity indices such as, Davies Bouldin, Silhouette and Calinski Harabasz, and the elbow method. Although guided by these validation methods, the final selection of the number of clusters were determined considering computational time and resources. To define an archetype, the mean values of each parameter per cluster were selected. Resulting to 5, 3, and 3, archetypes for gable, hip, and mono-slope roof buildings, respectively. The selection of the archetype was further evaluated by investigating its effects on the vulnerability of GI roof covers in order to see how distinct each archetype would behave. A Kruskal Wallis test on the vulnerability curves of the different building archetypes showed that there is a significant difference between vulnerability curves under a roof shape category, which reinforces the distinction between the selected building archetypes.
Addressing road–river infrastructure gaps using a model-based approach
Authors: Januchowski-Hartley Stephanie R , White James C , Pawar Sayali K , Januchowski-Hartley Fraser A , England Judy
Published: May 2021

The world’s rivers are covered over and fragmented by road infrastructure. Road–river infrastructure result in many socio-environmental questions and documenting where different types occur is challenged by their sheer numbers. Equally, the United Nations has committed the next decade to ecosystem restoration, and decision makers across government, non-government, and private sectors require information about where different types of road–river infrastructure occur to guide management decisions that promote both transport and river system resilience. Field-based efforts alone cannot address data and information needs at relevant scales, such as across river basins, nations, or regions to guide road–river infrastructure remediation. As a first step towards overcoming these data needs in Great Britain, we constructed a georeferenced database of road–river infrastructure, validated a subset of locations, and used a boosted regression tree model-based approach with environmental data to predict which infrastructure are bridges and culverts. We mapped 110 406 possible road–river infrastructure locations and were able to either validate or predict which of 110 194 locations were bridges (n = 60 385) or culverts (n = 49 809). Upstream drainage area had the greatest contribution to determining infrastructure type: when <10 km2 our model correctly predicted culverts 73% of the time but only 60% of the time for bridges. Road type and stream gradient also influenced model results. Our model-based approach is readily applied to other locations and contexts and can be used to inform decisions about management of smaller infrastructure that are frequently overlooked worldwide.
Flow Cytometric Findings in Clonal Cytopenia of Undetermined Significance
Authors: Nirmalanantham Priyatharsini , Sakhi Ramen , Beck Rose , Oduro Kwadwo , Gadde Ramya , Ryder Chris , Yoest Jennifer , Sadri Navid , Meyerson Howard J
Published: May 2021

Objectives

To examine flow cytometric (FCM) findings in clonal cytopenia of undetermined significance (CCUS) in relation to variant allele fraction (VAF) and mutation risk.

Methods

Nine FCM parameters, including 5 FCM metrics (Meyerson-Alayed scoring scheme [MASS] parameters) we previously used to identify myelodysplastic syndromes (MDS), were compared among 96 CCUS samples, 100 low-grade MDS samples and 100 samples from patients without somatic alterations (controls).

Results

FCM findings did not differ between CCUS samples with less than 20% VAF and controls. CCUS samples with more than 20% VAF (CCUS >20% VAF) demonstrated more than 1 abnormal FCM parameter at a frequency between MDS and controls. Abnormalities in CCUS with high-risk alterations (CCUS(hi)) were similar to MDS, with no statistical difference in the percentage of cases with more than 1 FCM abnormality or a positive MASS score. The positive predictive value (PPV) for clinically significant myeloid processes; MDS, CCUS(hi), and CCUS >20% VAF compared with other CCUS samples and controls was 94.8%, with 96.5% specificity and 61% sensitivity using a modified MASS score. A subset of MDS (43%) was distinguished from CCUS(hi) and CCUS >20% VAF using 3 parameters, with a 93.5% PPV and 83.3% specificity.

Conclusions

FCM abnormalities can distinguish high-risk CCUS based on VAF or alteration type from low-risk CCUS and MDS in many cases. The findings are of potential utility in the evaluation of patients with cytopenias.
Proteinous pancreatic lipase inhibitor is responsible for the antiobesity effect of young barley (Hordeum vulgare L.) leaf extract
Authors: Kato Eisuke , Tsuruma Ai , Amishima Ayaka , Satoh Hiroshi
Published: May 2021

Young barley leaves (Hordeum vulgare L.) have various health effects and are employed as an ingredient in the production of health-promoting foods. Promoting antiobesity is one such health effect; however, the mechanism and bioactive compounds are unclear. In this research, young barley leaf extract (YB) was demonstrated to possess pancreatic lipase inhibitory activity. The addition of YB to a high-fat diet in mice increased fecal lipid content, indicating reduced absorption of lipids as the mechanism underlying antiobesity effect. The investigation of bioactive compounds in YB resulted in the identification of fructose–bisphosphate aldolase as a proteinous lipase inhibitor. Maximum inhibition of the protein was 45%, but inhibition was displayed at a concentration as low as 16 ng/mL, which is a characteristic inhibition compared with other reported proteinous lipase inhibitors.
Bioinformatics tools used for whole-genome sequencing analysis of Neisseria gonorrhoeae: a literature review
Authors: Singh Reema , Kusalik Anthony , Dillon Jo-Anne R
Published: May 2021

