bluuebunny/crossref_metadata_2025 huggingface dataset:
Review of Thoracic Causes of Systemic Arterial Air Embolism on Computed Tomography
Authors: Kramer Michael , Parekh Maansi , Modi Roshan Y. , Donuru Achala
Published: November 2019

Systemic arterial air embolism (SAAE) is a rare but potentially life-threatening condition that may occur when air enters into pulmonary veins or directly into the systemic circulation after pulmonary procedures (biopsy or resection) or penetrating trauma to the lung. While venous air embolism is commonly reported, arterial air embolism is rare. Even a minor injury to the chest along with positive-pressure ventilation can cause SAAE. Small amounts of air may cause neurological or cardiac symptoms depending on the affected arteries, while massive embolism can result in fatal cardiovascular collapse. We discuss the various causes of SAAE, including trauma, computed tomography–guided lung biopsy, and various intervention procedures such as mechanical circulatory support device implantation, coronary catheterization, and atrial fibrillation repair. SAAE diagnosis can be overlooked because its symptoms are not specific, and confirmation of the presence of air in the arterial system is difficult. Although computed tomography is the optimal imaging tool for diagnosis, patient instability and resuscitation often precludes its use. When imaging is performed, awareness of the causes of SAAE allows the radiologist to promptly diagnose the condition and relay findings to the clinicians so that treatment, namely hyperbaric oxygen therapy, may be started promptly.
Revisiting the “July Effect” in Plastic Surgery
Authors: Coombs Demetrius M. , Ascha Mustafa S. , Ascha Mona , Gatherwright James , Knackstedt Rebecca , Gurunluoglu Raffi
Published: November 2019

Background

The “July Effect” represents a topic of considerable interest across residency programs. This study investigated the frequency of postoperative complications following procedures with plastic surgery resident participation (all postgraduate year [PGY] levels) during the first (quarter 3, July–September) and last academic quarters.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was used to calculate complication rates from 2006 to 2010. Resident involvement was analyzed as a categorical variable consisting of “juniors” (PGY1–PGY3), and “seniors” (PGY4–PGY6). Outcomes from procedures during Q3 were compared with all quarters. Propensity score matching and adjustment enabled logistic regression identifying the effect of resident involvement and admission.

Results

Among all cosmetic and reconstructive procedures (n = 6625), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.069); no significant differences in complication rates were observed between Q3 and all other quarters, though superficial surgical site infection (SSI) approached significance (3.3% of procedures in Q3 vs 2.5% in all other quarters, P = 0.063). Among reconstructive procedures only (n = 5677), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.119); the same held true for cosmetic procedures only (P = 0.275). Surgical site infection, however, was significantly more likely to occur with reconstructive procedures only, in Q3 compared with all other quarters (3.5% of cases vs 2.3%, P = 0.024). When adjusting for PGY status and matching populations, superficial SSI and return to the operating room were not significantly more common in Q3. When adjusting for quarter of admission, however, superficial SSI was significantly more common among the overall and noncosmetic cases with participation by junior residents (P = 0.013 and 0.020, respectively).

Conclusions

This may represent the first fully reproducible, transparent National Surgical Quality Improvement Program study in plastic surgery that demonstrates the absence of a clinically significant “July Effect,” and suggests that an appropriate degree of resident autonomy may pose minimal risk during both cosmetic and reconstructive procedures in residency training. Additionally, the findings encourage the development a plastic surgery-specific database to remedy inherent difficulties with larger, more comprehensive surgical databases.
The Multifactorial Contribution of Publications in Plastic Surgery Journals in Microsurgery Education
Authors: Boczar Daniel , Sisti Andrea , Restrepo David J. , Oliver Jeremie D. , Huayllani Maria T. , Ball Colleen T. , Spaulding Aaron C. , Cochuyt Jordan J. , Rinker Brian D. , Forte Antonio J.
Published: November 2019

Background

Microsurgery is one of the most complex operative skills. Recent restrictions on residents’ working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education.

Methods

A comprehensive literature search was performed.

Results

We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends.

Conclusion

There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.
Revisiting the Reverse Sural Artery Flap in Distal Lower Extremity Reconstruction
Authors: Daar David A. , Abdou Salma A. , David Joshua A. , Kirby David J. , Wilson Stelios C. , Saadeh Pierre B.
Published: November 2019

Background

The reverse sural artery flap (RSAF) is a popular option for patients with distal lower extremity defects who are not ideal candidates for free flap reconstruction. This is the first systematic review and pooled analysis of surgical characteristics, risk factors, and outcomes of the RSAF.

Methods

A systematic literature review was conducted. All studies reporting on patients undergoing RSAF reconstruction and their outcomes were included. Outcomes were pooled and analyzed using Fisher exact or χ2 test.

Results

Forty-three studies (479 patients, 481 flaps) were analyzed. The majority of patients were male (70.3%), and average ± SD age was 46.9 ± 16.7 years. Rates of smoking, diabetes mellitus (DM), and peripheral vascular disease (PVD) were 34.6%, 35.4%, and 12.3%, respectively. Defect etiologies were largely traumatic (60.4%). The most common defect location was the heel (40.8%). Flap modifications were reported in 123 flaps (25.6%). The most common modification was adipofascial extension (20.3%).

