bluuebunny/crossref_metadata_2025 huggingface dataset:
Valuing the SF-6Dv2 Classification System in the United Kingdom Using a Discrete-choice Experiment With Duration
Authors: Mulhern Brendan J. , Bansback Nick , Norman Richard , Brazier John
Published: March 2020

Objective:

An updated version of the SF-6D Classification System (SF-6Dv2) has been developed, and utility value sets are required. The aim of this study was to test the development of a United Kingdom SF-6Dv2 value set, and address limitations of the existing SF-6D value set (which results in a narrow range of utilities). This was done using 2 discrete-choice experiment (DCE) tasks. Interactions and preference heterogeneity were also investigated.

Research Design and Subjects:

An online sample of respondents (n=3014) completed 10 DCE with duration choice sets from an efficient design of 300 (Design 1) and 2 DCE with duration choice sets including immediate death from a set of 60 (Design 2). Conditional logit regression was used to estimate value set models with and without interactions. We investigated preference heterogeneity using latent class models.

Results:

Models including ordered coefficients within each dimension were developed, with the favored model including an additional interaction term when one dimension was at the most severe level. Value sets differed across Designs 1 and 2. Design 1 models had a wider utility range and a higher proportion of negative values. The most important dimensions were pain, mental health, and physical functioning. Preference heterogeneity was apparent, with a 2-class model describing the data.

Conclusions:

We developed and applied a protocol to value the SF-6Dv2 using DCE. The results provide a provisional value set for use in resource allocation. The protocol can be applied internationally. Further work should investigate how to account for preference heterogeneity in value set production.
Determinants of Therapeutic Alliance With People With Psychotic Disorders
Authors: da Costa Héloïse , Martin Brice , Franck Nicolas
Published: March 2020

Therapeutic alliance determines medical treatment adherence, the success of psychotherapy, and the effectiveness of care. This systematic review aims at better understanding its determinants. The electronic databases Pubmed, Cochrane Library, and Web of Science were searched, using combinations of terms relating to psychosis and therapeutic alliance. Studies were selected and data were extracted using a PRISMA statement. Forty-one studies were selected, including 20 cross-sectional studies, 10 cohort studies, five randomized controlled trials, four literature reviews, and two retrospective studies. The quality of therapeutic alliance correlates with clinical symptoms, insight, social and family support, the therapist's qualities, the availability of shared therapeutic decision making, and the types of hospitalization. Although current evidence needs to be completed with further studies, it is already clear that group and family psychoeducation, cognitive remediation, community-based psychiatric services, and shared therapeutic decision making are essential approaches in the management of patients with psychosis.
Aggression and Violence Toward Healthcare Workers in a Psychiatric Service in Italy
Authors: Bizzarri Jacopo V. , Piacentino Daria , Kotzalidis Georgios D. , Moser Sabine , Cappelletti Simone , Weissenberger Gerd , Pompili Maurizio , Conca Andreas
Published: March 2020

Workplace violence and aggression are receiving increasing attention, especially when perpetrated in at-risk services such as psychiatric and emergency departments. Many healthcare providers have been victims of verbal aggressions (VAs) and physical aggressions (PAs), as well as injuries (INs), at the hands of patients. We conducted a 1-year retrospective questionnaire-based survey to assess workplace violence and aggression experienced by staff working at the Psychiatric Service of the Health District of Bolzano-Bozen (Italy). We performed parametric statistics. Logistic regression estimated the size of the association between PA occurrence and staff characteristics. Our psychiatric service's employees were frequent victims (91.5%) of 1 or more aggression/injury in the previous year. VAs and INs showed comparable frequencies among the three sites of our service, that is, the inpatient (INP), the outpatient (OUTP), and the rehabilitation (REHAB) units, differently from PAs, which were more common at INP (p < 0.001). The logistic regression model showed that female sex, working at INP, and a shorter psychiatry work experience predicted PAs occurrence. Most of the staff felt they could benefit from aggression management. Findings show that VAs, PAs, and INs are common among our psychiatric service's employees and point to the need to provide staff training on de-escalation.
Improving Accuracy and Timeliness of Nursing Documentation of Pediatric Early Warning Scores
Authors: Dean Nathan P. , Cheng Jenhao J. , Crumbley Ian , DuVal Jennifer , Maldonado Eliana , Ghebremariam Emanuel
Published: March 2020

Introduction:

Accurate and timely documentation of pediatric early warning scores (PEWS) by the bedside nurse into the electronic health record (EHR) is important to promote early identification of patients in stages of deterioration. Through the implementation of a PEWS calculator embedded in the EHR, we hope to improve the accuracy of the recorded score and reduce the time between vital sign collection and final documentation in the EHR.

Methods:

Identification of the highest PEWS value in the 24 hours before all unplanned transfers or rapid response activations without a transfer occurred between the period November 1, 2013, through December 31, 2016. The accuracy of the calculated cardiac or respiratory subscore based on heart rate or the respiratory rate at the time of PEWS calculation was determined. We tracked the calculation of the time to chart via the difference between nursing documentation of PEWS compared to vital sign collection. Before September 3, 2015, PEWS was calculated mentally by the bedside nurse; afterward, the nurse entered the unique PEWS features into the EHR, and the EHR automatically calculated PEWS.

