bluuebunny/crossref_metadata_2025 huggingface dataset:
More Helmets Fewer Deaths: Motorcycle Helmet Legislation Impacts Traumatic Brain Injury-Related Mortality in Young Adults
Authors: Hassan Ahmed , Jokar Tahereh Orouji , Rhee Peter , Ibraheem Kareem , Kulvatunyou Narong , Anderson Kathryn Tinsley , Gries Lynn , Roward Zachary Thomas , Joseph Bellal
Published: June 2020

The aim of our study was to assess the impact of helmet legislations on the incidence and the mortality rate of motorcycle collision (MCC)-related traumatic brain injury (TBI) in young adult trauma patients. A 1-year (2011) retrospective analysis was performed of all patients under 21 years old with trauma-related hospitalization using the Nationwide Inpatient Sample database (representing 20% of all in-patient admissions). Patients with MCC were identified using E-codes. States were classified into three groups based on helmet legislations: universal age helmet legislation, <18 years helmet legislation, and <21 years helmet legislation. Outcome measures were the rates of TBI and mortality. Linear regression analysis was used to assess outcomes among the states. A total of 1,165,150 patients with trauma-related hospitalizations across 29 states were reviewed of which, 587 patients with MCC were included. Ten states had universal age legislation; 13 states had age <18 years legislation, and 6 states had age <21 years legislation. There was a lower incidence in the rate of TBI (P = 0.03) in states with universal helmet legislations compared with states with age-restricted helmet legislation. Universal helmet legislations lowered the rate of MCC-related TBI injures by a factor of 2.15 (β coefficient: 2.15; 95% confidence interval: 0.91–10.18; P = 0.04). States with age-restricted helmet legislations have a higher rate of traumatic brain injury and mortality compared with states with universal helmet legislations. Establishing universal helmet legislations across the states may provide a potential preventive strategy against traumatic brain injury.
Pretrauma Functional Independence Measure Score Predicts Survival in Geriatric Trauma
Authors: Fletcher Brian , Bradburn Eric , Baker Christopher , Collier Bryan , Hamill Mark , Shaver Katherine
Published: June 2020

The Functional Independence Measure (FIM) is used by rehabilitation professionals to access disability. The FIM score combines both motor and cognitive parameters to assess a patient's level of required assistance in performing activities of daily living (ADL). The geriatric trauma patient is becoming an increasingly important cohort for trauma services. FIM has been shown to predict discharge outcomes and those at high risk for falls. We hypothesized pretrauma FIM scores may predict survival in the geriatric trauma population. This was a retrospective study of patients 65 years and older that were admitted to our Level I trauma center from July 1, 2006 to July 1, 2012. A total 941 patients underwent stepwise regression to identify those factors predicting survival. Age, Injury Severity Score, revised trauma score, body mass index, and pretrauma FIM scores (12-point scale) were studied. The primary outcome was survival. Statistical significance reached at P value <0.05. Multiple logistic regression analysis was then performed. A total of 1315 patients were identified and complete data were available on 941 patients. Mean age was 78 (SD ± 8.2), mean Injury Severity Score was 13(SD ± 8.7), and mean body mass index was 26. Overall mortality was 11 per cent. The odds ratio of survival was 3.532 (95% confidence interval = 2.191–5.718) times greater for every 1-point increase in the preadmission FIM expression score. Glasgow Coma Scale, revised trauma score, gender, and pretrauma FIM expression scores were predictive of survival in the geriatric trauma patient. Pretrauma FIM expression can be used to predict survival in the elderly trauma victim. Further study is needed to establish the role of FIM as part of trauma scoring systems.
The Impact of Early Recurrence on Quality of Life after Cytoreduction with HIPEC
Authors: Hinkle Nathan M. , Botta Vandana , Sharpe John P. , Dickson Paxton , Deneve Jeremiah , Munene Gitonga
Published: June 2020

Improved oncological outcomes after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in highly selected patients have been well documented. The extensive nature of the procedure adversely affects quality of life (QoL). The aim of this study is to longitudinally evaluate QoL following CRS/HIPEC. This is a retrospective review of a prospectively maintained database of patients with peritoneal malignancies undergoing CRS/HIPEC. Clinicopathological data, oncologic outcomes, and QoL were analyzed preoperatively and post-operatively at 2 weeks, and 1, 3, 6, and 12 months. The Functional Assessment of Cancer Therapy-Colorectal instrument was used to determine changes in QoL after CRS/HIPEC and the impact of early recurrence (<12 months) on QoL. Thirty-six patients underwent CRS/HIPEC over 36 months. The median peritoneal cancer index score was 18 and the completeness of cytoreduction-0/1 rate was 97.2 per cent. Postoperative major morbidity was 16.7 per cent with one perioperative death. Disease-free survival was 12.6 months in patients with high-grade tumors versus 31.0 months in those with low-grade tumors (P = 0.03). QoL decreased postoperatively and improved to baseline in six months. Patients with early recurrence had a decrease in global QoL compared with preoperative QoL at 6 (P < 0.03) and 12 months (P < 0.05). This correlation was not found in patients who had not recurred. Patients who undergo CRS/HIPEC have a decrease in QoL that plateaus in 3 to 6 months. Early recurrence adversely impacts QoL at 6 and 12 months. This study emphasizes the importance of patient selection for CRS/HIPEC. The expected QoL trajectory in patients at risk for early recurrence must be carefully weighed against the potential oncological benefit of CRS/HIPEC.
Factors Affecting Choice of Treatment for Early-Stage Breast Cancer in West Virginia: A 10-Year Experience from a Rural Tertiary Care Center
Authors: Suggs Patrick D. , Holliday Tyler L. , Thompson Stephanie N. , Richmond Bryan K.
Published: June 2020