Overall, the partial and total flap loss rates were 15.4% and 3.1%, respectively. Partial flap loss was significantly increased in smokers (28.9% vs 12.2% in nonsmokers, P = 0.0195). Technical modifications decreased the odds of partial necrosis by almost 3-fold compared with traditional RSAF reconstruction (7.2% vs 17.9%; odds ratio, 2.8 [1.4–5.8]; P = 0.0035). Patient age, DM, and PVD were not significantly associated with flap loss.

Conclusions

The RSAF remains a safe salvage option for patients with DM or PVD but should be used with caution in smokers. Technical modifications to minimize pedicle compression significantly reduce rates of partial necrosis.
The American College of Surgeons National Quality Improvement Program Incompletely Captures Implant-Based Breast Reconstruction Complications
Authors: Banuelos Joseph , Taslakian Editt N. , Nguyen Minh-Doan T. , Manrique Oscar J. , Tran Nho V. , Martinez-Jorge Jorys , Hieken Tina , Jakub James , Habermann Elizabeth B. , Sharaf Basel
Published: November 2019

Background

Implant-based breast reconstruction (IBR) accounts for 70% of postmastectomy reconstructions in the United States. Improving the quality of surgical care in IBR patients through accurate measurements of outcomes is necessary. The purpose of this study is to compare the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data from our institution to our complete institutional health records database.

Methods

Data were collected and recorded for all patients undergoing IBR at our institution from 2015 to 2017. The data were completely identified and compared with our institutional NSQIP database for demographics and complications.

Results

The electronic health records data search identified 768 IBR patients in 3 years and NSQIP reported on 229 (30%) patients. Demographics were reported similarly among the 2 databases. Rates of tissue expander/implant infections (5.9% vs 1.8%; P = 0.003) and wound dehiscence (3.5% vs 0.4%; P = 0.003) were not reported similarly between our database and NSQIP. However, the rates of hematoma (2.7% vs 1.8%) and skin flap necrosis (2.5% vs 1.8%) were comparable between the two databases. In our database, 43% of all complications presented after 30 days of surgery, beyond NSQIP's capture period.

Conclusions

Databases built on partial sampling, such as the NSQIP, may be useful for demographic analyses, but fall short of providing data for complications after IBR, such as infections and wound dehiscence. These results highlight the utility and importance of complete databases. National comparisons of clinical outcomes for IBR should be interpreted with caution when using partial databases.
The Utility of Diagnostic Tests for Digital Nerve Injury
Authors: Rubin Guy , Orbach Hagay , Rinat Barak , Shay Ravit , Rozen Nimrod
Published: November 2019

Purpose

The purpose of this study was to present the sensitivity and specificity of 6 clinical tests for the diagnosis of digital nerve injury. The clinical tests are as follows: light touch, pinprick, static and dynamic 2-point discrimination (D2PD), Semmes-Weinstein monofilament, and wrinkle test.

Methods

We reviewed the charts of all the patients who were admitted to our department with hand lacerations and/or suspicions of digital nerve injury that were examined before surgery with the 6-sensation test, comparing the results to the surgical findings.

Results

The study included 70 patients with 85 injured nerves overall. Of the 85 nerves, 51 were found with full cut, 9 with partial cut, and 25 with no cut. Only 2 variables were significantly associated with the study outcome: D2PD > 4 (P = 0.0141, odds ratio = 3.9, 95% confidence interval = 1.3–11.8, sensitivity = 80.7%, specificity = 48%) and wrinkle test (P = 0.0098, odds ratio = 4.0, 95% confidence interval = 1.4–11.6, sensitivity = 69.5%, specificity = 62.5%).

Multivariable logistic regression included these variables and revealed the predictive probability for a nerve injury to be 92% if both risk factors exist and 43% if none of these risk factors exist. If one risk factor exists, the predictive probability for a cut is still very high (75%).

Conclusions

The combination of positive wrinkle test and D2PD > 4 gave a predictive probability for a nerve injury as 92% in the cases in our study and should be considered in the evaluation of patients with hand lacerations and suspicions of digital nerve injury.
Anterolateral Thigh Flap Design by Using Suprafascial Course of the Perforator
Authors: Ulas Bali Zulfükar , Keçeci Yavuz , Pabuşcu Yüksel , Yoleri Levent
Published: November 2019

Objectives

Recently, anterolateral thigh flap has become one of the most commonly used free flaps in reconstructive surgery. Although its pedicle has relatively sufficient length, it falls short in some circumstances. Eccentric perforator location can be used to lengthen the pedicle, but flap tip viability can be a problem in this case. In addition, partial flap loss can be encountered in perforator flaps. The aim of this study was the use of multidetector computed tomographic angiography in preoperative mapping to overcome these problems.