Results:

This study evaluated 2,409 PEWS scores, 1,411 before and 998 after initiation of the PEWS calculator. Accuracy before the EHR calculator was 71%, and the median time to document was 55 minutes. Following the implementation of the calculator, no scores were incorrectly calculated too low, and the median time to document was 20 minutes.

Conclusions:

Transition to an EHR-based PEWS calculator eliminated inaccurately low PEWS values and reduced time to document.
Suppressive Effect of Leukotriene Antagonists on Capsular Contracture in Patients Who Underwent Breast Surgery with Prosthesis: A Meta-Analysis
Authors: Wang Yuanliang , Tian Jing , Liu Jianshu
Published: March 2020

Background:

Capsular contracture is a troublesome and distressing complication in mammaplasty or breast reconstruction involving a prosthesis. Previous studies have indicated that leukotriene antagonists effectively reverse capsular contracture. However, this treatment method lacks comprehensive support from evidence-based medicine and remains considerably controversial. In this study, a meta-analysis was conducted to evaluate the therapeutic and preventive effects of leukotriene antagonists on capsular contracture in patients after breast prosthesis implantation.

Methods:

A comprehensive literature search was performed in English and Chinese databases. All clinical studies assessing the therapeutic and prophylactic effects of leukotriene antagonists on capsule contracture after breast prosthesis implantation were selected. Risk differences and 95 percent confidence intervals were applied as the final pooled statistics.

Results:

A total of five eligible studies were included, involving 1710 breast prosthesis implantations. The final results indicated that leukotriene antagonists markedly inhibited capsular contracture formation, with statistical significance at 32.02 (p < 0.001) (pooled risk difference, 0.84; 95 percent CI, 0.79 to 0.89). In subgroup analysis, subgroups based on different leukotriene antagonists included the montelukast and zafirlukast groups, with significant pooled statistical levels of 19.34 (p < 0.001) and 79.48 (p < 0.001), respectively (montelukast: pooled risk difference, 0.83; 95 percent CI, 0.75 to 0.92; zafirlukast: pooled risk difference, 0.85; 95 percent CI, 0.83 to 0.87), indicating that both montelukast and zafirlukast were effective in inhibiting encapsulation.

Conclusions:

This meta-analysis demonstrated that leukotriene antagonists (montelukast and zafirlukast) have significant effects in treating and preventing capsular contracture. These medications should be administered in a reasonable and safe way. Further studies of clinical efficacy, duration, safety, and exact mechanism of leukotriene antagonists for periprosthetic capsular contracture are warranted.
Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm
Authors: Lopez Joseph , Pineault Kevin , Pradeep Tejus , Khavanin Nima , Kachniarz Bart , Faateh Muhammad , Grant Michael P. , Redett Richard J. , Manson Paul N. , Dorafshar Amir H.
Published: March 2020

Background:

The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures.

Methods:

A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay.

Results:

A total of 174 patients with frontal bone fractures met the authors’ inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11).

Conclusions:

The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
The Impacts of Orthognathic Surgery on the Facial Appearance and Age Perception of Patients Presenting Skeletal Class III Deformity: An Outcome Study Using the FACE-Q Report and Surgical Professional–Based Panel Assessment
Authors: Denadai Rafael , Chou Pang-Yun , Su Yu-Ying , Lin Hsiu-Hsia , Ho Cheng-Ting , Lo Lun-Jou
Published: March 2020

Background:

A recent artificial intelligence–based investigation has shown the impacts of orthognathic surgery on the patient’s facial appearance and apparent age. However, appearance and age perception as reported by patients and surgical professionals have not been addressed in the same cohort to date.

Methods:

FACE-Q facial appraisal (appearance and age) and quality-of-life scale scores obtained before and after orthognathic surgery, in addition to three-dimensional photographs of 70 patients with skeletal class III deformity, were collected for a comparative cross-sectional study. Seven blinded plastic surgeons rated all photographs for apparent facial aesthetic and age scales. The FACE-Q data from 57 matched normal individuals were adopted for the comparative analyses. The correlation between the FACE-Q and the professional-based scales was tested.

Results:

Pre–orthognathic surgery versus post–orthognathic surgery comparisons showed significant differences (p < 0.001) for all FACE-Q scales and panel assessments, with higher (FACE-Q scales and professional-based aesthetic parameters) and lower (FACE-Q patient-perceived age scale and professional-based age parameter) values for post–orthognathic surgery measurements. Patients had significantly (p < 0.001) higher (patient-perceived age scale) and lower (facial appraisal and quality-of-life scales) FACE-Q values than normal individuals for pre–orthognathic surgery but not for post–orthognathic surgery measurements. The FACE-Q facial appearance overall scale had significant correlations (p < 0.001) with the panel assessment for the parameters “beautiful” and “attractive” but not for the “pleasant” parameter. No significant correlations were observed for facial age scales.

Conclusion:

This study contributes to the orthognathic surgery literature by revealing that orthognathic surgery positively impacts the perception of apparent facial age and improves facial appearance and quality of life.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Estimation of Contralateral Perfusion in the DIEP Flap by Scoring the Midline-Crossing Vessels in Computed Tomographic Angiography
Authors: Han Hyun Ho , Kang Min Kyu , Choe Jooae , Jaikel Karina , Kim Eun Key , Cha Han Gyu , Choi Eun Jeong , Eom Jin Sup
Published: March 2020

Background:

In deep inferior epigastric perforator flap surgery, the amount of perfusion achievable in the contralateral side over a midline is unclear. Predicting contralateral perfusion preoperatively using computed tomographic angiography will allow efficient breast reconstruction with decreased complications. The authors used computed tomographic angiography to determine whether contralateral perfusion is related to blood vessel status across the midline.