Recent literature shows changing trends in use of breast conservation surgery (BCS), mastectomy, and contralateral prophylactic mastectomy (CPM) in women with early-stage breast cancer (ESBC). We analyzed factors associated with selection of these treatment modalities in a rural West Virginia tertiary care hospital. We conducted a 10-year analysis of women treated for ESBC at our institution from the institutional cancer registry. Variables were compared between patients choosing BCS versus mastectomy. In women who chose mastectomy, predictors for choice of CPM were also examined. Variables with P < 0.05 on univariate analysis were entered into a multivariate logistic regression model to define independent predictors of treatment choice. The mastectomy rate increased from 18.0 per cent in 2006 to 40.2 per cent in 2013. On multivariate analysis, insurance status (P < 0.001), comorbidities (P = 0.001), and surgeon graduation after 1987—a surrogate for surgeon age—(P = 0.010) predicted receipt of mastectomy. Of those receiving mastectomy, 106 (25.1%) elected CPM. CPM rates increased from 8.0 per cent in 2006 to 45.0 per cent in 2013. Younger age at diagnosis (P < 0.001) and use of preoperative MRI (P = 0.012) independently predicted use of CPM versus unilateral mastectomy. Rates of mastectomy and CPM in ESBC have increased in West Virginia over time. Independent predictors of selecting mastectomy over BCS included insurance status, surgeon age, and associated comorbidities. Younger patients and patients receiving preoperative MRI were more likely to choose CPM. Awareness of these factors will aid in counseling women with ESBC and allow clinicians to address potential biases or disparities that may affect treatment choices. Further prospective study of these findings is warranted.
Medication Errors in Injured Patients
Authors: Dolejs Scott C. , Janowak Christopher F. , Zarzaur Ben L.
Published: June 2020

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.
Gaps in the Postoperative Conversation: A Comprehensive Review of Current Practices and the Unmet Needs of Surgeons, Families, and Waiting Room Personnel
Authors: Singletary Brandon , Patel Nisha , Mims Andrew , Smedley Andrew , Swords Jacob , O'Bierne Ronan , Morris Melanie S. , Safford Monika , Heslin Martin
Published: June 2020

Perioperative communication between surgeons and caregivers is an important aspect of patient care, with postoperative conversations (POCs) being critical. Literature suggests current communication practices may be suboptimal. Identifying barriers and opportunities could improve patient and caregiver satisfaction and increase surgeon efficiency. This mixed method study included 1) prospective study of all patients undergoing a surgery at an academic medical center between September 2014 and March 2016 and 2) nominal groups of physicians, caregivers, and waiting room personnel (WRP). Nominal groups ranked standard of care themes needing intervention. Multivariate logistic regression estimated the association of surgeon and procedure characteristics with POC practices considering both location and contact method. Data on 15,820 operations showed that surgical specialty (P ≤ 0.0001), inpatient status (P ≤ 0.0001), planned discharge destination (P = 0.0003), patient race (P = 0.02), and caregiver relationship (P ≤ 0.0001) were all significantly associated with receiving a private POC. Nominal group results provided opportunities for improvement: regular updates (caregivers), locating the caregivers postoperation (surgeons), clear communication between caregivers and surgeons (WRP). This study examines the perioperative communication. Surgeons, caregivers, and WRP identified effective communication as a top intervention priority. Managing caregiver expectations, addressing concerns of WRP, and creating an efficient environment for surgeons appear to be critical components to communication.
The Sestamibi Paradox: Improving Intraoperative Localization of Parathyroid Adenomas
Authors: Buicko Jessica L. , Kichler Kandace M. , Amundson Julia R. , Scurci Stephanie , Kozol Roberta
Published: June 2020

