bluuebunny/crossref_metadata_2025 huggingface dataset:
18F-Fluciclovine PET/CT in Suspected Residual or Recurrent High-Grade Glioma
Authors: Bogsrud Trond V. , Londalen Ayca , Brandal Petter , Leske Henning , Panagopoulos Ioannis , Borghammer Per , Bach-Gansmo Tore
Published: June 2019

Purpose

To retrospectively investigate the uptake of 18F-fluciclovine on PET/CT in patients with suspected recurrent high-grade glioma (HGG).

Methods

Twenty-one patients were included. The standard of truth was histopathologic interpretation if available. When histopathology was not available or rebiopsy did not show signs of malignancy, clinical follow-up including MRI and clinical outcome was considered the standard of truth.

Results

All 21 patients met the reference standard of either histopathologic proof of HGG recurrence (n = 10) or disease progression clinically and with tumor growth corresponding to the primary tumor sites on follow-up MRI (n = 11). Median time from PET/CT to death was 5 months (range, 1–20 months). Median time from primary diagnosis to death was 14.5 months (range, 6 to >400). Average SUVmax of the lesions was 8.3 ± 5.3 (SD) and 0.34 ± 0.13 for normal brain tissue. Median lesion-to-background ratio was 21.6 (range, 3.1–84.4). In 4 patients, 18F-fluciclovine PET/CT detected small satellite tumors that had not been reported on MR.

Conclusions

The uptake of 18F-fluciclovine in clinically and/or histopathologically confirmed recurrent HGG is high compared with the uptake reported for other amino acid PET tracers. Because of the high tumor uptake and thus high tracer contrast, small satellite tumors with a diameter below usual reported PET spatial resolution and not reported on MRI were detected in 4 patients. As no patients with confirmed treatment-related changes were included, we cannot as of yet ascertain the ability of 18F-fluciclovine PET to discriminate between recurrent HGG and treatment-related changes, for example, pseudoprogression and radionecrosis.
Rapid Decomposition of 99mTc-MAA Complex During Lung Perfusion Imaging
Authors: Ajdari Sadegh Ebrahim , Qutbi Mohsen
Published: June 2019

A 30-year-old woman with a recent episode of dyspnea was presented. The lung perfusion scan using 99mTc-MAA (macro-aggregated albumin) initially revealed an acceptable lung-to-background activity ratio implying a proper radiopharmaceutical preparation and radiolabeling efficiency. Unexpectedly, later during the scan, rapidly increasing concentration of activity was observed in salivary glands, thyroid and stomach. Rapid breakdown of 99mTc-MAA complexes was considered as a likely explanation for the increase in the circulatory level of the free pertechnetate.
Efficacy of 177Lu Peptide Receptor Radionuclide Therapy for the Treatment of Neuroendocrine Tumors
Authors: Saravana-Bawan Bianka , Bajwa Amandeep , Paterson John , McEwan Alexander J. B. , McMullen Todd P. W.
Published: June 2019

Objective

The purpose of this study was to assess the efficacy of 177Lu-labeled peptide receptor radionuclide therapy (PRRT) induction treatments for patients with unresectable metastatic neuroendocrine tumors.

Methods

MEDLINE, EMBASE, and Ovid were systematically searched with keywords “lutetium,” “Lu-177,” “PRRT,” “neuroendocrine,” and “prognosis.” Studies evaluating treatment with 177Lu-labeled PRRT were assessed for disease response and/or disease control rate by Response Evaluation Criteria in Solid Tumors (RECIST) 1.0 or 1.1, modified RECIST, Southwest Oncology Group (SWOG), or modified SWOG criteria. Pooled proportions of disease response and control rates were calculated for both fixed- and random-effects models.

Results

Eighteen studies with 1920 patients were included (11 with 1268 patients using RECIST and 6 with 804 patients using SWOG). By RECIST criteria, the pooled disease response rate by random-effects model was 29.1% (95% confidence interval [CI], 20.2%–38.9%), and disease control rate was 74.1% (95% CI, 67.8%–80.0%). By SWOG criteria, the pooled disease response rate by random-effects model was 30.6% (95% CI, 20.7%–41.5%), and disease control rate was 81.1% (95% CI, 76.4%–85.4%).

Conclusions

Induction therapy, typically 4 treatments, with 177Lu PRRT is an effective method of treating unresectable metastatic neuroendocrine tumors with significant disease response and control rates.
Quality and Safety in Healthcare, Part LIV
Authors: Harolds Jay A.
Published: June 2019

Physician burnout can be a contributing factor to depression, substance abuse, problems with relationships, and thoughts of suicide. Burnout of physicians also results in decreased quality, safety, and outcomes for patients and more financial costs for health-care institutions. It is not enough for health-care systems to focus on helping the individual; these organizations also need to understand that they are the main cause of physician burnout and take appropriate action to reform their processes.
Performance of 18F-FDG, 11C-Methionine, and 18F-FET PET for Glioma Grading
Authors: Katsanos Aristeidis H. , Alexiou George A. , Fotopoulos Andreas D. , Jabbour Pascal , Kyritsis Athanasios P. , Sioka Chrissa
Published: June 2019

Purpose

Gliomas constitute the most frequent primary brain tumors. Glioblastoma, the most common and malignant glioma in adults, has dismal prognosis with any current therapy. On the other hand, low-grade gliomas, the second most common type of gliomas, are potentially curative with appropriate treatment.