Methods:

Preoperative computed tomographic angiography scans and intraoperative perfusion in patients who underwent breast reconstruction with a deep inferior epigastric perforator flap between January of 2018 and July of 2018 were checked prospectively. A vessel scoring system was prepared according to vessel density across the flap midline on the scan (grade 0, no visible vessels; grade 1, visible vessels with disconnection or could not be judged as grade 0 or 2; grade 2, definite vessels). Intraoperative flap perfusion was confirmed with indocyanine green angiography. Postoperative fat necrosis was analyzed using ultrasonography.

Results:

Ninety-four patients were analyzed. Mean maximal contralateral perfusion length was as follows: grade 0, 7.50 ± 1.89 cm; grade 1, 7.93 ± 2.01 cm; and grade 2, 10.14 ± 2.29 cm. Grade 2 had a statistically significantly greater contralateral perfusion length than grade 0 (p < 0.001) and grade 1 (p < 0.001). Fat necrosis occurred in 27.3 percent (grade 0), 19.1 percent (grade 1), and 8 percent (grade 2), which was statistically significant (p = 0.035).

Conclusions:

A definite vessel connection across the midline (as in grade 2) in preoperative computed tomographic angiography indicates that contralateral perfusion will be sufficiently achieved. This vessel scoring system would be helpful in predicting flap perfusion and planning the surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Diagnostic, IV.
Cleidocranial Dysplasia: Management of the Multiple Craniofacial and Skeletal Anomalies
Authors: Jirapinyo Chutima , Deraje Vybhav , Huang Gwendolyn , Gue Sam , Anderson Peter J. , Moore Mark H.
Published: March 2020

Cleidocranial dysplasia (CCD) is a rare autosomal dominant disorder caused by mutations in the Runx2 gene. The CCD is characterized by frontal bossing, a patent anterior fontanelle, presence of Wormian bones, midface hypoplasia, multiple dental abnormalities, clavicular hypoplasia or aplasia, skeletal abnormalities, and short stature. The aims of this study are to report the phenotypic manifestations of all patients who presented with CCD and to review the multidisciplinary management of these patients. The longitudinal data of patients with a diagnosis of CCD treated at The Australian Craniofacial Unit from 1980 to 2019 were reviewed. Fourteen patients were identified for inclusion in this study. The age at referral to the unit ranged from 1 week old to 49 years old (mean 11.2 years old). All patients had clinical features of frontal bossing, a patent anterior fontanelle, multiple Wormian bones, midface hypoplasia, abnormal dentition, clavicular hypoplasia/aplasia, and normal intellect. Eleven patients had obstructive sleep apnea. Eight patients had positive family history. Speech issues were found in 6 patients and abnormal hearing was found in 4 patients. Seven patients who underwent skeletal survey were found to have skeletal abnormalities. All patients were evaluated and managed by the multidisciplinary team, which consisted of craniofacial surgeons, pediatric dentists, orthodontists, ENT surgeons, pediatricians, clinical geneticists, radiologists, orthopedic surgeons, and social workers. All patients were treated by dentists/orthodontists requiring multiple surgical interventions and orthodontic treatment. Seven patients who had recurrent ear infection underwent ventilation tube insertion. Seven of 11 patients who had obstructive sleep apnea underwent adenotonsillectomy. Four patients underwent orthognathic surgery to correct midface hypoplasia and malocclusion. Two patients had cranioplasty for correction of metopic depressions. The characteristic findings of patients with CCD involving multiple regions of the body should draw clinicians’ attention to the need for multidisciplinary management of these patients.
Comparative Three-Dimensional Finite Element Analysis on Miniplate and Lag Screw Fixation to Symphysis Fractures
Authors: Ertem Sinan Yasin
Published: March 2020

The purpose of this study was to compare the amount of stress on the fracture site via three-dimensional finite element analysis between lag screw and miniplate systems. Solid mathematical models were created from the CT of a patient and a fracture observed in the symphysis area. On the fracture site mini plates and lag screws applied to the bone to fixate segments. The physiologic mastication chewing forces were applied for simulation. These 2 fixation methods: were evaluated by their amount of stress values. The maximum Von Misses stress lag screw model was 2727 MPa on the apex of the lag screw and 934 MPa on the fracture site of the screw. At the miniplate model, the maximum Von Misses stress was 571 MPa on the head of the miniplate screw, and it was 202 MPa on the fracture site. Thus, lag screw model causes at least 4 times higher stress values than mini plate model. The stress level of lag screw model is higher than miniplate model. However, when the chewing forces are taken into account, the amount of stress in the lag screw system is also acceptable in clinical applications.
Delayed Traumatic Pseudoaneurysm of the Dorsal Nasal Artery
Authors: Kim Tae Hoon , Lim Eung Jung , Kim SungHee , Park Jun Ho
Published: March 2020