Accurate localization of parathyroid adenomas allows for minimally invasive parathyroidectomy. This results in a shorter length of stay and increased patient satisfaction. Preoperative Technetium (99mTc) sestamibi scans accurately localize parathyroid adenomas in 70 to 85 per cent of cases. If a patient has a negative scan, it is logical to believe that with a preoperative sestamibi injection, the gamma probe may fail to help find an adenoma. We hypothesized that the gamma probe would not be useful intraoperatively for patients with primary hyperparathyroidism (PHPTH) and a negative sestamibi scan. We retrospectively reviewed the cases of parathyroidectomy at our institution from 2010 to 2016. We selected patients with PHPTH and negative sestamibi scan. In all cases, an attempt was made to find adenomas intraoperatively with the gamma probe. A frozen section was obtained as well as intraoperative parathyroid hormone levels to confirm removal of hyperfunctioning parathyroid tissue. There were 132 parathyroidectomies of which 22 had PHPTH and a negative sestamibi scan. One case was excluded because of insufficient documentation of the intraoperative use of the gamma probe. In 19 of the 21 patients analyzed, the gamma probe successfully identified the adenoma in the operating room (sensitivity, 90.5%). In two patients, the gamma probe did not aid in localization. There were no false positives. In all cases, the parathyroid resected was confirmed by frozen section. The intraoperative parathyroid hormone levels dropped >50 per cent in all but three cases, two of which corresponded to those cases where the gamma probe did not help. Even in patients with negative sestamibi scans, intraoperative use of the gamma probe after preoperative sestamibi injection is effective in localizing parathyroid adenomas.
Mammographic Screening at Age 40 or 45? What Difference Does it Make? the Potential Impact of American Cancer Society Mammography Screening Guidelines
Authors: Fancher Crystal E. , Scott Anthony , Allen Ahkeel , Dale Paul
Published: June 2020

This is a 10-year retrospective chart review evaluating the potential impact of the most recent American Cancer Society mammography screening guidelines which excludes female patients aged 40 to 44 years from routine annual screening mammography. Instead they recommend screening mammography starting at age 45 with the option to begin screening earlier if the patient desires. The institutional cancer registry was systematically searched to identify all women aged 40 to 44 years treated for breast cancer over a 10-year period. These women were separated into two cohorts: screening mammography detected cancer (SMDC) and nonscreening mammography detected cancer (NSMDC). Statistical analysis of the cohorts was performed for lymph node status (SLN), five-year disease-free survival, and five-year overall survival. Women with SMDC had a significantly lower incidence of SLN positive cancer than the NSMDC group, 9 of 63 (14.3%) versus 36 of 81 (44 %; P < 0.001). The five-year disease-free survival for both groups was 84 per cent for SMDC and 80 per cent for NSMDC; this was not statistically significant. The five-year overall survival was statistically significant at 94 per cent for the SMDC group and 80 per cent for the NSMDC group (P < 0.05). This review demonstrates the significance of mammographic screening for early detection and treatment of breast cancer. Mammographic screening in women aged 40 to 44 detected tumors with fewer nodal metastases, resulting in improved survival and reaffirming the need for annual mammographic screening in this age group.
Physiologic Features of Brain Death
Authors: Essien Eno-Obong , Fioretti Kristina , Scalea Thomas M. , Stein Deborah M.
Published: June 2020

Brain death is known to be associated with physiologic derangements but their incidence is poorly described. Knowledge of the changes that occur during brain death is important for management of the potential organ donor. Thus, we sought to characterize the pathophysiology that occurs during brain death in patients with traumatic injuries. All brain-dead patients over a 10-year period were identified from the trauma registry at a level 1 urban trauma center. Patient demographics, injury characteristics, and clinical data for defining organ dysfunction were reviewed for the 24 hours surrounding brain-death declaration. Three hundred and seventy-three patients were identified. Mean age was 37 years (617.2). Seventy-five per cent were male. Major mechanism of injury was blunt trauma in 66 per cent. Median injury severity score was 34 (IQR 25–43) with a median head abbreviated injury scale score of 5. The most common physiological disturbance was hypotension with 91 per cent of subjects requiring vasopressors. Thrombocytopenia and acidosis both had an incidence of 79 per cent. The next most common disturbances were hypothermia and moderate-to-severe respiratory dysfunction in 62 per cent. Myocardial injury was seen in 91 per cent but only 5.7 per cent of patients manifested severe cardiac dysfunction with an ejection fraction of <35. Diabetes insipidus was diagnosed in 50 per cent of patients. Interestingly, coagulopathy was noted in only 61.3 per cent, and hyperglycemia was seen in 36 per cent despite widespread belief that these occur universally during brain death. This is the first and largest study to characterize the incidence of pathophysiological disturbances following brain death in humans. Appropriate management of these dysfunctions is important for support of potential brain-dead organ donors.
The Growing Utilization of Laparoscopy in Emergent Colonic Disease
Authors: Sujatha-bhaskar Sarath , Alizadeh Reza F. , Koh Christina , Inaba Colette , Jafari Mehraneh D. , Carmichael Joseph C. , Stamos Michael J. , Pigazzi Alessio
Published: June 2020