Whole-genome sequencing (WGS) data are well established for the investigation of gonococcal transmission, antimicrobial resistance prediction, population structure determination and population dynamics. A variety of bioinformatics tools, repositories, services and platforms have been applied to manage and analyze Neisseria gonorrhoeae WGS datasets. This review provides an overview of the various bioinformatics approaches and resources used in 105 published studies (as of 30 April 2021). The challenges in the analysis of N. gonorrhoeae WGS datasets, as well as future bioinformatics requirements, are also discussed.
Multimodal management of gastroesophageal junction adenocarcinoma: Which type of neoadjuvant treatment?
Authors: Zandirad E , Teixeira-Farinha H , Demartines N , Schäfer M , Mantziari S
Published: May 2021

Objective

The current treatment for locally advanced gastroesophageal junction (GEJ) adenocarcinoma consists of neoadjuvant treatment (NAT) followed by surgery. Preoperative chemotherapy (CT) and radio-chemotherapy (RCT) are both valid options, but comparative data for their efficacy remain scarce. This study aimed to assess the efficacy of RCT and CT to achieve a complete pathologic response (CPR) for locally advanced GEJ adenocarcinoma. Secondary endpoints were R0 resection rates, postoperative complications, long-term survival and recurrence.

Methods

All consecutive patients with locally advanced GEJ adenocarcinoma treated with CT or RCT and oncologic resection from 2009 to 2018 were included. A CPR was defined with the Mandard tumor regression score. Standard statistical tests were used as appropriate. Overall and disease-free survival were compared with the Kaplan Meier method and log-rank test. Multivariate analysis was performed to define independent predictors of CPR, and long-term survival.

Results

Among the 94 patients (84%male, median age 62 years [IQR 9.7]), 67 (71.3%) received preoperative RCT and 27 (28.7%) CT. Patient’s characteristics and pretreatment tumor stages were comparable. Surgical approach was thoracoabdominal Lewis resection in 95.5% RCT and 81.5% CT patients (P = 0.085). CPR was more frequent in the RCT than the CT group (13.4% vs 7.4%, P = 0.009), but R0 resection rates were similar (72.1% vs 66.7%, P = 0.628). There was a trend to higher ypN0 stage in the RCT group (55.2% vs 33.3%; P = 0.057). Postoperatively, RCT patients presented more cardiovascular complications (35.8% vs 11.1%; P = 0.017), although overall morbidity was similar (68.6% vs 62.9%, P = 0.988). 5-year overall survival was comparable (61.1% RCT vs 75.7% CT, P = 0.259), as was 5-year disease-free survival (33.5% RCT vs 22.8% CT, P = 0.763). Isolated loco-regional recurrence occurred in 2.9% RCT vs 3.7% CT patients (P = 0.976). NAT type was not an independent predictor for complete pathologic response nor long-term survival in the multivariate analysis. Median follow-up was 30 months [95%CI 21.3-38.8] for all patients.

Conclusion

Patients with locally advanced GEJ adenocarcinoma demonstrated higher rates of CPR after RCT than CT, and a trend to a better lymph node sterilization, although this did not translate in a significant survival benefit or decreased recurrence rate.
Comparison of robotic-assisted and open Ivor Lewis esophagectomies in 321 patients of a single center: A case-matched analysis
Authors: Neuschütz K J , Fourie L , Däster S , Bolli M , von Flüe M , Steinemann D C , Angehrn F V
Published: May 2021

Objective

We introduced robotic-assisted Ivor Lewis esophagectomies (rob-E) using the da Vinci Xi in Oct. 2015. Prior to that, esophagectomies were performed as open Ivor Lewis (open-E) procedures. Aim of this study is to evaluate the safety of rob-E in comparison to open-E procedures regarding perioperative outcomes.

Methods

Retrospective analysis of prospectively collected data between Feb. 1999 and Dec. 2020. A case-matched analysis, matching open-E to rob-E in a 1:1 manner, was conducted. Cases were matched regarding age, gender, American Society of Anesthesiologists (ASA) score, histological type of tumor, tumor location and stage.

Results

In the study period 321 patients underwent an esophagectomy. 76 received rob-E and 245 open-E. After matching the cases the comparison of preoperative patient and tumor characteristics revealed no differences between the rob-E and open-E group regarding age at time of operation with a median of 69.5 (35-83) respectively 70 (46-88) years (p = 0.900), gender with 84.2% male in both groups (p = 1.000), ASA score with 68.4% ASA 3 or 4 in both groups (p = 1.000), percentage of tumor stage III of 53.9% respectively 57.9% (p = 0.707), and rate of neoadjuvant treatment of 82.9% in rob-E and 81.6% in open-E (p = 1.000). Conversion from rob-E to open-E was never necessary. For rob-E versus open-E no difference was found regarding overall morbidity with 69.7% versus 60.5% (p = 0.307), major morbidity (Clavien-Dindo > = 3b) with 11.8% versus 14.5% (p = 0.811), incidence of anastomotic insufficiency with 7.9% versus 5.3% (p = 0.745), rate of surgical reintervention with 5.3% versus 7.9% (p = 0.745), and mortality with 2.6% versus 3.9% (p = 1.000). Postoperative details showed no difference including a similar duration of hospitalization with a median of 20 (13-62) respectively 18.5 (13-52) days (p = 0.368) and number of harvested lymph nodes with a median of 24.5 (7-59) in rob-E and 23 (2-64) in open-E (p = 0.203).