Methods

We conducted a meta-analysis to assess the performance of PET tracers with the best available evidence, namely, fluorodeoxyglucose (FDG), 11C-methionine (MET), and 18F-fluoroethyltyrosine (FET), in differentiating low- from high-grade gliomas.

Results

Twenty-three studies with a total of 994 participants were included in this meta-analysis. The pooled sensitivities of both MET PET and FET PET were found to be significantly higher than of FDG PET (94%, 88%, and 63% respectively, P < 0.001). The pooled specificity of FDG PET was found to be significantly greater compared with both MET PET and FET PET (89%, 55%, and 57%, respectively; P = 0.002). Fluorodeoxyglucose PET was superior in terms of higher positive likelihood ratio values compared with both FET PET and MET PET.

Conclusions

This meta-analysis indicated that both MET and FET were superior to FDG in terms of sensitivity for identifying glioma grade.
18F-FDG Whole-body PET/MRI of a 30-Week Pregnant Woman With Breast Cancer Revealed Interesting Fetal Findings
Authors: Blanc-Durand Paul , Milliner Milan , Huchet Virginie , Luciani Alain , Itti Emmanuel
Published: June 2019

A 35-year-old 30-week pregnant woman was referred to our institution for initial staging of a triple negative invasive ductal carcinoma of the left breast. To avoid fetal radiation exposure from CT, a whole-body 18F-FDG PET/MRI was performed. Simultaneous acquisition of PET, T1-, T2-, and diffusion-weighted sequences revealed left axillary node extension and no distant metastases. Fetal radiation dose was estimated at 1.9 mGy. Interestingly, low fetal brain uptake and high symmetrical myocardial metabolism in both ventricles were found. Delivery was induced at 37 weeks of amenorrhea, and the patient underwent 4 cycles of neoadjuvant chemotherapy.
Pediatric Blood Management Protocol in Cranial Vault Surgery
Authors: Kelley Joshua P. , Boville Brian M. , Sterken David J. , Sanfilipo Dominic J. , Fahrenkopf Matthew , Kelpin John , Polley John , Mann Robert , Girotto John A.
Published: June 2019

Background:

Cranial vault surgeries are invasive, extensive procedures with blood transfusions being frequently required. Previous interventions have been described to attempt to decrease the transfusion burden. The objective of this study is to determine if a Pediatric Blood Management (PBM) team can reduce transfusion requirements in children undergoing cranial vault surgery.

Methods:

A protocol was developed which involved preoperative optimization of hemoglobin (Hb), intraoperative use of tranexamic acid, cell saver technology, and blood sparing operative techniques. Patients were preoperatively screened with basic laboratory testing. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior were used as controls. Prospective data on patients was collected.

Results:

Groups were similar in age and weight. Postoperative Hb measurements were similar, with the control group 10.9 ± 2.2 g/dL and the intervention arm 9.6 + 2.7 g/dL. Discharge Hb concentrations also were similar with 9.6 ± 1.6 g/dL and 9.7 ± 2.5 g/dL in the control and PBM group, respectively. The rate of transfusion decreased from 80% to 42% after protocol implementation (P = 0.007). During the last 6 months of data collection, the transfusion rate decreased further to 17%. Furthermore, 4 patients were found to have von Willebrand disease preoperatively with only 1 requiring a transfusion.

Conclusions:

The authors found that the institution of a PBM team reduced the transfusion burden of patients, including complex patients with von Willebrand disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications.
Dermal-Fat Graft for Facial Contouring in Patients With Craniofacial Microsomia
Authors: Abduch Laís Schweiger Freitas , Rocha Polyanna Borges da , Nasser Isis Juliane Guarezi , Ono Maria Cecília Closs , Freitas Renato da Silva
Published: June 2019

Craniofacial microsomia (CFM) is a variable craniofacial malformation, related to the development of the structures originated from the first and second brachial arches, affecting skeletal tissue, soft tissue, and neuromuscular components. In the situation of subcutaneous tissue and chewing muscles hypoplasia, free tissue transfer is a treatment option. Dermal-fat graft allows easy modeling during surgery, volumetric gain and improvement of asymmetry. The aim of this study was to evaluate the facial contour and the percentage of symmetry after the use of dermal-fat graft in patients with CFM, who had already submitted to osteotomies, attended at the Associate Center for Cleft Lip and Palate (CAIF) during 2001 to 2018. For analysis, the authors selected 17 patients who fulfilled the above prerequisites. The symmetry study was done by the analysis of preoperative and postoperative photographs in the Image J software. Two standard points were used: nasal base and upper lip limit. On the nasal base, the preoperative analysis showed a hypoplastic side with a median of 93.00% of the normal side size, rising to 97.78% in the postoperative period. On the upper lip limit, the preoperative analysis showed a median of 87.80% and, in the postoperative period, 98.15%. Analysis of the interaction between the operative moments and the modified Pruzansky classification showed that there were no significant differences between grades. Long-term evaluation demonstrated that the use of a dermal-fat graft for correction of facial symmetry was effective and close to 100%, regardless of the degree of hypoplasia of the patient.
Artificial Intelligent Model With Neural Network Machine Learning for the Diagnosis of Orthognathic Surgery
Authors: Choi Hyuk-Il , Jung Seok-Ki , Baek Seung-Hak , Lim Won Hee , Ahn Sug-Joon , Yang Il-Hyung , Kim Tae-Woo
Published: June 2019