Emergent colonic disease has traditionally been managed with open procedures. Evaluation of recent trends suggests a shift toward minimally invasive techniques in this disease setting. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) targeted colectomy database from 2012 to 2014 was used to examine clinical data from patients who emergently underwent open colectomy (OC) and laparoscopic colectomy (LC). Multivariate regression was utilized to analyze preoperative characteristics and determine risk-adjusted outcomes with intent-to-treat and as-treated approach. Of 10,018 patients with emergent colonic operation, 90 per cent (9023) underwent OC whereas 10 per cent (995) underwent LC. Laparoscopic utilization increased annually, with LC composing 10.9 per cent of emergent colonic operations in 2014 compared with 9.3 per cent in 2012. Compared with LC, patients treated with OC had higher rates of overall morbidity (odds ratio 2.01, 95% confidence interval 1.74–2.34, P < 0.01) and 30-day mortality (odds ratio 1.79, 95% confidence interval 1.30–2.46, P < 0.01). Subset analysis of emergent patients without preoperative septic shock revealed consistent benefits with laparoscopy in overall morbidity, 30-day mortality, ileus, and surgical site infection. In select patients with hemodynamic stability, emergent LC appears to be a safe and beneficial operation. This study reflects the growing preference and utilization of minimally invasive techniques in emergent colonic operations.
Management and Outcomes of Appendectomy during Pregnancy
Authors: Won Roy P. , Friedlander Scott , Lee Steven L.
Published: June 2020

Acute appendicitis is a common nonobstetric indication for surgical intervention during pregnancy with serious potential complications for the mother and fetus. The aim of this study was to evaluate the presentation, management practices, outcomes, and costs of appendectomy during pregnancy. We did a retrospective analysis of 62,118 nonincidental appendectomies performed in women (age 15–45 years) identified from the California State Inpatient Database (2005–2011). Primary outcomes included diagnosis or type of appendicitis, use of laparoscopy, morbidity, length of stay, and cost. Pregnant women were less likely to undergo laparoscopy (OR = 0.51, P < 0.01). Pregnancy had no effect on perforation rates, but was associated with higher rates of negative appendectomy (OR = 9.29, P < 0.01). Pregnancy was not associated with nonpregnancy-related complications after appendectomy. Pregnant women had longer length of stay (RR = 1.07, P < 0.01) but similar costs. Appendectomy did increase risk of preterm delivery at the time of surgical admission (19.5 vs 8.8%, P < 0.01). However, once discharged, there was no difference in rates of preterm delivery (9.1 vs 8.9%, P = 0.23). Pregnant women had higher rates of negative appendectomy with lower rates of laparoscopy. Despite these differences, there was no difference in nonpregnancy-related morbidity and cost. Appendectomy did increase risk of preterm birth, but the increased risk normalized over time.
Early Contact after Hospital Discharge Does Not Prevent Readmission in Patients Undergoing Pancreaticoduodenectomy
Authors: Gebhardt Katherine M. , Young Stephanie , Difronzo L. Andrew
Published: June 2020

Studies suggest that early contact (EC) after hospital discharge may help reduce hospital read-missions among medical patients. The objective of this study is to determine if EC after hospital discharge in patients undergoing a pancreaticoduodenectomy (PD) can reduce readmission. We performed a retrospective study of 35 patients who underwent PD over 18 months. Early, focused contact after hospital discharge was either a telephone call by a registered nurse or a clinic visit with a provider within four days of discharge. Hospital readmission rates were analyzed between the EC and no-early contact (NC) cohorts. Nineteen patients received EC after hospital discharge and 16 were in the NC group. Fourteen patients (40%) were readmitted, with postoperative pancreatic fistula and delayed gastric emptying as the most common indications for readmission (71.4%). Overall readmission rates were not significantly different between the EC and NC groups (31.6 vs 50.0%, respectively, P = 0.27). EC after hospital discharge in patients undergoing PD does not prevent readmission. This is likely due to the high incidence of postoperative pancreatic fistula or delayed gastric emptying that clinically manifests after hospital discharge and EC and requires readmission for management.
Geographic and Institutional Trends in Ambulatory Surgery in the State of California, 2012-2014
Authors: O'Neill Sean M. , Frencher Stanley K. , Maggard-gibbons Melinda
Published: June 2020

Although geographic variation in health care services is well established, relatively less is known about ambulatory surgical procedures in California. Thus, we sought to describe statewide trends according to geographic and institutional factors. Using the California Office of State Health Planning and Development Ambulatory Surgery and Hospital Utilization datasets, overall and per-capita procedure rates by county and institution were calculated and compared across 2012 to 2014. There was substantial variation in services provided at the county level (Range: 49–382,142 cases/county). Among the 10 largest counties, there was a more than 2-fold difference in case volume per capita; across all counties, a 50-fold variation was observed. Changes in county population size and surgical case volume were correlated only if Los Angeles, the most populous and highest-volume county in the state, was excluded as an outlier. In the first year of California's full Medicaid expansion, Medicaid ambulatory surgery cases increased 29 per cent and self-pay cases decreased 16 per cent. The top 10 facilities by volume experienced substantial volatility in case volume over two years, ranging from 219.6 to 111.5 per cent. Geographic differences in rates of ambulatory surgery may be related to population shifts, but this was not uniformly true. The factors driving this variation and its impact on patient care warrant further investigation.
The Place of Elastography in Evaluating the Efficacy of Radiofrequency Ablation of Thyroid Nodules
Authors: Idiz Ufuk O. , Aysan Erhan , Elmas Leyla , Yildiz Seyma , Akbulut Huseyin
Published: June 2020