Conclusion

The introduction of rob-E in our institution was safe, as perioperative morbidity and mortality did not differ from the previously performed open-E. Overall, the incidence of major morbidity and anastomotic insufficiency in rob-E and open-E show a satisfactory rate compared to previous reports in literature. Further studies with a larger cohort of rob-E are planned in order to draw more decisive conclusions.
Prehabilitation in patients undergoing colorectal surgery fails to confer reduction in overall morbidity: Results of a single-center, single-blinded, randomized controlled trial
Authors: Gloor S , Misirlic M , Frei-Lanter C , Herzog P , Müller P , Schäfli-Thurnherr J , Schregel D , Lamdark T , Wyss R , Unger I , Gisi D , Greco N , Mungo G , Wirz M , Raptis D A , Tschuor C , Breitenstein S
Published: May 2021

Objective

Patients undergoing major surgery are prone to a functional decline due to the impairment of muscle, cardiorespiratory and neurological function as a response to surgical stress. Currently, there are solely weak recommendations in the ERAS protocol regarding the role of preoperative physical activity and prehabilitation in patients undergoing colorectal surgery. Studies in heterogenous cohorts showed contradictory results regarding the impact of prehabilitation on the reduction of postoperative complications. This randomized controlled trial assesses the impact of prehabilitation on postoperative complications in patients undergoing colorectal surgery within an ERAS protocol.

Methods

Between July 2016 and June 2019, a single-center, single-blinded , randomized controlled trial designed to test whether physiotherapeutic prehabilitation vs. normal physical activities prior to colorectal surgery may decrease morbidity within a stringent ERAS protocol was carried out. The primary endpoint was postoperative complications assessed by Comprehensive Complications Index (CCI®). Primary and secondary endpoints for both groups were analyzed and compared.

Results

A total of 107 patients (54 in the pERACS and 53 in the control cohort) were included in the study and randomized. Dropout rate was 4.5% (n = 5). Mean age (SD) in the control cohort was 65 (29–86) and 66 (24–90) years in pERACS cohort. The pERACS cohort contained more female patients (40% vs. 55%, p = 0.123) and a higher percentage of colorectal adenocarcinoma (32% vs. 23%, p = 0.384) although not significant. Almost all patients underwent minimally invasive surgery in both cohorts (96% vs 98%, p = 1.000). There was no between-cohort difference in the primary outcome measure 30-day Comprehensive Complications Index (15 [0 – 49] vs. 18 [0 – 43], p = 0.059). Secondary outcome as complications assessed according to Clavien-Dindo, length of hospital stay, reoperation rate and mortality showed no difference between both cohorts.

Conclusion

Routine physiotherapeutic prehabilitation cannot be recommended for patients undergoing colorectal surgery within an ERAS protocol (Grade A recommendation). To eliminate other confounders like geographical difference or difference in surgical technique, further multicenter RCTs are needed.
COVID-19-related abdominal pain is associated with elevated liver transaminases, which could predict poor clinical outcomes
Authors: Balaphas A , Gkoufa K , Colucci N , Perdikis K -C , Gaudet-Blavignac C , Lovis C , Goossens N , Toso C
Published: May 2021

Objective

Abdominal pain and liver injury have been frequently reported during Coronavirus Disease-2019 (COVID-19). In the setting of a systemic infection these features can induce misleading surgical diagnostics. Our aim was to investigate characteristics of abdominal pain in COVID-19 patients and its association with disease severity and liver injury.

Methods

Data of all COVID-19 hospitalized patients over 16 years old were retrieved from the beginning of the epidemic in Switzerland until end of June 2020. Patients admitted exclusively for other pathologies (including surgical abdominal conditions) and/or recovered from COVID-19, and pregnant women were excluded. Abdominal pain was linked to COVID-19 only after evident alternative diagnostic exclusion. Five times the upper limit of transaminases was considered as liver injury.

Results

Among the 1026 patients who fulfill the inclusion/exclusion criteria, 199 (19.4%) exhibited spontaneous abdominal pain and 165 (16.2%) after abdomen palpation. Systematized abdominal pain was most frequently localized in the epigastric (39.8%) and upper right quadrant (23.7%). Considering baseline ALT levels, 7.14% of patients with epigastric pain had pathological ALT value versus 0.29% of patients without symptoms (p = 0.008). When taking the 30days maximal transaminases value, this reached respectively 16.3% versus 2.7% (p < 0.001) and 20% versus 3.8% (p < 0.001) for respectively AST and ALT.

With logistic regression we demonstrated that baseline pathological AST value was associated with hospital mortality and/or admission to intensive/intermediate care unit with an odds ratio of 13.9 (CI 1.5-124.7, p = 0.019).