Diagnosis and treatment planning are the most important steps in the orthognathic surgery for the successful treatment. The purpose of this study was to develop a new artificial intelligent model for surgery/non-surgery decision and extraction determination, and to evaluate the performance of this model. The sample used in this study consisted of 316 patients in total. Of the total sample, 160 were planned with surgical treatment and 156 were planned with non-surgical treatment. The input values of artificial neural network were obtained from 12 measurement values of the lateral cephalogram and 6 additional indexes. The artificial intelligent model of machine learning consisted of 2-layer neural network with one hidden layer. The learning was carried out in 3 stages, and 4 best performing models were adopted. Using these models, decision-making success rates of surgery/non-surgery, surgery type, and extraction/non-extraction were calculated. The final diagnosis success rate was calculated by comparing the actual diagnosis with the diagnosis obtained by the artificial intelligent model. The success rate of the model showed 96% for the diagnosis of surgery/non-surgery decision, and showed 91% for the detailed diagnosis of surgery type and extraction decision. This study suggests the artificial intelligent model using neural network machine learning could be applied for the diagnosis of orthognathic surgery cases.
Composite Nasoseptal Flap for Palate Reconstruction
Authors: Gadkaree Shekhar K. , Feng Allen L. , Sharon Jeffery D. , Richmon Jeremy D. , Emerick Kevin S. , Lin Derrick T. , Deschler Daniel G. , Varvares Mark A. , Pipkorn Patrick , Zenga Joseph
Published: June 2019

Palatal fistulae represent a pathological connection from the oral cavity through the hard or soft palate to the nasal cavity and can present a significant reconstructive dilemma. Surgical correction of palatal fistulae is often limited by prior treatment, including ablative procedures and radiotherapy, or previous reconstructive attempts. In light of these challenges, the nasoseptal flap represents an excellent adjacent source of vascularized tissue which may be suitable for palatal fistula repair with minimal donor site morbidity, low associated risks, and a short recovery period. The purpose of this study was to fully understand the potential utility of this reconstructive option, including the ability to harvest a composite flap including both septal cartilage and contralateral mucoperichondrium. In this single institution prospective study consisting of a series of 5 cadaver dissections, primary outcome measures were the anterior reach of the flap as compared to the anterior nasal spine and the size of the palatal defect that the nasoseptal flap could be used to successfully reconstruct. Composite flaps were successfully harvested in continuity with a disc of septal cartilage and contralateral mucoperichondrium, providing structural integrity to the reconstruction and the ability to anchor the flap to the native hard palate mucosa. The nasoseptal flap's maximum anterior reach was within 2.0 cm (standard deviation of 0.1 cm) from the anterior nasal spine and could reliably reconstruct palate defects of 2.5 cm or less. The nasoseptal flap provides a viable regional option for reconstructing defects of the hard palate. Prospective clinical trials are needed to investigate long-term reconstructive and functional outcomes of the composite nasoseptal flap in palatal reconstruction.
Scalp Arteriovenous Malformation Resection With Novel Technique of Endovascular and Surgical Devascularization
Authors: Alawneh Khaled , Abuzayed Bashar , Al Qawasmeh Majdi , Raffee Liqaa
Published: June 2019

A 26-year-old female patient referred to our emergency service with complaint of increase headache and swelling of the left upper eye led. External examination of the head revealed left frontal scalp and left eye led swelling, which was soft and pulsatile. Brain computed tomography (CT) scan and magnetic resonance imaging showed left frontal soft tissue and left periorbital swelling with crowded left intraorbital contents. Brain CT angiography showed vascular mass lesion in the left frontal subcutaneous lesion. Six-vessel cerebral angiography showed left frontal scalp arteriovenous malformation (AVM) supplied from the right and left superficial temporal arteries from the external carotid artery and from the left supraorbital artery arising from the ophthalmic artery of the internal carotid artery. By endovascular technique, bilateral superficial temporal arteries were occluded with Onyx 18 (Micro-Therapeutics, Inc., Irvine, CA). The patient was operated after 2 days. Left eye-brow incision was performed and the supraorbital artery was exposed, ligated, and cut. Left fronto-temporal skin incision was performed and the AVM totally excised. No intraoperative nor postoperative complications seen. Follow-up cerebral angiography showed total resection of the AVM.
Comparative Effectiveness of Vertical Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Diabetes Treatment
Authors: Lewis Kristina H. , Arterburn David E. , Zhang Fang , Callaway Katherine , Wallace Jamie , Fernandez Adolfo , Ross-Degnan Dennis , Wharam James F.
Published: June 2019

Objective:

The aim of the study was to compare diabetes outcomes following vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB).