The usage of radiofrequency ablation (RFA) therapy and elastography to treat thyroid nodules has been increasing recently. Elastography specifically measures the stiffness of tissue using ultra-sonography (US). The aim of the present study was to evaluate the relationship between the elastography values of thyroid nodules and the efficacy of RFA therapy. Ultrasonography was performed on 49 patients who had a thyroid nodule with a diameter of 1 cm or greater before RFA therapy. The RFA was performed under local anesthesia, and elastography was used to measure the stiffness of the normal thyroid tissue, sternocleidomastoid muscle (SCM) and thyroid nodules three months after RFA. The nodule diameter significantly decreased three months after RFA (P < 0.05). According to a cross-evaluation of the mean elastography rates, the thyroid/SCM and nodule/thyroid elastography rates had an inverse relationship (P: 0.009). However, the thyroid/ SCM elastography rates and nodule/SCM elastography rates (P: 0.022) and the thyroid/SCM elastography rates and the rates of reduction (%) of the nodule diameter before and three months after RFA (P: 0.016) had positive relationships. In conclusion, RFA therapy is more effective in patients with thyroid nodules if there are high thyroid tissue/SCM rates in elastography.
Varying Presentations and Outcomes of Septic Shock: Should Septic Shock be Stratified?
Authors: Zhu Youfeng , Yin Haiyan , Zhang Rui , Ye Xiaoling , Wei Jianrui
Published: June 2020

Recent studies have revealed there are three presentations of septic shock in patients: refractory hypotension without hyperlactatemia, hyperlactatemia without refractory hypotension, and both refractory hypotension and hyperlactatemia. In this study, we sought to identify differences in the outcomes of septic shock patients with these three presentations. We performed a secondary analysis of a large-scale, multicenter, controlled trial. The septic shock patients were categorized into the following three groups according to the presence or absence of refractory hypotension and hyperlactatemia: a hypotension group (refractory hypotension without hyperlactatemia), a hyperlactatemia group (hyperlactatemia without refractory hypotension), and a typical group (both refractory hypotension and hyperlactatemia). The 90-day all-cause mortality was compared among these three groups. A total of 1588 septic shock patients were enrolled in the present study, including 854 (53.8%) in the hypotension group, 477 (30.0%) in the hyperlactatemia group, and 257 (16.2%) in the typical group. The 90-day all-cause mortality were 12.3 per cent for the patients in the hypotension group, 23.1 per cent for those in the hyperlactatemia group, and 31.9 per cent for those inthe typical group, these differences among the three groups were significant (Pearson's χ2 = 58.49, P < 0.001). And also, there was a significant difference between hyperlactatemia group and typical group (Pearson's χ2 = 6.77, P < 0.05). In this study, we demonstrated that the three different presentations of septic shock resulted in significantly different outcomes, suggesting that septic shock should be stratified.
Heroic Measures for an American Hero: Attempting to save the Life of General Douglas MacArthur
Authors: Pappas Theodore N.
Published: June 2020

General Douglas MacArthur was a towering public figure on an international stage for the first half of the 20th century. He was healthy throughout his life but developed a series of medical problems when he entered his 80s. This article reviews the General's medical care during two separate life-threatening medical crises that required surgical intervention. The first episode occurred in 1960 when MacArthur presented with renal failure due to an obstructed prostate. Four years later after his 84th birthday, MacArthur developed bile duct obstruction from common duct stones. He underwent an uncomplicated cholecystectomy and common duct exploration but developed variceal bleeding requiring an emergent splenorenal shunt. His terminal event was precipitated by strangulated bowel in long-ignored very large inguinal hernias. MacArthur died, despite state-of-the-art surgical intervention, due to renal failure and hepatic coma.
Laparoscopic Exploration Can Salvage Recurrent Common Bile Duct Stone after Cholecystectomy
Authors: Liu Wen-Song , Zou Yan , Yang Bo , Jiang Yong , sun Dong-lin
Published: June 2020

Conventionally, patients suffered from recurrent common bile duct (CBD) stone after cholecystectomy are suggested to be treated with endoscopic retrograde cholangiopancreaticography. This study was designed to explore the feasibility of laparoscopic common bile duct exploration (LCBDE) as a salvage procedure for recurrent CBD calculi after cholecystectomy. A retrospective review was conducted of data from 65 patients who underwent LCBDE for recurrent CBD calculi after cholecystectomy from January 2011 to July 2015. LCBDE was successfully carried out in 61 cases, with a successful rate of 93.8 per cent. Three cases required open conversion because of serious abdominal adhesion, and one case for intraoperative bleeding. Postoperative bile leakage occurred in two cases, and bile peritonitis developed in one case; all these three patients with complications were fully cured by conservative treatment. A postoperative retained CBD stone was found in one patient, which was extracted with endoscopic sphincterotomy. Furthermore, it was found that the mean operative time and length of postoperative hospital stay were much shorter in primary closure group (n = 49) than in T-tube drainage group (n = 12), and the hospital expense was also lower in primary closure group. We suggest that LCBDE could be a novel approach as a salvage procedure for the recurrent CBD stone after cholecystectomy, and we prefer to intraoperative primary closure of CBD if possible.
Occult Appendiceal Neoplasms in Acute and Chronic Appendicitis: A Single-Institution Experience of 1793 Appendectomies
Authors: Schwartz Jamie A. , Forleiter Craig , Lee David , Kim Grace J.
Published: June 2020