A pseudoaneurysm is an uncommon pathology arising from any artery in the human body. It typically presents as a pulsatile swelling in contact with a blood vessel. Of pseudoaneurysms of the head and neck region, the most common site is the superficial temporal artery while that of the dorsal nasal artery is extremely rare. A pseudoaneurysm can be routinely diagnosed by its clinical features and confirmed by radiologic evaluation. The authors report a case of pseudoaneurysm of the dorsal nasal artery, which was misdiagnosed as a hematoma owing to its non-pulsatile nature during initial presentation.
Investigation of the Relationship Between Mandibular Morphology and Upper Airway Dimensions
Authors: Golchini Ehsan , Rasoolijazi Homa , Momeni Farzaneh , Shafaat Pedram , Ahadi Reza , Jafarabadi Mohammad Asghari , Rahimian Saba
Published: March 2020

Introduction:

In this study, the authors aimed to perform a novel and extensive analysis, based on the most applicable correlations between the mandibular and upper airway parameters, using cone beam computed tomography across all malocclusion classes. The authors also focused on gender-dependent differences in an Iranian population.

Materials and Methods:

Images were acquired from adult patients using cone beam computed tomography. The patients were classified into three groups of malocclusion classes (class I: 13 males and 27 females, class II: 13 males and 27 females, and class III: 25 males and 15 females). For each patient, 10 parameters for the mandible and 23 parameters for the pharynx, pyriform aperture, and nasal cavity were evaluated in the images.

Results:

Pearson's correlation coefficient showed significant correlations between the mandibular morphology and upper airway dimensions in each malocclusion class. In females, the menton angle had a significant correlation with pharyngeal dimensions in all malocclusion classes. In males, the bigonial width, bicondylar width, and symphyseal height of the mandible were correlated with pharyngeal dimensions in all classes. The greatest correlation between the mandible and upper airways was observed in class III malocclusions, and the lowest correlation was observed in class I malocclusions. In addition, the mandibular parameters had relationships with the nasal cavity and pyriform aperture.

Conclusion:

It is important to consider the knowledge of the relationship between some characteristics of the mandible and airways in various clinical approaches.
Alternative Methods to Local Flap Applications in Large Tissue Losses Caused by Gunshot Injuries in the Syrian War
Authors: Uçak Murat
Published: March 2020

Purpose/Object/Background:

In gunshot injury (GSI), the distance, ballistic properties, and the site of injury of lead or scattering gain importance. The authors investigated alternative methods to local flap applications in large tissue losses on facial regions caused by GSI in the Syrian War at the light of our approaches and outcomes.

Materials and Methods:

The study was designed as a cross-sectional retrospective clinical cohort analyze. The authors analyzed data describing the distribution and comparisons of 187 Syrian patients who injured in the war due to GSI and transferred to our medical center from Jan 2011 and June 2018. The study included data of the patients with demographics, mechanisms of a war injury, clinical data, treatment, and outcomes.

Results:

131(70%) of all the patients were soldiers, while the rest 56 was civilians. 58% (n = 108) of the GSI was female while remaining was males (42%; n = 79). The rate for children was 32% in all the patients as the most common soft tissues of the face were around the maxilla-zygoma (38.4%), orbita-nose region (29.3%), mandibula-teeth (18.5%). The authors performed a fascio cutaneous transposition flap that was planned from the cervical region (58%), interpolation flap that was planned from the frontotemporal region (28%), and forehead rotation flap (14%). The authors did not lose any patients due to plastic reconstruction.

Conclusion:

The fasciocutaneous transposition flap, interpolation flap, and forehead rotation flap that The authors apply to these patients are extremely rare flaps today. These flap applications have achieved tremendous outcomes, even without any sign of necrosis in war surgery.
Subtotal Exenteration of the Orbit for Benign Orbital Disease
Authors: Furdova Alena , Babal Pavel , Zahorjanova Pavlina , Sekac Juraj
Published: March 2020

Purpose:

Total exenteration of the orbit with removal of the eye globe and surrounding tissues is most frequently indicated for malignant tumors. The indications for exenteration of the orbit for benign orbital lesion are rare. Not adequately treated infection of the orbit by systemic antibiotics can lead to destructive changes of soft tissues in the region of the orbit and partial exenteration with eyelid sparing technique is necessary.

Design:

Retrospective case series.

Methods:

Data of all patients between 2010 and 2018 who underwent exenteration of the orbit for periocular lesions infiltrating the region of the orbit were reviewed for patient demographics, previous treatment options, tumor localization and histopathologic type.

Results:

In group of 14 patients with periocular lesions total orbital exenteration underwent 12 patients (86%), in 1 patient biorbital exenteration was performed and in one patient orbital exenteration with eyelid sparing technique was performed. For 2 patients (14%) orbital exenteration was the first surgical procedure performed. In the group of total exenteration in 12 cases histopathologically basal cell carcinoma from eyelids was confirmed, in one case squamous cell epibulbar carcinoma was confirmed and in 1 case subtotal exenteration with eyelid sparing technique was performed—the authors reported the case.