Materials and Methods

Anterolateral thigh perforator flap was planned for various soft-tissue reconstructions in 19 patients. There were 15 males and 4 female patients with ages ranging from 19 to 65 years. These patients were evaluated with preoperative multidetector computed tomographic angiography to choose and to trace the course of the perforators. Flaps were designed according to the suprafascial course of the perforators. Perforators were safely located eccentrically when needed. Pedicle length and complications, such as infection, wound dehiscence, and partial or total flap loss, were recorded.

Results

Perforators were located eccentrically in 8 patients and centrally in the other 11 patients. Eleven flaps were used in lower leg reconstruction, 2 flaps in popliteal region, and 6 flaps in head and neck. All flaps survived and any partial or total loss did not occur. There was not any infection and wound problem.

Conclusions

Multidetector computed tomographic angiography can reveal the suprafascial course of the perforator and help design anterolateral thigh perforator flap. By using this kind of mapping, perforators can be safely located eccentrically to lengthen the pedicle and partial flap loss can be prevented.
The Epidemiology of Upper Extremity Nerve Injuries and Associated Cost in the US Emergency Departments
Authors: Tapp Marion , Wenzinger Eric , Tarabishy Sami , Ricci Jerec , Herrera Fernando A.
Published: November 2019

Background

The purpose of our study was to determine the incidence and average cost of nerve injuries in patients presenting with upper extremity trauma.

Methods

The Nationwide Emergency Department Sample database was queried using International Classification of Diseases, Ninth Revision codes specific to peripheral nerve injuries of the upper extremity. Data on the incidence, patient demographics, average number of associated diagnoses, Injury Severity Scale (ISS) score, mechanism of injury, and average cost of care were collected and analyzed.

Results

Of 1.58 million upper extremity traumatic injuries, there were 5244 nerve injuries, resulting in an annual incidence of 16.9 per 100,000 persons with an average age of 38.42 years. Ulnar nerve injuries were the most common (3.86 per 100,000) followed by digital nerve (2.96 per 100,000), radial nerve (2.90 per 100,000), and median nerve (2.01 per 100,000). Injuries to the brachial plexus had the highest average ISS score (9.79 ± 0.71) and number of presenting diagnoses (8.85 ± 0.61) while having a lower than average emergency department (ED) cost. Patients with digital nerve injuries had the highest average ED cost ($8931.01 ± $847.03), whereas their ISS score (2.82 ± 0.19) and number of presenting diagnoses (4.92 ± 0.22) were the lowest. The most commonly reported mechanism of injury in this study population was from a laceration (29.2%) followed by blunt injury, fall (14.8%), and being struck (7.20%). Males were 2.14 (2.01–2.28) times more likely to have an injury to an upper extremity nerve and 3.25 (2.79–3.79) times more likely to injure a digital nerve.

Conclusions

While there was a low incidence of upper extremity nerve injuries associated with upper extremity trauma, the ulnar nerve was most frequently injured. Males were twice as likely to sustain a traumatic upper extremity nerve injury, with laceration being the most common mechanism of injury. The average ED cost associated with upper extremity nerve injuries in the United States was determined to be approximately $5779.
Factors Affecting Healing in the Treatment of Hidradenitis Suppurativa
Authors: Worden Andrew , Yoho Daniel J. , Houin Herman , Moquin Kenneth , Hamzavi Iltefat , Saab Ihab , Siddiqui Aamir
Published: November 2019

Background

Hidradenitis suppurativa (HS) is a chronic debilitating condition. Treatment of HS depends on disease stage, goals of care, access to care, and frequency of symptoms. We present our experience with surgical treatment for patients with HS.

Methods

Patients were followed longitudinally for at least 2 years postsurgical intervention. Demographic data, participation in a multidisciplinary program, type of surgery, healing rates, and potential factors contributing to wound healing were retrospectively reviewed in all cases using multivariate analysis.

Results

Two hundred forty-eight patients met the inclusion criteria with a total of 810 involved sites. Overall, 59% of patients had Hurley stage 3 disease at the time of surgery. Healing rates of 80% were observed in stages 1 and 2, and 74% were observed in stage 3. Hurley stage was not a significant predictor of healing (P = 0.09). Surgical treatment consisted of 38% incision and drainage, 44% excision without closure, and 17% excision with primary closure. Incisional and excisional treatments healed 78% and 79%, respectively, at 2 years. Primarily repaired defects (grafts and flaps) were 68% healed at 2 years. Observed healing rates were uniform regardless of the number of sites involved (P = 0.959). Participation in the multidisciplinary program was the strongest predictor of healing (78% vs 45%, P = 0.004). Sex, age, body mass index, tobacco use, diabetes, presurgery hemoglobin, and family history of HS were statistically not significant. Continuation of immune modulating therapy within 2 weeks of surgery was a predictor of reduced healing (odds ratio, 0.23; P = 0.004), whereas holding biologics for at least 2 weeks was not significant (odds ratio, 1.99; P = 0.146).