The incidence of appendiceal neoplasms may have been underreported in the past. Patients undergoing incidental appendectomies or appendectomies for chronic appendicitis may be at higher risk for an incidental appendiceal neoplasm. To determine the incidence of occult appendiceal neoplasms and identify risk factors associated with this pathology, a retrospective review of a pathology specimen database was conducted from November 2007 to December 2011, in a single tertiary care hospital center. All patients with appendectomies were included for analysis (n = 1793). Pathology specimens were grouped based on the indication for appendectomy, and the incidence of appendiceal neoplasms, and patient variables among the groups were compared using χ2 test and Student's t test. A total of 1793 appendectomy specimens met criteria for evaluation. The total number of appendiceal neoplasms was 31 (1.7%). There were 14 neoplasms in 1337 (1.0%) cases of acute appendicitis with 2 in 41 (4.9%) cases of chronic and 15 in 415 (3.6%) cases, where an incidental appendectomy was performed (P < 0.001). Patients with carcinoid tumors were significantly younger than patients with noncarcinoid tumors (P = 0.0001). Indication for operation was the only significant factor for predicting an appendiceal tumor on final pathology. Patients who undergo interval or incidental appendectomies may be at higher risk of appendiceal neoplasm compared with those performed for other indications. Younger patients may be at a higher risk of occult appendiceal carcinoid neoplasms than other age groups. Pathologic diagnosis in specific high-risk patient groups may be the only way to effectively capture these tumors for optimal treatment.
Lymphatic Permeation Predicts Systemic Recurrence in Combination with Vascular Involvement in Laparoscopically Resected N0 Colon Cancer
Authors: Kojo Ken , Katoh Hiroshi , Naito Masanori , Yamashita Keishi , Nakamura Takatoshi , Sato Takeo , Yamanashi Takahiro , Watanabe Masahiko
Published: June 2020

High-risk patient selection is required in N0 colon cancer. Although a number of studies have suggested high-risk clinicopathological predictors, most of these are based on analyses in heterogeous patients in terms of surgical procedures. Laparoscopic surgery for colon cancer is becoming a standard procedure worldwide because of its less invasiveness. Accordingly, we aimed to identify bona fide high-risk factors of recurrence in homogeneous N0 patients who underwent laparoscopic surgery. Two hundred and twenty-five patients who underwent laparoscopic curative resection for N0 colon cancer were analyzed. Clinicopathological parameters were tested for their relation to survival. The 5-year recurrence-free survival rate (RFS) was 96.1 per cent. Lymphatic involvement (P < 0.001), vascular involvement (P = 0.007), and size of tumor (P = 0.023) were significantly associated with worse prognosis in the univariate analyses. Lymphatic involvement was the independent prognostic factor associated with RFS in the multivariate analysis (P = 0.013). Importantly, lymphatic involvement predicts detrimental prognosis only when vascular involvement is present. The RFS of the patients with both lymphatic and vascular involvement was 88.9 per cent, whereas it was 100 per cent in the counterpart. Differentiation, vascular involvement preoperative carcinoembryonic antigen, and CA 19-9 levels were significantly associated with lymphatic involvement in a multivariate logistic regression analyses. The present study concludes that lymphatic involvement in the presence of vascular involvement may be a high risk for systemic recurrence in the laparoscopically resected N0 colon cancer.
The Implications of Transfer to an Acute Care Surgical Tertiary Service
Authors: Britt Rebecca , Davis Pamela , Gresens Anjali , Weireter Leonard , Novosel T.J. , Collins Jay , Britt L.D.
Published: June 2020

Tertiary hospitals are increasingly called on by smaller hospitals and free-standing emergency rooms (ERs) to provide surgical care for complex patients. This study assesses patients transferred to an acute care surgery service. The ER and transfer center logs, as well as billing data, were reviewed for 12 months for all cases evaluated by acute care surgery. The charts were reviewed for demographics, comorbidities, and outcomes. A total of 111 transferred patients with complete data were identified, with 59 transferred from another hospital and 52 from a free-standing ER. The hospital transfer patients were older with more comorbidities, had a longer length of stay, and were more likely discharged to skilled care. There was no difference in the percent of patients requiring a procedure; however, significantly more procedures in the hospital transfer group were done by nonsurgical specialties Better infrastructure to monitor the impact of hospital transfers is warranted in the setting of the complex patient population transferred to tertiary hospitals.
Is Routine Continuous EEG for Traumatic Brain Injury Beneficial?
Authors: Aquino Lia , Kang Christopher Y. , Harada Megan Y. , Ko Ara , Do-nguyen Amy , Ley Eric J. , Margulies Daniel R. , Alban Rodrigo F.
Published: June 2020