Conclusion

These results suggest that COVID-19-induced abdominal pain is associated with liver injury which could predict poor evolution of disease.
Extended lymph node resection versus standard resection for pancreatic head and peri-ampullary adenocarcinoma: A systemic review
Authors: Vuille-dit-Bille R N , Staerkle R F , Soll C , Troller R , Muff J , Choudhury R , Holland-Cunz S G , Grochola L F , Samra J , Puhan M , Breitenstein S
Published: May 2021

Objective

For patients with pancreatic and peri-ampullary adenocarcinoma, it has been hypothesized that extended lymphadenectomy may result in higher R0 resection rates and improved survival. As such, the objective of this systematic review was to compare the oncologic outcomes after pancreaticoduodenectomy (PD) with standard lymphadenectomy (SLA) versus PD with extended lymphadenectomy (ELA).

Methods

A Cochrane systematic review was conducted to identify all randomized controlled trials comparing PD with SLA versus PD with ELA for participants with periampullary or pancreatic cancer. The following electronic databases were reviewed: the Cochrane Central Register of Controlled Trials; MEDLINE; PubMed and EMBASE. The methodological quality of the included studies was assessed using the Cochrane risk of bias criteria and the quality of evidence for important outcomes using GRADE. Extended lymphadenectomy included the interaortocaval space, left side of the celiac trunk, and superior mesenteric artery.

Results

Seven randomized controlled trials were included with 843 patients (421 ELA and 422 SLA). No difference in overall survival (1- and 3-years after surgery) was seen between groups. Mortality and morbidity rates (including pancreatic fistula, delayed gastric emptying, and postoperative bleeding) were similar between the two groups. Operative time was significantly longer following extended resection (Mean Difference 50.1 min; 95% CI 19.2 to 81.1 min; P = 0.001). Total amount of blood loss during surgery was significantly increased following extended resection (Mean Difference 137 ml; 95% CI 12 to 263 ml; P = 0.03), as well as transfusion requirements (Mean Difference 0.15 units; 95% CI 0.13 to 0.17 units; P < 0.00001).

More lymph nodes were retrieved during ELA (Mean Difference 11 nodes; 95% CI 7 to 15 nodes; P < 0.00001). Incidence of positive resection margins was not different between groups.

Conclusion

There is no indication for extended lymphadenectomy in pancreatic head resection as a routine procedure.
Long-term effects of laparoscopic sleeve gastrectomy and Roux-Y-gastric bypass on body composition and bone mass density
Authors: Rast S , Bühler J , Beglinger C , Peterli R , Peters T , Gebhart M , Gerspach A C , Wölnerhanssen B K
Published: May 2021

Objective

Currently, the two most common bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB). Long-term data comparing the two interventions in terms of their effect on body composition and bone mass density (BMD) is scarce. The aim of this study was to assess body composition and BMD at least five years after sleeve gastrectomy (LSG) and gastric bypass (LRYGB).

Methods

Bariatric patients at least five years post-surgery (LSG or LRYGB) were recruited and body composition and BMD was measured by means of DEXA. Data from body composition before surgery was included in the analysis. Blood samples were taken for determination of plasma calcium, parathyroid hormone (PTH), Vitamin D3, alkaline phosphatase and C-terminal telopeptide (CTX), and individual risk for osteoporotic fracture assessed by The Fracture Risk Assessment Tool (FRAX) score was calculated. After surgery, all patients received multivitamins, vitamin D3, and zinc. In addition, LRYGB-patients were prescribed calcium.

Results

A total of 142 patients were included, 72 LSG and 70 LRYGB, before surgery: median BMI 43.1 kg/m2, median age 45.5 years, 62.7% females. Follow-up after a median of 6.7 years. For LRYGB, percentage total weight loss (%TWL) at follow up was 26.3%, and for LSG 24.1%, (p = 0.243). LRYGB lead to a slightly lower fat percentage in body composition. At follow-up, 45% of both groups had a T-score at the femoral neck below -1, indicating osteopenia. No clinically relevant difference between the groups in BMD was found.

Conclusion

At 6.7 years post-surgery, no difference in body composition and BMD between LRYGB and LSG was found. Deficiencies and bone loss remain an issue after both interventions and should be monitored.
Incidence and prognostic factors for the development of symptomatic and asymptomatic marginal ulcers after Roux-en-Y gastric bypass procedures
Authors: Süsstrunk J , Wartmann L , Mattiello D , Köstler T , Zingg U
Published: May 2021

Objective

Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU.

Methods

All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively.

Results

568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m2. Median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58 – 26.2) postoperatively and 24.4% of patients with MU were asymptomatic. 76.7% of MUs were located on the side of the Roux-limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively.

Conclusion

MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.
Distinct fracture characteristics influence decision making and patient management in fragility fractures of the pelvis – an alternative approach for fracture evaluation
Authors: Ramser M , Cadosch D , Vach W , Saxer F , Eckardt H
Published: May 2021

Objective

Pelvic ring fractures in the elderly with osteoporotic bone are often caused by a minor trauma. A separate classification for these fragility fractures of the pelvis (FFP) has been proposed by Rommens. However, at our institution the management algorithm is rather based on patient profile, clinical course and the ability to mobilize than on the fracture category. We aimed to identify fracture characteristics that might better reflect clinical decision making and show an association with outcome.