Conclusions

Participation in a multidisciplinary program is a strong predictor of long-term success when treating HS. Hurley score and number of involved sites did not correlate with successful healing after surgery. If taking biologics, we identified 2 weeks as an appropriate break from biologics before and after surgical intervention. Healing rates were highest with ablative procedures (incision and drainage, excision) alone.
Chest Wall Masculinization in Female-to-Male Transsexuals
Authors: Morselli Paolo G. , Summo Valeria , Pinto Valentina , Fabbri Erich , Meriggiola Maria C.
Published: November 2019

Esthetic masculinization of the chest wall is one of the first surgical steps in female-to-male transsexual (FTMTS) reassignment.

This surgical procedure is not a simple mastectomy: it is required for removal of breast tissue with glandular resection and skin excess revision, to reduce and replace the nipple-areola complex in the right location, minimizing chest wall scars. The creation of an esthetically pleasing male chest allows the patient to live at ease in the male gender role.

In this article, we present our series of 68 FTMTSs who underwent bilateral mastectomies for surgical sexual reassignment (a total of 136 mastectomies) according to our algorithm, in the period between January 2010 and December 2017. We selected 4 different operative procedures, classified as subcutaneous (“pull-through” and “concentric circular” techniques) and skin extended (“ultrathin vertical bipedicle” and free nipple graft).

We achieved a total complication rate of 6.6%, less than that reported in the literature; additional procedures for esthetic improvements were performed in 14.7% of cases. The mean patient satisfaction was approximately 4.57% of a maximal value of 5 (excellent).

To help surgeons in choosing the most appropriate FTMTS surgical technique and to reduce unfavorable results, we propose the use of our treatment algorithm in preoperative evaluation of the chest wall according to the breast volume, degree of glandular ptosis, and skin elasticity.
Impact of Obesity on Quality of Life After Breast Reconstruction
Authors: Koh Eugene , Watson David I. , Dean Nicola R.
Published: November 2019

Background

There is an increasing prevalence of obesity in society, often associated with increased medical comorbidities and surgical complications. Some health providers are now placing a body mass index (BMI) limit on whom can be offered breast reconstruction. The objective of this study was to determine the impact of obesity on quality of life as measured by the BREAST-Q, in women undergoing breast reconstruction.

Methods

A review of the breast reconstruction database (n = 336) at the Flinders Breast Reconstruction Service was performed, with demographic data, complication rates, and BREAST-Q data being extracted and analyzed. Participants were divided into 2 groups: nonobese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2) for comparison.

Results

Preoperatively, obese women scored lower than nonobese women in terms of BREAST-Q scores. Mean prereconstruction scores were 51.62 versus 57.10 (psychosocial), 40.18 versus 48.14 (satisfaction with breasts), and 34.30 versus 40.72 (sexual well-being) (all P < 0.05), and 68.48 versus 72.15 (physical well-being) (P = 0.08). At 12 months post–mound reconstruction, there was a significant improvement in scores in both groups. Additionally, there were no significant differences for BREAST-Q scores between the 2 groups 12 months after surgery. While there was a significantly higher minor complication rate in the obese group compared with the nonobese group, there was no significant difference in the rate of major complications (eg, requiring revision surgery) between the 2 groups.

Conclusions

Obese participants gain a similar, if not better, improvement in quality of life after breast reconstruction, despite a higher rate of minor complications. This study did not support withholding breast reconstruction from obese women.
Segmental Corticotomy-Assisted Orthodontic Treatment With Platelet-Rich Fibrin Augmentation of Class III Anomaly
Authors: Esenlik Elçin , Günaydin Arzu , Findik Yavuz
Published: November 2019

This clinical report presents the outcomes of segmental corticotomy-assisted orthodontic treatment in a class III patient. A 13.5-year-old female patient presented with class III anomaly and a thin alveolus in the mandibular anterior region. After the alignment of the mandibular incisors, segmental corticotomy with platelet-rich fibrin (PRF) was performed in the mandibular incisor area to facilitate incisor retraction to ensure periodontal support after the changes in the inclination of the teeth. Lateral cephalograms were taken at the beginning (T0), precorticotomy (T1), at the end of the treatment (T2), and 2 years after the treatment (T3). Cone-beam computed tomography (CBCT) records were collected at the T1, T2, and T3 periods to evaluate the bone structures. The measurements included the inclination and the position of the mandibular incisors, symphysis width, symphysis height, B-B′ width, cervical alveolar width, the vertical alveolar bone level on the labial and the lingual sides, and the amount of labial and lingual bone at the apex in the mandibular central incisor and canine areas.

The class I molar and canine relationship was achieved in this borderline case. The amount of labial bone at the root apex and the B-B′ width increased. A vertical alveolar bone gain was observed. The facial profile was improved significantly. The treatment outcome was stable at the 2-year follow-up. The segmental anterior mandibular corticotomy provided an effective correcting inclination of the mandibular teeth with the use of class III elastics. This technique ensured the maintenance of a sufficient amount of labial bone with no periodontal side effects.
The Surface and Intracranial Location of Asterion
Authors: Babacan Serdar , Yildiz-Yilmaz Meriç , Kafa Ilker Mustafa , Coşkun Ihsaniye
Published: November 2019

Background:

Asterion is identified as the connection point of sutura parietomastoidea, sutura occipitomastoidea, and sutura lambdoidea. The location of asterion, which is primarily preferred as a landmark during posterolateral surgical approach for intracranial operations, shows many variables. The aim of this study was to identify the surface location of the asterion and determine the distances between intracranial anatomical structures and asterion.