Severe traumatic brain injury (TBI) is associated with increased risk for early clinical and sub-clinical seizures. The use of continuous electroencephalography (cEEG) monitoring after TBI allows for identification and treatment of seizures that may otherwise occur undetected. Benefits of “routine” cEEG after TBI remain controversial. We examined the rate of subclinical seizures identified by cEEG in TBI patients admitted to a Level I trauma center. We analyzed a cohort of trauma patients with moderate to severe TBI (head Abbreviated Injury Score ≥3) who received cEEG within seven days of admission between October 2011 and May 2015. Demographics, clinical data, injury severity, and costs were recorded. Clinical characteristics were compared between those with and without seizures as identified by cEEG. A total of 106 TBI patients with moderate to severe TBI received a cEEG during the study period. Most were male (74%) with a mean age of 55 years. Subclinical seizures were identified by cEEG in only 3.8 per cent of patients. Ninety-three per cent were on antiseizure prophylaxis at the time of cEEG. Patients who had subclinical seizures were significantly older than their counterparts (80 vs 54 years, P = 0.03) with a higher mean head Abbreviated Injury Score (5.0 vs 4.0, P = 0.01). Mortality and intensive care unit stay were similar in both groups. Of all TBI patients who were monitored with cEEG, seizures were identified in only 3.8 per cent. Seizures were more likely to occur in older patients with severe head injury. Given the high cost of routine cEEG and the low incidence of subclinical seizures, we recommend cEEG monitoring only when clinically indicated.
Surgical and Endovascular Management of Patients with Chronic Mesenteric Ischemia: A Single Center Experience
Authors: Paliogiannis Panagiotis , Ginesu Giorgio C. , Fancellu Alessandro , Pischedda Aldo , Maiore Mario , Maiore Eleonora , Pinna Antonio , Barmina Michele , Porcu Alberto
Published: June 2020

Chronic mesenteric ischemia is a rare intestinal disorder, with a potential evolution toward intestinal infraction. The choice of the appropriate treatment is currently the most crucial issue in the management of patients with chronic mesenteric ischemia. We describe our experience with 16 cases, and we discuss the current diagnostic and therapeutic approaches. A retrospective review of the clinical records was performed, and demographic, clinical, therapeutic, and prognostic data were collected. Six patients were females (37%), and the mean age was 62 years. Postprandial pain was present in all the cases, whereas sitophobia and weight loss were detected in 87 per cent of them. Eight patients were treated with open surgery; no perioperative deaths or relevant complications occurred. One patient had a restenosis of the celiac trunk and superior mesenteric artery 10 months after surgery. No deaths or relevant complications occurred in the remaining patients, who underwent an endovascular procedure. One patient presented a restenosis distal to the vascular stent, whereas two patients died due to comorbidities. The low rates of postoperative morbidity, mortality, and restenosis obtained suggest that surgical or endovascular correction of chronic mesenteric ischemia is satisfactory when performed by experienced surgeons, with an adequate selection of the patients.
Evaluation of the Safety and Efficacy of Percutaneous Transhepatic Gallbladder Drainage Combined with Laparoscopic Cholecystectomy for Treating Acute Complicated Cholecystitis
Authors: Jia Baoxing , Liu Kai , Tan Ludong , Jin Zhe , Fu Yu , Liu Yahui
Published: June 2020

The rate of acute cholecystitis in patients with severe underlying diseases is currently increasing. Several studies have reported percutaneous transhepatic gallbladder drainage (PTGBD) combined with laparoscopic cholecystectomy (LC) as a safe and reliable therapeutic option in such patients. This study aimed to elucidate the optimal time interval between PTGBD and LC. In total, 65 patients with acute complicated cholecystitis from our hospital were divided into two groups, short-term LC (sLC) and postponed LC (pLC) group according to whether the procedure was performed within 5 days of gallbladder drainage or after 5 days, respectively. The complications after PTGBD, rate of conversion to open surgery, and complications and mortality after LC were compared between the groups. The sLC group showed significantly lesser operating time, blood loss, postoperative peritoneal drainage time, postoperative oral intake time, and complications compared to the pLC group ( P < 0.05). Other factors such as the length of hospital stay (LOS), conversion to open cholecystectomy, and mortality were not statistically significant between the groups. Combined treatment with PTGBC and sLC showed superior outcomes compared to PTGBC and pLC for acute cholecystitis in severely ill patients, thus constituting a feasible and secure treatment option in specialized centers.
The Bethesda Classification for Thyroid Fine Needle Aspiration: A Predictor or an Alarmist?
Authors: Galbraith John D. , Swann Noah , Cox Brian , Letendre Nobel , Recabaren James
Published: June 2020