Background:

There are few comparative studies on diabetes outcomes after VSG and RYGB.

Methods:

We used a US-wide commercial insurance claims database to identify adults with diabetes undergoing VSG or RYGB in 2010 to 2016. We matched patients on baseline insulin use, total diabetes medication burden, age, presence of diabetes complications, and follow-up duration, and used adjusted Cox proportional hazards models to compare diabetes medication discontinuation between procedures. We used difference-in-differences analyses to compare changes in medication use intensity up to 2 years after surgery.

Results:

The matched cohort included 1111 VSG and 922 RYGB patients: 16% were younger than 40 years, 11% were 60 years or older, 67% were women, 67% had a body mass index of 40 kg/m2 or higher, and 23% were on insulin at the time of surgery. Thirteen percent were lost to follow-up at 1 year, and 30% at 2 years after surgery. Patients with VSG were less likely than matched RYGB patients to discontinue all diabetes medications (hazard ratio 0.80, 95% confidence interval 0.72–0.88). Although both groups had substantial decreases in medication use after surgery, RYGB patients had an 86% (32%, 140%) lower total diabetes medication dose than VSG by the second half of postoperative year 2.

Conclusions:

In a large claims-based, nationwide cohort of bariatric patients with diabetes, those undergoing RYGB were more likely to come off all medications than those undergoing VSG. Patients with diabetes should consider this potential benefit of RYGB when making informed decisions about obesity treatments.
Straddle injuries to the bulbar urethra: What is the best choice for immediate management?
Authors: Peng Xufeng , Guo Hailin , Zhang Xinru , Wang Jihong
Published: June 2019

BACKGROUND

Cystostomy, endoscopic realignment, and emergency anastomosis are three methods used to treat bulbous urethral injury (BUI). The aim of the study is to determine the optimal management.

METHODS

A retrospective study was performed on 328 male patients with blunt straddle injury to the perineum. In total, 304 patients were included in the analysis due to strict criteria. Among these 304 patients, 197 had partial urethral disruption diagnosed, and 107 had complete urethral disruption. Group placement of the patients was based on the extent of injury. Each group was further divided into two subgroups based on the immediate management. Propensity score matching was used to correct for differences in baseline characteristics.

RESULTS

In the partial disruption group, the propensity score-matched subgroups set comprised of 164 patients. Of the 82 patients treated with endoscopic realignment, 34 (41.5%) patients required no urethral surgery, in contrast to 12 (14.6%) patients with cystostomy (p < 0.05). No significant difference was found in the other respects (p > 0.05). In the complete disruption group, the propensity score-matched subgroups set comprised of 104 patients. The success rate of emergency anastomosis was 90.4% (47 patients), and urethral stricture occurred in five patients (96%), while urethral stricture developed in all 52 patients in the cystostomy subgroup. With regard to surgical management of complications, the choice of management methods significantly differed between the two subgroups (all, p < 0.05). The time to natural urination and duration of hospital stay were significantly shorter in the emergency anastomosis subgroup (29.1 ± 5.4 days vs. 57.1 ± 6.4 days; 7.2 ± 3.1 days vs. 12.5 ± 2.3 days; each p < 0.05).

CONCLUSION

Endoscopic realignment is associated with a lower stricture rate than cystostomy as immediate management for partial disruption. Emergency anastomosis provides better clinical outcomes for patients with complete disruption.

LEVEL OF EVIDENCE

Therapeutic Level IV.
Undertriaged trauma patients: Who are we missing?
Authors: Schellenberg Morgan , Benjamin Elizabeth , Bardes James M. , Inaba Kenji , Demetriades Demetrios
Published: June 2019

BACKGROUND

Trauma team activation (TTA) criteria, set by the American College of Surgeons Committee on Trauma, are used to identify patients prehospital who are at highest risk for severe injury and mobilize the optimal resources. Patients are undertriaged if they are severely injured (Injury Severity Score, ≥16) but do not meet TTA criteria. This study examined the epidemiology and injury patterns of undertriaged patients and potential clinical effects.

METHODS

All patients presenting to our Level I trauma center (June 1, 2017 to May 31, 2018) were screened for inclusion using modified TTA criteria (mTTA), that is, age over 70 years added to the standard American College of Surgeons Committee on Trauma TTA criteria. Demographics, injury/clinical data, and outcomes of undertriaged patients were analyzed. Undertriaged patients were further subcategorized as “high-risk” if they expired or required emergent intervention.

RESULTS

233 undertriaged patients were identified from 1423 routine trauma consults (16%). Mean Injury Severity Score was 20 (range, 16–43). Most undertriage occurred following blunt trauma (n = 224, 96%), especially motor vehicle collisions (n = 66, 28%) and auto versus pedestrian collisions (n = 57, 24%). Thirty-two (14%) patients were identified as high-risk undertriaged patients: 16 (50%) required emergency surgery (mainly craniectomy; n = 10, 63%), 5 (16%) required angioembolization, and 14 patients (44%) died. In this high-risk group, the cause of death was almost exclusively traumatic brain injury (TBI) (n = 13, 93%). Of the patients who died of TBI, the majority had a depressed Glasgow Coma Scale score on presentation to the ED (<11) (n = 10, 77%) despite not meeting field criteria for TTA.