Methods:

At this present study, 11 hemicraniums (22 asterion points), situated at the laboratory of Department of Anatomy, Faculty of Medicine, Bursa Uludag University, were used. The asterion points which the sesamoid bone located were classified as type I and the ones which sesamoid bone did not locate were classified as type II. According to the proximity of asterion with sinus transversus, 3 groups were classified. About 19 parameters were measured related to asterion. The obtained data were analyzed in SPSS 22.

Results:

As a result of findings, while sesamoid bone was seen at 7 asterion points (type I), at 15 points sesamoid bone was not detected (type II) (respectively, 31.81%, 68.19%). It was identified that 15 asterion points were at the surface, 5 ones were average 3.42 ± 2.52 mm over, 2 ones average 3.21 ± 2.26 mm below of the projection of sinus transversus. Statistically significance was not seen between the measurements taken from left and right sides.

Discussion and Conclusion:

Asterion is an important landmark for the retrosigmoid approaches. The surface and intracranial location of the asterion and proximity with dural sinuses are important for surgeons not to cause fatal subdural hematomas during the approaches using “Burr Hole” technic in neurochirurgie operations.
An Objective Assessment of Orthognathic Surgery Patients
Authors: Eslamian Ladan , Borzabadi-Farahani Ali , Badiee Mohammad Reza , Le Bach T.
Published: November 2019

Objectives:

To retrospectively assess malocclusions, skeletal relationships and the functional needs of orthognathic patients treated in a University teaching hospital.

Subjects and methods:

This study used clinical records of 100 consecutive patients [51 female, 49 males, mean (SD) age =21.5 (2.71) years] who had orthognathic surgery in a Shahid Beheshti University of Medical Sciences affiliated hospital (9/2014–7/2017). Malocclusion type (incisor classification), sagittal skeletal pattern (ANB angle), index of orthognathic functional treatment need (IOFTN) score, and osteotomy type were recorded.

Results:

Overall, 66%, 31%, and 3% had Class III, II, and Class I malocclusions, respectively. Similarly, 68% and 32% had Class III and II sagittal skeletal relationships, respectively. Overall, 95% of patients scored IOFTN 4 or 5. The most prevalent IOFTN score were 4.3 (37%), 5.3 (16%), 5.4 (16%), and 4.2 (10%). There were no gender differences (P >0.05) for the distribution of malocclusions, sagittal skeletal relationships, different IOFTN scores, or when IOFTN scores were re-grouped (5, 4, and ≤3). When IOFTN scores were re-grouped (5, 4, and ≤3), they were equally distributed among patients with Class II or III skeletal relationships (P >0.05), but when the authors looked at different malocclusions, there were significant differences in IOFTN score distribution (P= 0.006). The use of genioplasty (4%) or distraction osteogenesis (2%) was limited. Single jaw surgery of either maxilla or mandible was used in 15% and 22% of patients, respectively. About 63% had undergone double-jaw surgery.

Conclusion:

Retrospective assessment using IOFTN identified 95% of patients as having great and very great functional needs, but prospective studies using IOFTN is needed to assess the need for orthognathic surgery. Class III malocclusions and Class III sagittal skeletal relationships were more common in this sample.
Closure of Multiple Defects From Titanium Mesh After Cranioplasty With a Super-Long Diagonal Tubed Flap of the Neck
Authors: Wang Di , Chen Wen
Published: November 2019

Objective:

Titanium mesh is one of the most widely used materials for cranioplasty, but risk of exposure is significant. Hence, removal of implants is a routine procedure. We used a diagonal tubed flap of the neck to repair 3 defects without removal of the titanium mesh.

Patient and Methods:

An outpatient, who suffered from three fistulas on the scalp after titanium cranioplasty received a super-long diagonal tubed flap of the neck surgery. The entire procedure was performed in the outpatient operating room.

Results:

All the 3 fistulas were completely covered by the tubed flap, and no complications were observed. In the 5-year follow-up, the color, thickness and texture were satisfactory, and the scars were inconspicuous.

Conclusion:

The surgery using a super-long diagonal tubed flap of the neck was innovative, flexible and economical, and is recommended as a suitable choice for reconstruction of local multiple defects, especially the rounded ones.
Oncologic Outcomes After Robotic Pancreatic Resections Are Not Inferior to Open Surgery
Authors: Girgis Mark D. , Zenati Mazen S. , King Jonathan C. , Hamad Ahmad , Zureikat Amer H. , Zeh Herbert J. , Hogg Melissa E.
Published: November 2019

Objective:

Compare oncologic outcomes after open and robotic pancreatic resections for pancreatic adenocarcinoma (PDAC).