Thyroid malignancies comprise only 2 per cent of all cancers. Yet the incidence of thyroid cancers has been increasing faster than other malignancies, likely due to increased screening and surveillance of thyroid nodules. The Bethesda system represents the preferred method of evaluating thyroid nodules for malignancy using fine needle aspiration (FNA). Many thyroidectomies are performed for small, asymptomatic nodules found on ultrasound. These small papillary cancers (<0.5 cm) are termed microcarcinomas and represent a more indolent natural history causing some to name them “occult papillary tumors.” The objective is to assess the relationship between the Bethesda classification and pathologic stage of thyroid cancer with attention to T1a lesions. A single institution, retrospective study of thyroidectomy patients who had a preoperative FNA and a final pathology of thyroid malignancy were performed. The distribution of stage relative to Bethesda classification was significantly different than expected ( P = 0.00382). The low risk Bethesda II, (odds ratio;OR 9.15, 2.7931–29.97, P = 0.0003) and the intermediate group, Bethesda III, (OR 3.48, 1.4436–8.4124, P = 0.0055) had a statistically significant higher incidence of T1a. The Bethesda classification for thyroid FNA falls short in the accuracy of intermediate stage malignancies. Patients whose FNA were Bethesda II or III had a higher likelihood of indolent T1a disease.
eFAST for Pneumothorax: Real-Life Application in an Urban Level 1 Center by Trauma Team Members
Authors: Maximus Steven , Figueroa Cesar , Whealon Matthew , Pham Jacqueline , Kuncir Eric , Barrios Cristobal
Published: June 2020

The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultra-sonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical “real-life” application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFASTwas either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.
Frailty Predicts Morbidity after Colectomy for Ulcerative Colitis
Authors: Telemi Edwin , Trofymenko Oleksandr , Venkat Raghunandan , Pandit Viraj , Pandian T.K. , Nfonsam Valentine N.
Published: June 2020

The rate of ulcerative colitis (UC), an inflammatory bowel disease, has been on the rise in the United States for the last several decades. Colectomy can be performed when other treatment options cannot provide a reasonable quality of life to patients with UC. Frailty has been shown to be a strong tool for evaluating preoperative risk factors for poor postoperative outcomes. The National Surgical Quality and Improvement Program cross-institutional database was used for this study. Data from 943 patients who underwent colectomy for UC between 2005 and 2012 were evaluated. Modified frailty index (mFI) is a previously described and validated 11-variable frailty measure used in the National Surgical Quality and Improvement Program to assess frailty. Outcome measures included serious morbidity; overall morbidity; cardiopulmonary, septic, and wound complications; and Clavien class IV (requiring ICU) and V (mortality) complications. Median age was 46 years and median body mass index was 25.5 Kg/m2. In all, 54.3 per cent of patients were male and 39.38 per cent of patients were American Society of Anesthesiologists Class lll or higher. The median mFI was 0 (0–0.54). As the mFI increased from 0 (nonfrail) to 0.18 and above, the overall morbidity increased from 25.40 to 52.1 per cent ( P < 0.05), serious morbidity increased from 14.9 to 42.1 per cent ( P < 0.05), septic complications increased from 9.87 to 21.49 per cent ( P < 0.05), cardiopulmonary complications increased from 2.98 to 23.14 per cent ( P < 0.05), Clavien class IV complications increased from 3.5 to 26.5 per cent ( P < 0.05), and Clavien V complications increased from 0.16 to 6.61 per cent ( P < 0.05). On multivariate analysis, mFI was an independent predictor of septic complications [Adjusted Odds Ratio (AOR): 31.26; P = 0.006], cardiopulmonary complications (AOR: 216.3; P ≤ 0.001), serious morbidity(AOR: 66.8; P ≤ 0.001), overall morbidity (AOR: 25.5; P ≤ 0.001), Clavien class IV (AOR: 204.9; P ≤ 0.001) complications, and return to the operating room (AOR: 14.29; P = 0.048). Frailty is associated with an increase in morbidity and mortality after colectomy in patients with UC. mFI is an easy-to-use tool and can play an important role in the risk stratification of these patients.
Prehospital Extrication Techniques: Neurological Outcomes Associated with the Rapid Extrication Method and the Kendrick Extrication Device
Authors: Misasi Adam , Ward Jeanette G. , Dong Fanglong , Ablah Elizabeth , Maurer Chad , Haan James M.
Published: June 2020

Most emergency medical service personnel rely on one of two techniques to extricate motor vehicle crash victims; the Rapid Extrication Maneuver (REM) or the Kendrick Extrication Device (KED). The purpose of this study was to compare pre- and postextrication neurological outcomes between these two techniques. A retrospective review was conducted of all adult patients with a vertebral column injury resulting from motor vehicle collision and admitted to a Level I trauma center between January 1, 2003 and December 31, 2010. Standardized pre- and postextrication neurological examinations were reviewed for all patients. More than half of patients (N = 81) were extricated using the KED (53.1%, n = 43) and 46.9 per cent (n = 38) were extricated with the REM. Except for the thoracic Abbreviated Injury Score, no differences between groups emerged related to the Glasgow Coma Scale score, Injury Severity Score or Abbreviated Injury Score. There were no pre- and postextrication changes for motor to all extremities and sensation to all extremities using either method. The results of this study suggest that the REM and the KED are equivalent in protecting the patient from neurologic injury after motor vehicle collision.