Methods

Four fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Ventral comminution/dislocation; 4. Presence of a horizontal sacral fracture.

These four characteristics were assessed retrospectively in a series of 548 patients with a CT scan proven FFP. The association of the fracture morphology with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined.

Results

Three of the four evaluated characteristics showed an independent and significant association with clinical decision making and patient management. In particular the extent of the dorsal fractures was identified as an independent risk factor for the decision to perform surgery with a 7.3-fold increase per category (p < 0.001). The same was observed for the presence of ventral comminution/dislocation (OR = 2.4; p = 0.002). The extent of ventral fractures (OR = 1.5; p = 0.047) was an independent risk factor for a longer LOS in conservatively treated patients.

Conclusion

Three evaluated morphologic aspects of FFPs showed a clear and independent relation to current clinical decision making and patient management at our institution. Importantly, the ventral fracture component has been shown to have major impact on treatment decision and outcome, which has been underestimated in the current FFP classification system.

These four easily distinguishable fracture characteristics have the potential to form the basis of an alternative classification system that matches clinical reality and captures prognostic aspects.
Development of a visual analytics tool for polytrauma patients: Proof of concept for a new assessment tool using a multiple layer sankey diagram in a single-center database
Authors: Niggli C , Pape H -C , Mica L
Published: May 2021

Objective

Early physiological assessment of multiply injured patients is crucial for decision-making and has relied on personal experience of trauma experts. We have developed a new visual analytics tool (Sankey diagram, Watson Trauma Health care tool) that includes known prognostic parameters for polytrauma patients to help guide assessment and treatment decisions for physicians involved in trauma care.

Methods

A prospectively collected trauma database of a single level I trauma center (3655 patients) was used. Inclusion criteria: age > 16 years, an Injury Severity Score (ISS) > 16, and presence of a complete data set in the database. Data collected included admission values of patient age, injury scoring, shock classification, temperature, acid-base and hemostasis parameters. All of these parameters were collected daily as longitudinal parameters. Endpoints of the clinical course we considered were sepsis, SIRS and early in-hospital mortality (<72 hours). A proof of concept of the visualization was developed over a 2-year period in a cooperation between physicians and engineers. Statistically, the most predictive parameters were selected by binary logistic regression and ROC analysis.

Results

A dynamic interactive multi-layer Sankey diagram, based on cohort similarities, was developed in a collaboration between a level I trauma center and IBM, from August 2017 until January 2018. It is a modular tool and allows any user to add a new patient, or work with an existing case. The visualisation used the Data-Driven Documents (D3) interactive visualisation library to create a responsive graphic.

Conclusion

This application summarizes the experience of 3655 polytrauma patients and might serve as a guide for clinical decisions and educative purposes, as well as new scientific questions for the polytrauma patient.
Wide awake local anesthesia no tourniquet (WALANT) – a revolutionary improvement in hand surgery
Authors: Cardell M , Jung F , Zechmann-Müller N , Greminger M , Kern L , Jandali A R
Published: May 2021

Objective

Wide awake local anesthesia no tourniquet (WALANT) hand surgery offers the opportunity to create a bloodless field without using an arm tourniquet. Lidocaine for anesthesia mixed with epinephrine for hemostasis is frequently used without concerns in the hand and finger. This is a major improvement for the patient and the surgeon in terms of patient comfort and having the opportunity to test the hand and finger function intraoperatively. The movement away from tourniquet surgery, which often requires sedation or general anaesthesia is one of the most significant recent advances in hand surgery.

Methods

A subcutaneous infiltration of a mixture (1:100’000) of lidocaine (1%) and epinephrine (buffered 10:1 with 8.4% bicarbonate) is done with a 27 G canula. The mixture is infiltrated wherever surgical dissection, k-wire insertion, or manipulation of fractured bones will occur. The local anesthetic results in an extravascular Bier block. The injection is done slowly from proximal to distal to minimize injection pain. After the last injection a minimum time of 30 minutes should be waited for maximal epinephrine vasoconstriction in the finger.

Results

In the beginning WALANT was only used for small procedures like trigger finger or carpal tunnel release. Meanwhile also major hand surgical procedures like finger fractures, flexor tendon repairs, tendon transfers, arthroscopies, arthroplasties and open triangular fibrocartilage complex (TFCC) repair are performed in WALANT. Even procedures like trapeziectomy have been described using wide awake hand surgery, which involves numbing the joint itself.

Conclusion

The use of WALANT is a proven safe technique that can be used in up to 95% of hand surgical procedures. The benefits for patients and surgeons are obvious. Patients prefer the technique because there are no side effects of opiates or sedation. The anesthetic risk is minimized. Time at hospital is reduced. Patients do not have to suffer tourniquet pain.