Summary of Background Data:

Receipt of adjuvant chemotherapy improves survival after resected PDAC. Complications after pancreatectomy have been shown to prohibit the administration of adjuvant chemotherapy and survival. We examined the effect of surgical approach on receipt of adjuvant chemotherapy, complications, and overall survival after pancreatectomy.

Methods:

A single-institution retrospective review of all patients with PDAC who underwent robotic or open pancreatectomy from 2011 to 2016 with 24-month follow-up.

Results:

Four hundred fifty-six patients underwent resection: 226 robotic and 230 open. No significant difference was identified in major complications or receipt of adjuvant chemotherapy between robotic and open pancreatectomy, nor was approach an independent predictor of these outcomes. Robotic pancreatectomy patients had a shorter length of stay than patients who underwent open pancreatectomy (7 days vs 9 days; P < 0.001). Additionally, wound infection rate (32.3% vs 12.4%, P < 0.0001) and transfusion (39.6% vs 12.4%, P < 0.0001) was improved in robotic pancreatectomy group with no differences in perioperative mortality. Improved median overall survival approached statistical significance for the robotic cohort (25.6 months vs 23.9 months; P = 0.055); however, on multivariable analysis the robotic approach predicted overall survival, (hazard ratio 0.77, P = 0.041). Robotic approach was an independent predictor of decreased blood loss and less transfusions than the open approach.

Conclusions:

Robotic pancreatectomy was not inferior compared to open pancreatectomy in a high-volume experienced center for oncologic outcomes and due to decreased blood loss and transfusion may have improved survival.
The 100 Most Cited Papers in the History of the American Surgical Association
Authors: Landreneau Joshua P. , Weaver Matthew , Delaney Conor P. , Aminian Ali , Dimick Justin B. , Lillemoe Keith D. , Schauer Philip R.
Published: November 2019

Objective:

The aim of this study was to determine characteristics of the most cited publications in the history of the American Surgical Association (ASA).

Summary Background Data:

The Annals of Surgery has served as the journal of record for the ASA since 1928, with a special issue each year dedicated to papers presented before the ASA Annual Meeting.

Methods:

The top 100 most cited ASA publications in the Annals of Surgery were identified from the Scopus database and evaluated for key characteristics.

Results:

The 100 most cited papers from the ASA were published between 1955 and 2010 with an average of 609 citations (range: 333–2304) and are included among the 322 most cited papers in the Annals of Surgery. The most common subjects of study included clinical cancer (n = 43), gastrointestinal (n = 13), cardiothoracic/vascular (n = 9), and transplant (n = 9). Ninety-three institutions were included lead by Johns Hopkins University (n = 9), University of Pittsburgh (n = 8), Memorial Sloan-Kettering (n = 7), John Wayne Cancer Institute (n = 7), University of Texas (n = 7), and 5 each from Brigham and Women's Hospital, Mayo Clinic, and University of Chicago. The majority of manuscripts came from the United States (n = 85), followed by Canada (n = 7), Germany (n = 5), and Italy (n = 5). Study design included randomized controlled trials (n = 19), retrospective matched cohort studies (n = 11), retrospective nonmatched studies (n = 46), and other (n = 24).

Conclusions:

The top 100 most cited publications from the ASA are highly impactful, landmark studies representing a diverse array of subject matter, investigators, study design, institutions, and countries. These influential publications have immensely advanced surgical science over the decades and should serve as inspiration for all surgeons and surgical investigators.
Multicenter Study of the Treatment of Appendicitis in America
Authors: Yeh Daniel Dante , Eid Ahmed I. , Young Katelyn A. , Wild Jeffrey , Kaafarani Haytham M. A. , Ray-Zack Mohamed , Kana’an Tala , Lawless Ryan , Cralley Alexis L. , Crandall Marie
Published: November 2019

Objective:

We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States.

Summary Background Data:

Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons.

Methods:

This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a “complicated” outcome variable and risk factors were assessed using multivariable logistic regression.

Results:

A total 3597 subjects were enrolled across 28 sites: median age was 37 (27–52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1–2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of “complicated” appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not.

Conclusion:

In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for “complicated” appendicitis.
Prevalence of Nocturia in United States Women: Results From National Health and Nutrition Examination Survey
Authors: Daugherty Michael , Ginzburg Natasha , Byler Timothy
Published: November 2019

Introduction

Nocturia can be one of the most bothersome lower urinary tract symptoms that can significantly affect quality of life. In both sexes, nocturia has been associated with decreased overall health. We aim to assess the prevalence of nocturia in US females and identify factors associated with significant nocturia.

Methods

A cross-sectional, US population-based database (National Health and Nutrition Examination Survey) was queried for females surveyed during the years 2009 to 2014. Nocturia information was obtained from the question, “how many times do you urinate at night?” Significant nocturia was defined as those women who urinated 2 or more times per night. Demographic characteristics, information on urinary incontinence, and gynecologic/obstetrical history were analyzed. Multivariable logistic regression was performed to identify factors associated with significant nocturia.