Case report of patient with long inflammation of the lacrimal pathway leading to orbital inflammation with eye globe destruction and partial exenteration with eyelids sparing technique was indicated. A 75-year-old man presented in 2014 with blepharoconjunctivitis and lacrimal sac inflammation of the left side. Treated in outpatient tract with local antibiotics, the drainage lacrimal system was transient. Few months later developed chronic blefaroconjunctivitis in cultivation result Citrobacter koseri positive was found. Patient was treated only with local therapy at outpatient tract again. In 2017 sent to hospital with painful eye-globe, visual acuity was no light perception. Computed tomography and magnetic resonance presented soft tissue mass extending along the medial orbit region in the m.rect. medialis and m. obliquus sup. and partly also m. rect. inf. space as a lesion of size 23 × 30 mm with a slight postcontrast homogeneous saturation and this lesion tightly fitted to the eyeball. Exenteration with lid sparing technique was performed. In 2019 after healing process patient got an individual epithesis.

Conclusions:

Basal cell carcinoma is the most frequent indication of orbital exenteration. Rarely is indicated subtotal exenteration with eyelid sparing technique for non-cancer reason as it was in our 1 case.
Pneumonectomy for Pediatric Tumors—a Pediatric Surgical Oncology Research Collaborative Study
Authors: Polites Stephanie F. , Heaton Todd E. , LaQuaglia Michael P. , Kim Eugene S. , Barry Wesley E. , Goodhue Catherine J. , Murphy Andrew J. , Davidoff Andrew M. , Langham Max R. , Meyers Rebecka L. , Short Scott S. , Lautz Timothy B. , Glick Richard D. , Vasudevan Sanjeev A. , Bence Christina M. , Lal Dave R. , Baertschiger Reto M. , Emr Bryanna , Malek Marcus M. , Dasgupta Roshni
Published: March 2020

Objective:

To describe utilization and long-term outcomes of pneumonectomy in children and adolescents with cancer.

Summary Background Data:

Pneumonectomy in adults is associated with significant morbidity and mortality. Little is known about the indications and outcomes of pneumonectomy for pediatric tumors.

Methods:

The Pediatric Surgical Oncology Research Collaborative (PSORC) identified pediatric patients <21 years of age who underwent pneumonectomy from 1990 to 2017 for primary or metastatic tumors at 12 institutions. Clinical information was collected; outcomes included operative complications, long-term function, recurrence, and survival. Univariate log rank, and multivariable Cox analyses determined factors associated with survival.

Results:

Thirty-eight patients (mean 12 ± 6 yrs) were identified; median (IQR) follow-up was 19 (5–38) months. Twenty-six patients (68%) underwent pneumonectomy for primary tumors and 12 (32%) for metastases. The most frequent histologies were osteosarcoma (n = 6), inflammatory myofibroblastic tumors (IMT; n = 6), and pleuropulmonary blastoma (n = 5). Median postoperative ventilator days were 0 (0–1), intensive care 2 (1–3), and hospital 8 (5–16). Early postoperative complications occurred in 10 patients including 1 death. Of 25 (66%) patients alive at 1 year, 15 reported return to preoperative pulmonary status. All IMT patients survived while all osteosarcoma patients died during follow-up. On multivariable analysis, metastatic indications were associated with nonsurvival (HR = 3.37, P = 0.045)

Conclusion:

This is the largest review of children who underwent pneumonectomy for cancer. There is decreased procedure-related morbidity and mortality than reported for adults. Survival is worse with preoperative metastatic disease, especially osteosarcoma.
Oncologic Outcomes of Nipple-sparing Mastectomy and Immediate Reconstruction After Neoadjuvant Chemotherapy for Breast Cancer
Authors: Wu Zhen Yu , Kim Hee-Jeong , Lee Jong-Won , Chung Il-Yong , Kim Ji-Sun , Lee Sae-Byul , Son Byung-Ho , Eom Jin-Sup , Kim Sung-Bae , Gong Gyung-Yub , Kim Hak-Hee , Ahn Sei-Hyun , Ko BeomSeok
Published: March 2020

Objectives:

To evaluate the oncologic outcomes and risk factors for locoregional recurrence (LRR) and nipple-areola complex recurrence (NR) in a large series of breast cancer patients who underwent nipple-sparing mastectomy (NSM) and immediate reconstruction after neoadjuvant chemotherapy (NACT).

Summary of Background Data:

The use of NSM and immediate reconstruction in breast cancer patients receiving NACT is increasing. However, the oncologic safety of this approach is unclear.

Patients and Methods:

A total of 310 breast cancer patients (319 breasts) who underwent NACT and NSM between February 2010 and November 2016 were retrospectively analyzed. Clinical and pathologic factors associated with increased risks of LRR and NR were analyzed using univariate (Chi-square or Fisher exact test) and multivariate (Cox proportional hazard regression model) analyses.

Results:

During a mean follow-up of 63 ± 22 months, 38 cases had LRR as the first event, including 6 cases of NR as the first event. The 5-year cumulative LRR and NR rates were 11.0% and 1.9%, respectively. In univariate analysis, clinical T stage, pathologic nodal status, histologic grade, lymphovascular invasion, and post-NACT Ki67 status were associated with increased LRR risk, and post-NACT Ki67 status was the only significant risk factor for NR. In multivariate analysis, post-NACT Ki67 ≥10% (hazard ratio, 4.245; 95% confidence interval, 1.865–9.663; P = 0.001) was an independent risk factor for LRR.