CONCLUSION

Using mTTA criteria, undertriage rates are relatively low, particularly after penetrating trauma. However, there is a high-risk population that is not captured, among whom mortality and need for emergent intervention are high. Most undertriage deaths are secondary to severe TBI. Despite not qualifying for highest-level activation, patients with head trauma and Glasgow Coma Scale score less than 11 on admission are at high-risk for adverse outcomes and additional resource mobilization should be considered.

LEVEL OF EVIDENCE

Care Management, level IV.
The association between self-declared acute care surgery services and operating room access: Results from a national survey
Authors: Ricci Kevin B. , Rushing Amy P. , Ingraham Angela M. , Daniel Vijaya T. , Paredes Anghela Z. , Diaz Adrian , Heh Victor K. , Baselice Holly E. , Oslock Wendelyn M. , Strassels Scott A. , Santry Heena P.
Published: June 2019

BACKGROUND

Timely access to the operating room (OR) for emergency general surgery (EGS) diseases is key to optimizing outcomes. We conducted a national survey on EGS structures and processes to examine if implementation of acute care surgery (ACS) would improve OR accessibility compared with a traditional general surgeon on call (GSOC) approach.

METHODS

We surveyed 2,811 acute care general hospitals in the United States capable of EGS care. The questionnaire included queries regarding structures and processes related to OR access and on the model of EGS care (ACS vs. GSOC). Associations between the EGS care model and structures and processes to ensure OR access were measured using univariate and multivariate models (adjusted for hospital characteristics).

RESULTS

Of 1,690 survey respondents (60.1%), 1,497 reported ACS or GSOC. 272 (18.2%) utilized an ACS model. The ACS hospitals were more likely to have more than 5 days of block time and a tiered system of booking urgent/emergent cases compared with GSOC hospitals (34.2% vs. 7.4% and 85.3% vs. 57.6%, respectively; all p values <0.001). Surgeons at ACS hospitals were more likely to be free of competing clinical duties, be in-house overnight, and cover at a single hospital overnight when covering EGS (40.1% vs. 4.7%, 64.7% vs. 25.6%, and 84.9% vs. 64.9%, respectively; all p values <0.001). The ACS hospitals were more likely to have overnight in-house scrub techs, OR nurses, and recovery room nurses (69.9% vs. 13.8%, 70.6% vs. 13.9%, and 45.6% vs. 5.4%, respectively; all p values <0.001). On multivariable analysis, ACS hospitals had higher odds of all structures and processes that would improve OR access.

CONCLUSION

The ACS implementation is associated with factors that may improve OR access. This finding has implications for potential expansion of EGS care models that ensure prompt OR access for the EGS diseases that warrant emergency surgery.

LEVEL OF EVIDENCE

Therapeutic, Level III.
Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction
Authors: Lyu Heather G. , Castillo-Angeles Manuel , Bruno Melanie , Cooper Zara , Nehra Deepika , Nitzschke Stephanie L. , Askari Reza , Kelly Edward , Shimizu Naomi , Riviello Robert , Salim Ali , Havens Joaquim M.
Published: June 2019

BACKGROUND

Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge.

METHODS

A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management.

RESULTS

There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03–3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts.

CONCLUSION

Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions.

LEVEL OF EVIDENCE

Therapeutic study, level IV.
Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers
Authors: Roden-Foreman Jacob Watkin , Rapier Nakia R. , Foreman Michael L. , Zagel Alicia L. , Sexton Kevin W. , Beck William C. , McGraw Constance , Coniglio Raymond A. , Blackmore Abigail R. , Holzmacher Jeremy , Sarani Babak , Hess Joseph C. , Greenwell Cynthia , Adams Charles A. , Lueckel Stephanie N. , Weaver Melinda , Agrawal Vaidehi , Amos Joseph D. , Workman Cheryl F. , Milia David J. , Bertelson Annette , Dorlac Warren , Warne Maria J. , Cull John , Lyell Cassie A. , Regner Justin L. , McGonigal Michael D. , Flohr Stephanie D. , Steen Sara , Nance Michael L. , Campbell Marie , Putty Bradley , Sherar Danielle , Schroeppel Thomas J.
Published: June 2019

BACKGROUND

Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.

METHODS

Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).

RESULTS

The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46–10.53]; ISS = 5.94 [5.36–6.60], RTS = 4.79 [4.29–5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08–3.22], ISS = 2.87 [2.80–2.94], RTS = 2.37 [2.30–2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52–2.66], ISS = 2.51 [2.44–2.59], RTS = 2.37 [2.28–2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.

CONCLUSION

In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.