Results

A total of 7620 adult women were available for analysis. Of all women, 28.8% (95% confidence interval, 27.3–30.3) reported significant nocturia. Nocturia rates increased with increasing age (P < 0.0001). For those women who underwent childbirth, delivery type had no association with nocturia (P = 0.23). On multivariable analysis, only increasing age, black race, body mass index of 30 or greater, urge incontinence, and poor overall health were associated with increased rates of nocturia. Higher levels of education and increased household income were associated with lower rates of nocturia.

Conclusions

Nocturia is prevalent in the United States with almost 30% of all women reporting significant nocturia. Importantly, nocturia does not affect only older individuals, as 1 in 6 women under the age of 40 years report waking 2 or more times per night to urinate.
Use of ketamine for prehospital pain control on the battlefield: A systematic review
Authors: de Rocquigny Gaël , Dubecq Christophe , Martinez Thibault , Peffer John , Cauet Amandine , Travers Stéphane , Pasquier Pierre
Published: November 2019

BACKGROUND

Intravenous ketamine is commonly used for pain management in the civilian prehospital setting. Several studies have evaluated its effectiveness in the military setting. To date, there has been no report reviewing the published data on the use of ketamine in this context. The objective of this systematic review was to analyze the content and quality of published data on the use of ketamine for prehospital pain management in military trauma.

METHODS

The MEDLINE database was searched for studies on ketamine use in combat prehospital settings, at point of injury or during evacuation, published between 2000 and 2019. The systematic review was conducted following PRISMA guidelines, and the protocol was registered on PROSPERO (CRD42019115728). Civilian reports and case series lacking systematic data collection were excluded.

RESULTS

Eight studies were included with 2029 casualties receiving ketamine. All but one were American reports from Afghanistan and Iraq conflicts. Studies implied retrospective cohorts or prospective observational analysis. Ketamine use rose from 3.9% during the period preceding its addition to the Tactical Combat Casualty Care guidelines in 2012 to 19.8% thereafter. It was the most common analgesic administered (up to 52% of casualties) in one of the studies. Ketamine was more likely given during tactical medical evacuation when no analgesic was provided at the point of injury. The median total intravenous dose was 50 mg. Pain intensity decreased from moderate or severe to mild or none, sometimes after only one dose. In one study, ketamine administration during tactical evacuation was associated with increased systolic blood pressure as opposed to morphine. Incoherent speech, extremity movements, and hallucinations were the main adverse events reported.

CONCLUSION

Published data on ketamine use in military trauma are rare and heterogeneous. Though, all studies tend to strengthen the belief in the efficacy and safety of ketamine when given at 50-mg to 100-mg intravenous for prehospital analgesia in combat casualties.

LEVEL OF EVIDENCE

Systematic Review, Level IV.
Prevalence and prognostic impact of inhalation injury among burn patients: A systematic review and meta-analysis
Authors: Galeiras Rita , Seoane-Quiroga Leticia , Pértega-Díaz Sonia
Published: November 2019

BACKGROUND

The objective of our study was to perform a systematic review and meta-analysis aimed at assessing the prevalence of inhalation injury in burn patients and its prognostic value in relation to in-hospital mortality.

METHODS

We searched the PubMed and EMBASE databases for noninterventional studies published between 1990 and 2018 investigating in-hospital mortality predictors among burn patients.

The primary meta-analysis evaluated the association between inhalation injury and mortality. A secondary meta-analysis determined the global estimate of the prevalence of inhalation injury and the rate of mortality. Random effects models were used, and univariate meta-regressions were used to assess sources of heterogeneity. This study is registered in the PROSPERO database with code CRD42019127356.

FINDINGS

Fifty-four studies including a total of 408,157 patients were selected for the analysis. A pooled inhalation prevalence of 15.7% (95% confidence interval, 13.4%–18.3%) was calculated.

The summarized odds ratio of in-hospital mortality secondary to an inhalation injury was 3.2 (95% confidence interval, 2.5–4.3). A significantly higher odd of mortality was found among the studies that included all hospitalized burn patients, those that included a lower proportion of male patients, those with a lower mean total body surface area, and those with a lower prevalence of inhalation injury.

CONCLUSION

Despite our study's limitations due to the high risk of bias and the interstudy heterogeneity of some of our analyses, our results revealed a wide range of prevalence rates of inhalation injury and a significant association between this entity and in-hospital mortality in burn patients. However, this association is not significant if adjusted for disease severity.

LEVEL OF EVIDENCE

Systematic review/meta-analysis, level III.
Is all plasma created equal? A pilot study of the effect of interdonor variability
Authors: Chipman Amanda M. , Pati Shibani , Potter Daniel , Wu Feng , Lin Maximillian , Kozar Rosemary A.
Published: November 2019

BACKGROUND

Clinical benefits of plasma as an adjunct for treatment of hemorrhagic shock (HS) have been well established. However, its use is not without risk. Little is understood regarding the clinical implications of plasma variability. We hypothesized there to be interdonor variability in plasma that would impact endothelial and organ function postinjury.