Conclusions:

NSM and immediate reconstruction seem to be oncologically safe with acceptable LRR and NR rates for appropriately selected breast cancer patients treated with NACT. Post-NACT Ki67 ≥10% was associated with increased risk of LRR or NR, and therefore, necessitates cautious follow-up.
Safe Dissemination of Laparoscopic Liver Resection in 27,146 Cases Between 2011 and 2017 From the National Clinical Database of Japan
Authors: Ban Daisuke , Tanabe Minoru , Kumamaru Hiraku , Nitta Hiroyuki , Otsuka Yuichiro , Miyata Hiroaki , Kakeji Yoshihiro , Kitagawa Yuko , Kaneko Hironori , Wakabayashi Go , Yamaue Hiroki , Yamamoto Masakazu
Published: March 2020

Objective:

To investigate the frequency of laparoscopic liver resection (LLR) nationwide in Japan.

Background:

LLR was initially limited to basic liver resection, but is becoming more common in advanced liver resection.

Methods:

Retrospective observational study of 148,507 patients registered in the National Clinical Database 2011–2017. Excluded: liver resection with biliary and vascular reconstruction.

Results:

LLR or open liver resection (OLR) was performed in 1848 (9.9%) and 16,888 (90.1%) patients, respectively, in 2011, whereas in 2017, LLR had increased to 24.8% and OLR decreased to 75.2% of resections (5648 and 17,099 patients, respectively). There was an annual increasing trend of LLR, starting at 9.9%, then 13.8%, 17.3%, 21.2%, 18.1%, 21.0%, and finally 24.8% in 2017. Basic LLR became more common, up to 30.8% of LR in 2017. Advanced LLR increased from 3.3% of all resections in 2011 to 10.8% in 2017. Throughout the years observed, there were fewer complications in LLR than OLR. Operative mortality was 3.6% for both advanced LLR and OLR in 2011, and decreased to 1.0% and 2.0%, respectively, in 2017. Mortality for both basic LLR and basic OLR were low and did not change throughout the study, at 0.5% and 1.6%, respectively, in 2011 and 0.5% and 1.1%, in 2017.

Conclusions:

LLR has rapidly become widespread in Japan. Basic LLR is now a standard option, and advanced LLR, while not as common yet, has been increasing year by year. LLR has been safely developed with low mortality and complications rate relative to OLR.
Impact of the Affordable Care Act Insurance Marketplaces on Out-of-Pocket Spending Among Surgical Patients
Authors: Liu Charles , Maggard-Gibbons Melinda , Weiser Thomas G. , Morris Arden M. , Tsugawa Yusuke
Published: March 2020

Objective:

To evaluate the association between the introduction of the Affordable Care Act (ACA) Health Insurance Marketplaces (“Marketplaces”) and financial protection for patients undergoing surgery.

Background:

The ACA established Marketplaces through which individuals could purchase subsidized insurance coverage. However, the effect of these Marketplaces on surgical patients’ healthcare spending remains largely unknown.

Methods:

We analyzed a nationally representative sample of adults aged 19–64 who underwent surgery in 2010–2017, using the Medical Expenditure Panel Survey. Low-income patients eligible for cost-sharing and premium subsidies in the Marketplaces [income 139%–250% federal poverty level (FPL)] and middle-income patients eligible only for premium subsidies (251%–400% FPL) were compared to high-income controls ineligible for subsidies (>400% FPL) using a quasi-experimental difference-in-differences approach. We evaluated 3 main outcomes: (1) out-of-pocket spending, (2) premium contributions, and (3) likelihood of experiencing catastrophic expenditures, defined as out-of-pocket plus premium spending exceeding 19.5% of family income.

Results:

Our sample included 5450 patients undergoing surgery, representing approximately 69 million US adults. Among low-income patients, Marketplace implementation was associated with $601 lower [95% confidence interval (CI): −$1169 to −$33; P = 0.04) out-of-pocket spending; $968 lower (95% CI: −$1652 to −$285; P = 0.006) premium spending; and 34.6% lower probability (absolute change: −8.3 percentage points; 95% CI: −14.9 to −1.7; P = 0.01) of catastrophic expenditures. We found no evidence that health expenditures changed for middle-income surgical patients.

Conclusions:

The ACA's insurance Marketplaces were associated with improved financial protection among low-income surgical patients eligible for both cost-sharing and premium subsidies, but not in middle-income patients eligible for only premium subsidies.
Methods of Colostomy Construction: No Effect on Parastomal Hernia Rate
Authors: Correa Marinez Adiela , Bock David , Erestam Sofia , Engström Anette , Kälebo Peter , Nielsen Yousef Wirenfeldt , Rosenberg Jacob , Haglind Eva , Angenete Eva
Published: March 2020

Objective:

The primary objective of this trial was to compare the parastomal hernia rates 1 year after the construction of an end colostomy by 3 surgical techniques: cruciate incision, circular incision in the fascia and using prophylactic mesh. Secondary objectives were evaluation of postoperative complications, readmissions/reoperations, and risk factors for parastomal hernia.

Summary of Background Data:

Colostomy construction techniques have been explored with the aim to improve function and reduce stoma complications, but parastomal herniation is frequent with an incidence of approximately 50%.

Methods:

A randomized, multicenter trial was performed in 3 hospitals in Sweden and Denmark; all patients scheduled to receive an end colostomy were asked to participate. Parastomal hernia within 12 months was determined by computed tomography of the abdomen in prone position and by clinical assessment. Complications, readmissions, reoperations, and risk factors were also assessed.