Surgeons prefer the technique because of the bloodless surgical field without tourniquet, the possibility of intraoperative testing of stability of prosthesis or fracture stabilization, strength of a tendon repair, the movement and gliding properties in the flexor tendon sheath after repair or testing the tension of tendon transfers. These are probably the reasons for the continuously growing popularity of this technique worldwide.
Treatment of humeral fractures with long PHILOS plates using a modified technique and approach avoids radial nerve palsy in the last 10 years
Authors: Schmeichel S , Oberreiter B , Rikli D
Published: May 2021

Objective

Radialis paresis is a known complication of plate osteosynthesis of the proximal humeral shaft. There are major differences with regard to surgical approach and implant. The standard treatment is a lateral-lateral approach. Here, iatrogenic damage to the radial nerve is a relevant complication. In our institution, these fractures have been treated with an adapted procedure for about 10 years. A long Philos plate is inserted proximally via a deltoido-pectoral approach. The plate is first torqued distally by about 45°-90° and then lies anteriorly on the humerus. The distal screws can be placed via anterior stab incisions. The advantage of this technique is that the implant and approach respect the anatomical course of the radial nerve and it does not have to be manipulated in an open exploratory manner. The aim of the study is to demonstrate the effectiveness of the surgical technique in relation to iatrogenic radial nerve paresis in comparison to the literature.

Methods

We analysed patients with a proximal humeral shaft fracture who were treated at our clinic with a long torqued philos plate using the adapted surgical method over the last 10 years. The fracture, the occurrence of iatrogenic radial damage and biometric data of the patients were analysed retrospectively.

Results

We found a total of 59 patients who underwent surgery according to the above-mentioned scheme between 2010 and 2020. The average age was 70.1 (40-101) years. There were 44 women and 15 men. 2 patients had a preoperatively documented radial nerve damage. In 57 patients, no damage could be found in the radialis supply area both pre- and postoperatively. 2 patients died shortly after surgery, 6 patients were loss to follow up. 2 patients had a tear of the distal plate bearing (1 malcompliance/1 pseudarthrosis). Both had to be revised. In the remaining 47 patients (78%), the healing process was unremarkable.

Conclusion

The described treatment of the proximal humeral shaft fracture has been successfully practised at our clinic for 10 years. Most of the fractures healed without complications. Compared to the exploration of the nerve, this method respects the anatomical course of the nerve and shows in the retrospective analysis that no iatrogenic damage to the radial nerve occurred. Thus, the surgical method represents a valid alternative to the established implants and classical surgical treatments.
VE/VCO2 slope predicts short- and long-term outcome after anatomical pulmonary resection by VATS
Authors: Bédat B , Koliakos E , Licker M -J , Demarchi M , Perentes J , Triponez F , Krueger T , Karenovics W , Gonzalez M
Published: May 2021

Objective

The ventilation-to-carbon dioxide output (VE/VCO2) slope could predict morbidity and mortality after lung resection. The aim of the study was to identify whether VE/VCO2 slope obtained from cardiopulmonary exercise test (CPET) was an independent predictor of cardiopulmonary complications after anatomical pulmonary resection by video-assisted thoracic surgery (VATS).

Methods

We reviewed the files of all consecutive patients that underwent pulmonary anatomical resections by VATS between January 2010 and October 2020. The data were extracted from the registry of the Centre for Thoracic Surgery of Western Switzerland. Pneumonectomies were excluded from the study. We used a multivariable Cox regression to investigate the risk of cardiopulmonary complications associated with the VE/VCO2 slope and other possible confounders, including the Charlson Comorbidity Index (CCI), the CPET data and pulmonary functions.

Results

In total, 1392 patients (mean age: 66±11 years; ratio female: 47%) underwent anatomical resection by VATS. CPET was performed in 204 patients (15%). However, the VE/VCO2 slope data were available in 145 patients, which were included for the analysis. Patients underwent segmentectomies (N = 42) and lobectomies (N = 101) mainly for lung cancer (96%). The average percentage of the predicted VO2max was of 70±17%. Maximal effort during the CPET (respiratory coefficient ratio >1.1) was not reached in 30% of patients, without impact on the VE/VCO2 slope (39±6 vs 37±7, P = 0.21). Cardiopulmonary complications appeared in 32% of patients with no mortality at 90 days. In the multivariate analysis, VE/VCO2 slope >35 was correlated with cardiopulmonary complications (OR 3.5, 95% CI [1.3-9.3], P = 0.012). CCI, pulmonary functions, peak VO2 and the extension of the anatomical resection was not associated with cardiopulmonary complications.

Conclusion

VE/VCO2 slope above 35 predicts postoperative cardiopulmonary complications in anatomical resections by VATS. The VE/VCO2 slope is independent of the intensity of effort during the CPET. The impact of prehabilitation on the slope should be determined.
Is faster better? Impact of operative time on postoperative outcomes after VATS anatomical pulmonary resection
Authors: Forster C , Ojanguren A , Perentes J Y , Zellweger M , Krueger T , Gonzalez M
Published: May 2021

Objective

Video-Assisted Thoracic Surgery (VATS) is now the preferred approach for standard anatomical pulmonary resections. However, operative time (OT) for this technique is correlated to many aspects, such as the surgical complexity or the surgeon’s experience and skills. The aim of this study was to identify the factors associated with prolonged OTs and to assess the impact of OT on the development of post-operative complications after VATS anatomical pulmonary resections.