LEVEL OF EVIDENCE

Prognostic, level IV.
An inflammatory pulmonary insult post-traumatic brain injury worsens subsequent spatial learning and neurological outcomes
Authors: Jacovides Christina L. , Ahmed Syed , Suto Yujin , Paris Andrew J. , Leone Ryan , McCarry Jordan , Christofidou-Solomidou Melpo , Kaplan Lewis J. , Smith Douglas H. , Holena Daniel N. , Schwab C. William , Pascual Jose L.
Published: June 2019

BACKGROUND

Severe traumatic brain injury (TBI) patients are at high risk for early aspiration and pneumonia. How pneumonia impacts neurological recovery after TBI is not well characterized. We hypothesized that, independent of the cerebral injury, pneumonia after TBI delays and worsens neurological recovery and cognitive outcomes.

METHODS

Fifteen CD1 male mice were randomized to sham craniotomy or severe TBI (controlled cortical impact [CCI] − velocity 6 m/s, depth 1.0 mm) ± intratracheal lipopolysaccharide (LPS-2 mg/kg in 0.1 mL saline) as a pneumonia bioeffector. Neurological functional recovery by Garcia Neurologic Testing (GNT) and body weight loss were recorded daily for 14 days. On Days 6–14, animals underwent Morris Water Maze learning and memory testing with cued trials (platform visible), spatial learning trials (platform invisible, spatial cues present), and probe (memory) trials (platform removed, spatial clues present). Intergroup differences were assessed by the Kruskal-Wallis test with Bonferroni correction (p < 0.05).

RESULTS

Weight loss was greatest in the CCI + LPS group (maximum 24% on Day 3 vs. 8% [Sham], 7% [CCI], both on Day 1). GNT was lowest in CCI + LPS during the first week. Morris Water Maze testing demonstrated greater spatial learning impairment in the CCI + LPS group vs. Sham or CCI counterparts. Cued learning and long-term memory were worse in CCI + LPS and CCI as compared to Sham.

CONCLUSION

A pneumonia bioeffector insult after TBI worsens weight loss and mortality in a rodent model. Not only is spatial learning impaired, but animals are more debilitated and have worse neurologic performance. Understanding the adverse effects of pneumonia on TBI recovery is the first step d patients.
Implementation of a prehospital air medical thawed plasma program: Is it even feasible?
Authors: Adams Peter W. , Warren Kayla A. , Guyette Frank X. , Yazer Mark H. , Brown Joshua B. , Daily Brian J. , Miller Richard S. , Harbrecht Brain G. , Claridge Jeffrey A. , Phelan Herb A. , Witham William R. , Putnam A. Tyler , Zuckerbraun Brian S. , Neal Matthew D. , Sperry Jason L.
Published: June 2019

BACKGROUND

The Prehospital Air Medical Plasma (PAMPer) trial demonstrated a 30-day survival benefit among hypotensive trauma patients treated with prehospital plasma during air medical transport. We characterized resources, costs and feasibility of air medical prehospital plasma program implementation.

METHODS

We performed a secondary analysis using data derived from the recent PAMPer trial. Intervention patients received thawed plasma (5-day shelf life). Unused plasma units were recycled back to blood bank affiliates, when possible. Distribution method and capability of recycling varied across sites. We determined the status of plasma units deployed, utilized, wasted, and returned. We inventoried thawed plasma use and annualized costs for distribution and recovery.

RESULTS

The PAMPer trial screened 7,275 patients and 5,103 plasma units were deployed across 22 air medical bases during a 42-month period. Only 368 (7.2%) units of this total thawed plasma pool were provided to plasma randomized PAMPer patients. Of the total plasma pool, 3,716 (72.8%) units of plasma were returned to the blood bank with the potential for transfusion prior to expiration and 1,019 (20.0%) thawed plasma units were deemed wasted for this analysis. The estimated average annual cost of implementation of a thawed plasma program per air medical base at an average courier distance would be between US $24,343 and US $30,077, depending on the ability to recycle plasma and distance of courier delivery required.

CONCLUSION

A prehospital plasma program utilizing thawed plasma is resource intensive. Plasma waste can be minimized depending on trauma center and blood bank specific logistics. Implementation of a thawed plasma program can occur with financial cost. Products with a longer shelf life, such as liquid plasma or freeze-dried plasma, may provide a more cost-effective prehospital product relative to thawed plasma.

LEVEL OF EVIDENCE

Therapeutic, level III.
Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017
Authors: Cimbanassi Stefania , O'Toole Robert , Maegele Marc , Henry Sharon , Scalea Thomas M. , Bove Federico , Mezzadri Umberto , Capitani Dario , Sala Francesco , Kanakaris Nicolaus , Coccolini Federico , Ansaloni Luca , Sgardello Sebastian , Bindi Francesca , Renzi Federica , Sammartano Fabrizio , Masse Alessandro , Rampoldi Antonio , Puoti Massimo , Berlusconi Marco , Moretti Biagio , Rueger Johannes , Arnez Zoram , del Bene Massimo , Chieregato Arturo , Menarini Maurizio , Gordini Giovanni , De Blasio Elvio , Cudoni Sebastiano , Dionigi Paolo , Fabbri Andrea , Scandroglio Ildo , Chiara Osvaldo
Published: June 2019

BACKGROUND

In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries.