Results:

Two hundred nine patients were randomized to 1 of the 3 arms of the study. Patient demographics were similar in all 3 groups. Assessment of parastomal hernia was possible in 185 patients. The risk ratio (95% confidence interval) for parastomal hernia was 1.25 (0.83; 1.88), and 1.22 (0.81; 1.84) between cruciate versus circular and cruciate versus mesh groups, respectively. There were no statistically significant differences between the groups with regard to parastomal hernia rate. Age and body mass index were found to be associated with development of a parastomal hernia.

Conclusion:

We found no significant differences in the rates of parastomal hernia within 12 months of index surgery between the 3 surgical techniques of colostomy construction.
Recent Modifications of the Nuss Procedure
Authors: Kelly Robert E. , Obermeyer Robert J. , Goretsky Michael J. , Kuhn M. Ann , Frantz Frazier W. , McGuire Margaret M. , Duke Duane S. , Daniel Antarius , Nuss Donald
Published: March 2020

Objective:

To review standardized Nuss correction of pectus excavatum and vacuum bell treatment over the last 10 years.

Summary of Background Data:

In 2010, we reported 21 years of the Nuss procedure in 1215 patients.

Methods:

Over the last 10 years, 2008–2018, we evaluated 1885 pectus excavatum patients. Surgery was indicated for well-defined objective criteria. A consistent operation was performed by 8 surgeons in 1034 patients, median 15 years, (range 6–46); 996 were primary, and 38 redo operations. Surgical patients’ mean computed tomography index was 5.46. Mitral valve prolapse was present in 5.4%, Marfan syndrome in 1.1% and scoliosis in 29%. Vacuum bell treatment was introduced for 218 patients who did not meet surgical criteria or were averse to surgery.

Results:

At primary operation, 1 bar was placed in 49.8%; 2 bars, 49.4%; and 3 bars, 0.7%. There were no deaths. Cardiac perforation occurred in 1 patient who had undergone previous cardiac surgery. Paraplegia after epidural catheter occurred once. Reoperation for bar displacement occurred in 1.8%, hemothorax in 0.3%, and wound infection in 2.9%; 1.4% required surgical drainage. Allergy to stainless steel was identified in 13.7%. A good anatomic outcome was always achieved at bar removal. Recurrence requiring reoperation occurred in 3 primary surgical patients. Two patients developed carinate overcorrection requiring reoperation. Vacuum bell treatment produced better results in younger and less severe cases.

Conclusions:

A standardized Nuss procedure was performed by multiple surgeons in 1034 patients with good overall safety and results in primary repairs. Vacuum bell treatment is useful.
Expression Patterns and Prognostic Value of DNA Damage Repair Proteins in Resected Pancreatic Neuroendocrine Neoplasms
Authors: Hua Jie , Shi Si , Xu Jin , Wei Miaoyan , Zhang Yiyin , Liu Jiang , Zhang Bo , Yu Xianjun
Published: March 2020

Objective:

This study aimed to examine the expression profiles and prognostic value of multiple DDR proteins in resected PanNENs.

Background:

DDR proteins play important roles in various cancers, including pancreatic ductal adenocarcinoma. However, the expression patterns and prognostic value of DDR proteins in PanNENs remain unclear.

Methods:

This retrospective analysis included PanNEN patients who underwent resection at the Fudan University Shanghai Cancer Center from 2012 to 2018. Immunohistochemical staining was performed for 12 DDR proteins in tissue microarrays. The associations of DDR protein expression and clinicopathological features with recurrence-free survival (RFS) were examined via a Cox regression model and random survival forest. A recurrence signature was constructed using recursive partitioning analysis.

Results:

In total, 131 PanNEN patients were included, with 32 (24.4%) cases of recurrence. Among the 12 DDR proteins, low checkpoint kinase 2 (CHK2) expression (P = 0.020) and loss of ataxia-telangiectasia–mutated (ATM) (P = 0.0007) significantly correlated with recurrence. Multivariable Cox regression analysis identified tumor size ≥3 cm, lymph node (LN) metastasis, high tumor grade, low CHK2 expression, and ATM loss as independent risk factors for recurrence. A recurrence signature was established based on the importance of recurrence-specific risk factors; patients with the LNnegTumorSize<3cm signature had a 5-year RFS rate of 96.8%, whereas patients with the LNposCHK2low signature had the worst 5-year RFS rate (0%). Discrimination (concordance index: 0.770) and calibration plots indicated that the recurrence signature had a good ability to identify patients at risk for recurrence.

Conclusions:

By analyzing large-scale tissue microarrays of PanNENs, we evaluated 12 DDR protein expression profiles. We developed a recurrence signature that can identify distinct subpopulations according to RFS, which may help refine individual follow-up.
Perioperative Complications After Proctectomy for Rectal Cancer
Authors: Bauer Philip S. , Chapman William C. , Atallah Chady , Makhdoom Bilal A. , Damle Aneel , Smith Radhika K. , Wise Paul E. , Glasgow Sean C. , Silviera Matthew L. , Hunt Steven R. , Mutch Matthew G.
Published: March 2020

Objective:

Investigate the association between neoadjuvant treatment strategy and perioperative complications in patients undergoing proctectomy for nonmetastatic rectal cancer.