Methods

Retrospective monocentric study including all consecutive patients undergoing a VATS anatomical pulmonary resection for benign or malignant lesions between January 2010 and December 2019. Postoperative outcomes were compared between short (<150 minutes) and long (≥150 minutes) OTs. A multivariate analysis was carried out to identify predictors of longer OTs and post-operative complications.

Results

A total of 836 patients underwent a VATS anatomical pulmonary resection for malignant (n = 767, 91.7%) or benign (n = 69, 8.3%) lesions. Lobectomies were performed in 555 (66.4%), segmentectomies in 250 (29.9%), sleeve lobectomies in 16 (1.9%), bilobectomies in 11 (1.3%) and pneumonectomy in 4 (0.5%) patients. The conversion rate to thoracotomy was 7.7%. Of those 836 patients, 495 (59.2%) were operated within 150 minutes. During the 30-postoperative day period, the overall morbidity was significantly lower in the short OT group (29.1% vs. 40.5%; p = 0.001). Both the duration of drainage (3 vs. 4 days; p < 0.00001) and the length of hospital stay (6 vs. 7 days; p < 0.00001) were significantly reduced in the short OT group. Two predictors of long OT were identified on multivariate analysis: male sex (OR 1.41, p = 0.04) and neoadjuvant chemotherapy (OR 3.46, p = 0.003). A long OT was identified as an individual predictor of postoperative complications (OR 1.84, p < 0.0001).

Conclusion

A prolonged OT is an individual risk factor for postoperative complications in patients undergoing VATS anatomical pulmonary resection.
Modulating hepatocarcinogenesis by porto-systemic vein shunting in a high-fat diet mouse model
Authors: Peloso A , Gex Q , Tihy M , Moeckli B , Slits F , Rubbia-Brandt L , Oldani G , Lacotte S , Toso C
Published: May 2021

Objective

Non-alcoholic fatty liver disease (NAFLD) is an increasingly common disease, which can lead to hepatocellular carcinoma (HCC). It is associated with an increased portal pressure, which can alter the intestinal barrier, increase the translocation of bacterial products, and further worsen NAFLD. We hypothesized that this vicious circle can be broken by surgical porto-systemic vein shunting (PSVS), and previously demonstrated that PSVS can decrease the histological features of NAFLD in a high-fat diet (HFD) mouse model. We now test whether PSVS can also impact de-novo hepatocarcinogenesis.

Methods

C57BL/6 mice received HFD starting from 4 weeks of age. HCC was induced by intraperitoneal injection of DEN at 25mg/kg on week 2 and PSVS (n = 18) (or sham surgery (n = 18)) are created at 8 weeks. HCC burden was assessed by MRI and, finally, by macroscopic and histomorphology assessments. HCC features of aggressiveness, including solid growth pattern and fat component have been also evaluated.

Results

At 40 weeks of HFD feeding, tumors were identified in all the animals. Shunted HFD mice showed a reduced number of tumor nodules compared to sham (median nodules 8 vs 14, -42.9%; p = 0.0471) while associated to a greater average total tumor volume (709.3 vs 197 mm3, +258,6%; p = 0.0245). This correlated with an increased median tumor volume in shunted mice (16.30 vs 72.45 mm3, +344,5%; p = 0.0011). Notably, HCC histology of shunted mice was hallmarked by accentuated trend concerning HCC fatty change combined to a less pronounced solid growth pattern (p = 0.193).

Conclusion

PSVS leads to the presence of larger HCCs, potentially linked to the proportionally increased arterial supply of the liver. However, it demonstrates a protective effect on HCC carcinogenesis (< number of tumors). Collectively, this data suggests that portal pressure could represent a potential therapeutic target to attenuate liver steatosis and NAFLD-related HCC carcinogenesis.
Dynamic assessment of the impact of gut microbiota transfer in a mouse model of chronic intestinal dysbiosis
Authors: Orci L , Lacotte S , Gex Q , Lazarevic V , Schrenzel J , Toso C
Published: May 2021

Objective

There is growing evidence supporting that the gut microbiota is a major driver of human health and disease. While gut microbiota transfer (GMT) is commonly used as an approach to restore "eubiosis", there is a surprising lack of data on whether the transferred microbiota efficiently and durably repopulate the gut of the transplanted subject. Moreover, little is known on the effects of GMT on non-alcoholic fatty liver disease (NAFLD).

Methods

Chronic dysbiosis and NAFLD-like liver injury were induced by feeding C57Bl/6j mice for 16 weeks with a high-fat diet. For GMT, dysbiotic mice underwent preliminary gut cleansing, followed by oral gavage with a suspension of fresh fecal matter procured from a pool of lean mice (1 dose, or 10 doses). We next characterized microbiota composition and we measured the relative abundance of specific pathobionts in recipient mice, using high-throughput shotgun analysis in a dynamic manner, over time. All experiments took place in a specific germ-free environment.