METHODS

The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held.

RESULTS

The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non–life-threatening injuries, mostly of upper limb.

CONCLUSION

Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions.

LEVEL OF EVIDENCE

Systematic review of predominantly level II studies, level II.
The Outcomes of Portal Vein Reconstruction With Vein Graft Interposition in Pediatric Liver Transplantation for Small Children With Biliary Atresia
Authors: Sakamoto Seisuke , Uchida Hajime , Kitajima Toshihiro , Shimizu Seiichi , Yoshimura Shohei , Takeda Masahiro , Hirata Yoshihiro , Fukuda Akinari , Kasahara Mureo
Published: June 2019

Background.

Several technical modifications in portal vein (PV) reconstruction have shown excellent outcomes in pediatric liver transplantation (LT); however, which procedure is the best for PV reconstruction of the hypoplastic PV in pediatric LT remains unclear.

Methods.

One hundred sixteen pediatric patients aged 1 or younger with biliary atresia (BA) undergoing living donor LT (LDLT) at our center were enrolled in the present study to investigate the outcomes of the different types of PV reconstruction. We compared the results between patients with and without vein graft (VG) interposition (VG group, n = 33; non-VG group, n = 83) to analyze the risk factors for PV complications (PVCs). The median follow-up period was 4.7 years.

Results.

PVCs occurred in 10 cases (7.2%), including 5 cases in the non-VG group and 5 in the VG group. Stenosis and thrombosis occurred in 10 and 3 cases, respectively, and 3 cases suffered from both. Three patients were surgically treated for PVCs, and 2 underwent stent insertion to treat short-term recurrence after the initial treatment. The incidence of PVCs in the 2 groups did not differ to a statistically significant extent. Although retrograde PV flow was 1 of the significant risk factors in a univariate analysis, a multivariate analysis revealed that early transplant era was the only independent risk factor for PVCs.

Conclusions.

VG interposition for PV reconstruction in LDLT appears to be a feasible alternative option with acceptable outcomes for patients with BA. Achieving sufficient PV flow is essential to preventing PVCs after LDLT.
Clostridium difficile: A Frequent Infection in Children After Intestinal Transplantation
Authors: Duclaux-Loras Rémi , Berthiller Julien , Ferroni Agnès , Chardot Christophe , Goulet Olivier , Lacaille Florence , Norsa Lorenzo
Published: June 2019

Background.

Organ transplantation (Tx) is a risk factor for Clostridium difficile infection (CDI). After intestinal transplantation (ITx), few data are available on the impact of this graft infection and the possible induction of rejection.

Methods.

We included retrospectively all children after ITx in our unit, with at least 1 year of graft survival. All samples positive for Clostridium difficile (CD) and its toxin were considered.

Results.

Among the 57 ITx recipients (60 Txs), 22 children (39%) developed culture-proven CDI, 12 after isolated small bowel Tx, 9 after liver-small bowel Tx, and 1 after multivisceral Tx. Twenty patients had diarrhea, 8 bloody stools, 4 fever, and 1 hypothermia. Nine were hospitalized for an average of 6.5 days (2–20) and 4 with severe dehydration. Nine (40%) had received antibiotics for an average of 19 days (7–60) before CDI. Two patients were asymptomatic. CDI was treated with metronidazole in 12 children, vancomycin in 6, and both in 3. Three children presented mild-to-severe rejections. Two patients presented concomitantly CDI and rejection. The third patient presented a rejection with severe complications 4 years after CDI. Recurrence of toxinogenic CD was observed in 9 children, in 7 associated with clinical symptoms. During the last follow-up, the stool number was the same as before CDI except for 1 patient with ongoing infection.

Conclusions.

CDI is more prevalent in children after ITx compared with other organ Tx; it is most often symptomatic but mildly or moderately severe. Standard antibiotics efficiently control the symptoms. Induction of rejection is a rare event.
Cytotoxic Effects of Rabbit Anti-thymocyte Globulin Preparations on Primary Human Thymic Epithelial Cells
Authors: Kaebisch Eva M. , Cho Mi-Young , Oh Young-Seong , Olfe Lisa I. , Szyska Martin , Becker Sonya C. , Reinke Petra , Volk Hans-Dieter , Gillissen Bernhard , Bullinger Lars , Thiel Andreas , Na Il-Kang
Published: June 2019

Background.

Graft-versus-host disease (GvHD) presents a major cause for morbidity and mortality after allogeneic hematopoietic stem cell transplantation. Rabbit-derived antithymocyte globulin (rATG) treatment reduces the incidence of GvHD after allogeneic hematopoietic stem cell transplantation. However, delayed immune reconstitution following rATG treatment, partly caused by hampered thymic function, is being discussed. The present study aims at elucidating possible cytotoxic effects of 2 commonly used rATG preparations on cultured human thymic stroma, especially thymic epithelial cells (TECs).

Methods.