Summary of Background Data:

Neoadjuvant SC-TNT is an alternative to neoadjuvant CRT for rectal cancer. Some have argued that short-course radiation and extended radiation-to-surgery intervals increase operative difficulty and complication risk. However, the association between SC-TNT and surgical complications has not been previously investigated.

Methods:

This single-center retrospective cohort study included patients undergoing total mesorectal excision for nonmetastatic rectal cancer after SC-TNT or CRT between 2010 and 2018. Univariate analysis of severe POM and multiple secondary outcomes, including overall POM, intraoperative complications, and resection margins, was performed. Logistic regression of severe POM was also performed.

Results:

Of 415 included patients, 156 (38%) received SC-TNT and 259 (62%) received CRT. The cohorts were largely similar, though patients with higher tumors (69.9% vs 47.5%, P < 0.0001) or node-positive disease (76.9% vs 62.6%, P = 0.004) were more likely to receive SC-TNT. We found no difference in incidence of severe POM (9.6% SC-TNT vs 12.0% CRT, P = 0.46) or overall POM (39.7% SC-TNT vs 37.5% CRT, P = 0.64) between cohorts. Neoadjuvant regimen was also not associated with a difference in severe POM (odds ratio 0.42, 95% confidence interval 0.04–4.70, P = 0.48) in multivariate analysis. There was no significant association between neoadjuvant regimen and any secondary outcome.

Conclusion:

In rectal cancer patients treated with SC-TNT and proctectomy, we found no significant association with POM compared to patients undergoing CRT. SC-TNT does not significantly increase the risk of POM compared to CRT.
The Impact of Adjuvant Therapy on Survival After Esophagectomy for Node-negative Esophageal Adenocarcinoma
Authors: Rucker A. Justin , Raman Vignesh , Jawitz Oliver K. , Voigt Soraya L. , Harpole David H. , D’Amico Thomas A. , Tong Betty C.
Published: March 2020

Objective:

Determine whether adjuvant chemotherapy is associated with a survival benefit in high risk T2-4a, pathologically node-negative distal esophageal adenocarcinoma.

Summary of Background Data:

There is minimal literature to substantiate the NCCN guidelines recommending adjuvant therapy for patients with distal esophageal adenocarcinoma and no pathologic evidence of nodal disease.

Methods:

The National Cancer Database was used to identify adult patients with pT2-4aN0M0 esophageal adenocarcinoma who underwent definitive surgery (2004–2015) and had characteristics considered high risk by the NCCN. Patients were stratified by receipt of adjuvant chemotherapy with or without radiation. The primary outcome was overall survival, which was evaluated using Kaplan-Meier and multivariable Cox Proportional Hazards models. A 1:1 propensity score-matched analysis was also performed to compare survival between the groups.

Results:

Four hundred three patients met study criteria: 313 (78%) without adjuvant therapy and 90 who received adjuvant chemotherapy with or without radiation (22%). In both unadjusted and multivariable analysis, adjuvant chemotherapy with or without radiation was not associated with a significant survival benefit compared to no adjuvant therapy. In a subgroup analysis of 335 patients without high risk features by NCCN criteria, adjuvant chemotherapy was not independently associated with a survival benefit.

Conclusion:

In this analysis, adjuvant chemotherapy with or without radiation was not associated with a significant survival benefit in completely resected, pathologically node-negative distal esophageal adenocarcinoma, independent of presence of high risk characteristics. The risks and benefits of adjuvant therapy should be weighed before offering it to patients with completely resected pT2-4aN0M0 esophageal adenocarcinoma.
The Supervisor's Toolkit: Strategies of Supervisors to Entrust and Regulate Autonomy of Residents in the Operating Room
Authors: Nieboer Patrick , Huiskes Mike , Cnossen Fokie , Stevens Martin , Bulstra Sjoerd K. , Jaarsma Debbie A. D. C.
Published: March 2020

Objective:

To identify what strategies supervisors use to entrust autonomy during surgical procedures and to clarify the consequences of each strategy for a resident's level of autonomy.

Background:

Entrusting autonomy is at the core of teaching and learning surgical procedures. The better the level of autonomy matches the learning needs of residents, the steeper their learning curves. However, entrusting too much autonomy endangers patient outcome, while entrusting too little autonomy results in expertise gaps at the end of training. Understanding how supervisors regulate autonomy during surgical procedures is essential to improve intraoperative learning without compromising patient outcome.

Methods:

In an observational study, all the verbal and nonverbal interactions of 6 different supervisors and residents were captured by cameras. Using the iterative inductive process of conversational analysis, each supervisor initiative to guide the resident was identified, categorized, and analyzed to determine how supervisors affect autonomy of residents.

Results:

In the end, all the 475 behaviors of supervisors to regulate autonomy in this study could be classified into 4 categories and nine strategies: I) Evaluate the progress of the procedure: inspection (1), request for information (2), and expressing their expert opinion (3); II) Influence decision-making: explore (4), suggest (5), or declare the next decision (6); III) Influence the manual ongoing action: adjust (7), or stop the resident's manual activity (8); IV) take over (9).

Conclusions:

This study provides new insights into how supervisors regulate autonomy in the operating room. This insight is useful toward analyzing whether supervisors meet learning needs of residents as effectively as possible.