Results

After 4 months on a high-fat diet, mice displayed fatty liver infiltration with moderate parenchymal inflammatory changes. Dysbiosis was evidenced by a reduced bacterial diversity, as well as a dramatically increased abundance of Firmicutes, and lower Verrucomicrobia and Actinobacteria. Gut microbiota transfer was associated with a transitory reduction in NAFLD-induced hepatocellular injury. While dysbiotic mice displayed a shift in their microbiota composition towards that of lean donors after GMT, this effect rapidly faded after one week, and mice recovered their initial, dysbiotic microbiota.

Conclusion

The current study indicates that, when used in mice with chronically established dysbiosis, GMT is merely associated with transitory changes in gut microbiota composition, as well as significant but moderate reduction in hepatocellular injury.
Brief dietary protein dilution using carbohydrate rich drink protects from kidney ischemia and reperfusion injuries trough IGF-1
Authors: Emsley R , Agius T , Macabrey D , Faivre A , Déglise S , De Seigneux S , Corpataux J -M , Allagnat F , Longchamp A
Published: May 2021

Objective

Lifelong low-protein, high-carbohydrate diets extend lifespan in rodent. Consistently in human, the administration of oral carbohydrate drinks the day before surgery might improve clinical outcome. However, the fundamental questions of what represents a macronutritionally balanced diet, and how this impact surgical stress remain unanswered.

Methods

Here, we induced dietary protein dilution by giving mice ad libitum access to 50% sucrose water, without any food restriction. Mice were randomized into four regimens: regular diet (17,6 % protein, Ctrl), and a low protein diet (5.6% protein, LP), with or without high sucrose water (50% sucrose) for 7 days. At the end of the preconditioning, calorimetric data, fasting blood glucose, IGF1, glucose tolerance, and finally resistance to renal failure following a bilateral renal ischemia-reperfusion was evaluated.

Results

We demonstrate that access to carbohydrate drinks promotes dietary protein restriction despite a total caloric intake that was twice higher. This short-term self-restriction in daily protein, independent of caloric intake, improved insulin sensitivity, reduced serum triglyceride, and enhanced mitochondrial respiration as well as energy expenditure. Importantly, a 7-day pre-conditioning protein dilution regimen promotes recovery following kidney ischemia and reperfusion (IRI), a model of surgical stress. This protection from kidney IRI inversely correlated with pre-operative protein intake, but not carbohydrate or fat. The benefit of a low protein, high-carbohydrate regimen was independent of the protein sensing pathway eIF2α/ATF4, NRF2 and hydrogen sulfide, but instead required Insulin-like growth factor 1 (IGF1) downregulation.

Conclusion

These results support further clinical studies of a low protein diet combined with carbohydrate drinks prior to surgery.
How surgical training in Switzerland affects outcomes and new predictors for teaching
Authors: Moeckli B , Käser S A , Andres A , Toso C
Published: May 2021

Objective

Teaching in the operating room represents the cornerstone of surgical education. Residents need to perform a sufficient number of basic procedures in order to gain independence. However, it is still debated what impact surgical teaching has on outcomes. With this study, we provide recent data of a large national cohort and identify new factors that are associated with increased teaching.

Methods

We studied common procedures that are essential for surgical training: Laparoscopic Appendectomy (LA), Laparoscopic Cholecystectomy (LC), ostomy closure (OC), laparoscopic (LH) and Open Inguinal Hernia Repair (OH). The national database of the Swiss association for quality management in surgery was screened, and 72072 patients were identified from 2009 to 2019. Teaching was defined as a procedure mainly performed by a surgeon in training under supervision.

Results

A minority of basic surgical procedures were used for teaching (LA 28.1%, LC 22.3%, OC 21.5%, OH 31.8%, LH 6.3%), even in teaching hospitals of > 200 beds (LA 33.0%, LC 32.9%, OC 27%, OH 51.5%, LH 6.5%). During the study period, there was also generally a trend towards less teaching, exemplified by the two most frequent procedures: LA 35.6 to 26.7% (-25.0%, p = <0.001), LC 27.6 to 18.9% (-31.5%, p = <0.001). Operating time was significantly longer for procedures that were used for teaching with a more pronounced effect for inguinal hernia repairs: LA 63.4 vs 57.5min (+10.3%, p = <0.001), LC 84.0 vs 74.9min (+12.1%, p = <0.001), OC 88.6 vs 81.6min (+8.6%, p = <0.001), OH 81.5 vs 68.3min (+19.3%, p = <0.001), LH 97.9 vs 73.8min (+32.7%, p = <0.001). The overall complication rate for LA (2.6 vs 1.8%, p = <0.001) and LC (3.6 vs 2.8%, p = <0.001) were slightly higher in the no-teaching group and without a significant difference between the groups for OC, LH and OH. We identified the following parameters associated with increased teaching: A hospital size above 200 beds (OR = 2.48, p = <0.001), an operation during office hours (OR = 1.27, p = <0.001), the summer months (OR = 1.11, p = <0.001) and weekdays (OR = 1.10, p = 0.003).

Conclusion

The teaching of basic surgical procedures appears safe. Even if associated with longer operating times, it should be promoted as teaching is currently only performed in a minority of procedures (10-33%).