A primary TEC culture was established and the binding and cytotoxicity of 2 rATG preparations to the aforementioned cells were assessed by flow cytometry and immunofluorescence analyses. The release of several cytokines by cultured thymic stroma cells in response to rATG was analyzed via multiplex enzyme-linked immunosorbent assays.

Results.

Both preparations showed a comparable dose-dependent binding to TECs and exerted a similar complement-independent, dose-dependent cytotoxicity. rATG exposure further resulted in hampered secretion of interleukin (IL)-7, IL-15, and IL-6, cytokines being involved in thymic T cell development and proliferation. Pretreatment with keratinocyte growth factor diminished rATG-induced cytotoxicity of TECs and restored their IL-7 and IL-15 secretion.

Conclusions.

Cytotoxic effects on TECs link the rATG-induced thymic damage to the delayed T cell reconstitution, witnessed after rATG treatment. Our data support a combination treatment of rATG and thymus-protective strategies such as keratinocyte growth factor to simultaneously offer sufficient GvHD prophylaxis and overcome delayed T cell reconstitution caused by thymic damage.
Differential Impact of Delayed Graft Function in Deceased Donor Renal Transplant Recipients With and Without Donor-specific HLA-antibodies
Authors: Haller Jana , Wehmeier Caroline , Hönger Gideon , Hirt-Minkowski Patricia , Gürke Lorenz , Wolff Thomas , Steiger Jürg , Amico Patrizia , Dickenmann Michael , Schaub Stefan
Published: June 2019

Background.

Delayed graft function (DGF) and pretransplant donor-specific HLA-antibodies (DSA) are both regarded as risk factors for rejection and lower graft survival. However, the combined impact of DGF and DSA has not been studied in detail.

Methods.

We investigated 375 deceased donor kidney transplantations, which had DSA assignment by single-antigen bead technology and which had surveillance biopsies at 3 of 6 months. Median follow-up time was 6.1 years.

Results.

DGF occurred in 137 of 375 patients (37%), and DSA were present in 85 of 375 patients (23%). The incidence of DGF was similar in DSA-positive (DSApos)-patients and DSA-negative (DSAneg)-patients (40% versus 36%; P = 0.45). In DSAneg-patients, 5-year graft survival was not different with/without DGF (81% versus 83%; P = 0.48). By contrast, in DSApos-patients, 5-year graft survival was significantly lower with DGF (64% versus 79%; P = 0.01). Moreover, DSApos-patients with DGF had a higher 1-year incidence of subclinical rejection, which were mostly antibody-mediated or mixed rejection phenotypes. Graft loss due to rejection was significantly more frequent in DSApos-patients with DGF (5/34; 15%) compared to DSApos-patients without DGF (2/51; 4%), and DSAneg-patients with/without DGF (3/103; 3% and 4/187; 2%, respectively) (P = 0.005). In a multivariate Cox model, DSA with DGF was an independent predictor for graft (hazard ratio = 2.84 [95% confidence interval, 1.54-5.06]; P = 0.001) and death-censored graft loss (hazard ratio = 4.65 [95% confidence interval, 1.83-11.51]; P = 0.002).

Conclusions.

DGF has a much more detrimental impact in DSApos-patients than in DSAneg-patients, which is likely related to a higher incidence of antibody-mediated rejection. If possible, the combined risks of DGF and DSA should be avoided.
An Outpatient Hospital-based Exercise Training Program for Patients With Cirrhotic Liver Disease Awaiting Transplantation: A Feasibility Trial
Authors: Morkane Clare M. , Kearney Orla , Bruce David A. , Melikian Clare N. , Martin Daniel S.
Published: June 2019

Background.

Time spent on the waiting list before liver transplantation (LT) provides an opportunity to optimize recipient fitness through prehabilitation, potentially reducing the physiological impact of major surgery. We assessed the feasibility and effectiveness of a 6-week exercise program in patients with cirrhotic liver disease awaiting LT.

Methods.

This single-center, prospective cohort, feasibility study, enrolled patients awaiting LT to a 6-week period of thrice weekly, supervised exercise on a static bike. Cardiopulmonary exercise testing (CPET) was used to objectively assess cardiopulmonary fitness at baseline and after 6 weeks of exercise. A follow-up CPET was performed at 12 weeks. CPET-derived measures were used to guide prescription of the training program. A nonrandomized control cohort of LT patients were selected to match the exercise group based on specific demographic data. Allocation to study arms was primarily based on the distance participants lived from the hospital where training occurred. Both groups received structured nutritional advice.

Results.

The exercise program was feasible, with 9 of 16 (56%) patients completing the full program of 6 weeks. Peak oxygen consumption (VO2peak) in the exercise group rose from a mean (SD) of 16.2 (±3.4) mL/kg/min at baseline to 18.5 (±4.6) mL/kg/min at week 6 (P = 0.02). In the control group, VO2peak decreased from a mean (SD) of 19.0 (±6.1) mL/kg/min to 17.1 (±6.0) at week 6 (P = 0.03).

Conclusions.

We have demonstrated that it is feasible to engage patients awaiting LT in an intensive aerobic exercise program with a signal of improvement in fitness being detected.