METHODS

Pulmonary endothelial cells (ECs) were incubated with plasma from 24 random donors, and transendothelial electrical resistance was measured. Plasma units with a more or less protective effect on reducing EC permeability were selected for testing in vivo. Syndecan-1 and cytokines were measured. Mice underwent laparotomy and then HS followed by resuscitation with the selected plasma units and were compared with mice receiving no resuscitation and shams. Lung tissue was sectioned and stained for myeloperoxidase and pulmonary syndecan-1 and scored for lung histopathologic injury.

RESULTS

Plasma from 24 donors revealed variability in the reversal of EC monolayer hyperpermeability; transendothelial electrical resistance for the more protective plasma was significantly higher than that for the less protective plasma (0.801 ± 0.022 vs. 0.744 ± 0.035; p = 0.002). Syndecan-1 was also markedly increased in the less protective compared with the more protective plasma (38427 ± 1257 vs. 231 ± 172 pg/mL, p < 0.001), while cytokines varied. In vivo, the more protective plasma mitigated lung histopathologic injury compared with the less protective plasma (1.56 ± 0.27 vs. 2.33 ± 0.47, respectively; p = 0.005). Similarly, myeloperoxidase was significantly reduced in the more protective compared with the less protective plasma group (2.590 ± 0.559 vs. 6.045 ± 1.885; p = 0.02). Lastly, pulmonary syndecan-1 immunostaining was significantly increased in the more protective compared with the less protective plasma group (20.909 ± 8.202 vs. 9.325 ± 3.412; p = 0.018).

CONCLUSION

These data demonstrate significant interdonor variability in plasma that can adversely influence the protective effects of plasma-based resuscitation on HS-induced lung injury. This may have important implications for patient safety and clinical outcomes.
Safe Management of Nausea and Vomiting During Pregnancy in the Emergency Department
Authors: Garcia Saborio Olga Elena , Hines Brittany K. , Wesselman Jillian
Published: November 2019

Nausea and vomiting during pregnancy are a frequent complaint in the emergency department, with a significant economic burden on the patient and health care system. The American College of Obstetricians and Gynecologists (ACOG) in January 2018 released an updated practice bulletin discussing the latest guidelines to managing nausea and vomiting during pregnancy. This article discusses the incidence, prevalence, and economic costs regarding medical visits for pregnancy-associated nausea and vomiting. It also discusses ACOG guidelines and furthermore outlines special considerations, management, admission, and discharge criteria for pregnant patients presenting to the emergency department for nausea and vomiting.
A Practical Guide for Managing Antibiotic Allergies in the Emergency Department
Authors: Chastain Daniel B. , Steele Gregory M. , Sams Joeanna I.
Published: November 2019

Up to 30% of patients report at least one antibiotic allergy, but oftentimes these antibiotic allergies are misdiagnosed. In fact, of the 10% of patients reporting penicillin allergies, 90%–98% are not truly allergic. In an era of increasing antibiotic resistance coupled with a limited number of new antibiotics, evaluating antibiotic allergies is critical in providing optimal patient care. Differentiating adverse drug reactions from antibiotic allergies may seem like a daunting task for clinicians and providers, especially in the emergency department, where decisions are made quickly. However, a systemic approach, including medical record review coupled with patient and/or family interview, is vital in managing patients with antibiotic allergies. Inappropriate, alternative antibiotics are frequently chosen due to patient allergies, and data suggest higher rates of broad-spectrum antibiotic use, antibiotic resistance, and poor outcomes as a result. Herein, we review antibiotic selection in patients reporting antibiotic allergies in the emergency department.
Spontaneous, Voluntary, and Reflex Blinking in Clinical Practice
Authors: Valls-Sole Josep
Published: November 2019

Blinking is one of the motor acts performed more frequently by healthy human subjects. It involves the reciprocal action of at least two muscles: the orbicularis oculi shows a brief phasic activation while the levator palpebrae shows transient inhibition. In clinical practice, noninvasive recording of the orbicularis oculi activity is sufficient to obtain useful information for electrodiagnostic testing. Blinking can be spontaneous, voluntary, or reflex. Although the analysis of spontaneous blinks can already furnish interesting data, most studies are based on reflex blinking. This article is a review of some of the alterations that can be observed in blinking, focusing in four patterns of abnormality that can be distinguished in the blink reflex: (1) afferent versus efferent, which allows characterization of trigeminal or facial lesions; (2) peripheral versus central, which distinguishes alterations in nerve conduction from those involving synaptic delay; (3) upper versus lower brainstem lesions, which indicates the lesions involving specific circuits for trigeminal and somatosensory blink reflexes; and (4) asymmetric abnormal excitability pattern, which shows a unilateral alteration in the descending control of excitability in brainstem circuits. The blink reflex excitability recovery curve to paired stimuli may provide information about other modulatory inputs to trigemino-facial circuits, such as those proposed for the connection between basal ganglia and trigeminal neurons. Finally, prepulse inhibition of blink reflex reflects the motor surrogate of subcortical gating on sensory volleys, which is still another window by which electrodiagnosis can document motor control mechanisms and their abnormalities in neurologic diseases.