bluuebunny/crossref_metadata_2025 huggingface dataset:
Heart Rate Variability Assessment and Its Application for Autonomic Function Evaluation in Patients with Hyperhidrosis
Authors: Niwa Aracy Satoe Mautari , Gregório Michele Lima , Leão Luiz Eduardo Villaça , de Godoy Moacir Fernandes
Published: June 2020

Background: Pathophysiology mechanism of primary focal hyperhidrosis (PFHH) is controversial. Heart rate variability (HRV) could explain if there is a systemic component present. We aimed to investigate the functions of the autonomic nervous system in patients diagnosed with PFHH compared to controls using the analysis of HRV in the domains of time, frequency, and nonlinearity, as well as analysis of the recurrence plots (RPs). Methods: We selected 34 patients with PFHH (29.4 ± 10.2 years) and 34 controls (29.2 ± 9.6 years) for HRV analysis. Heart beats were recorded with Polar RS800CX monitor (20 min, at rest, in supine position), and RR intervals were analyzed with Kubios Premium HRV software. RPs were constructed with Visual Recurrence Analysis software. Statistical analysis included unpaired t test (p < 0.05). Results: Our results showed that HRV parameters in the 3 domains evaluated did not show any differences between the groups. The same was observed with RPs. Conclusions: The findings suggest that PFHH, from the pathophysiological point of view, may be caused by peripheral involvement of the sympathetic nervous system (glandular level or nerve terminals), as there was no difference between the groups studied. More specific studies should help elucidate this issue.
Efficient and scalable multitenant placement approach for in-memory database over supple architecture
Authors: Shah Arpita , Patel Narendra
Published: June 2020

Of late Multitenant model with In-Memory database has become prominent area for research. The paper has used advantages of multitenancy to reduce the cost for hardware, labor and make availability of storage by sharing database memory and file execution. The purpose of this paper is to give overview of proposed Supple architecture for implementing in-memory database backend and multitenancy, applicable in public and private cloud settings. Backend in-memory database uses column-oriented approach with dictionary based compression technique. We used dedicated sample benchmark for the workload processing and also adopt the SLA penalty model. In particular, we present two approximation algorithms, Multi-tenant placement (MTP) and Best-fit Greedy to show the quality of tenant placement. The experimental results show that Multi-tenant placement (MTP) algorithm is scalable and efficient in comparison with Best-fit Greedy Algorithm over proposed architecture.
Feature analysis of ontology visualization methods and tools
Authors: Florrence Joseph Merlin , Lourdusamy Ravi
Published: June 2020

Visualization is a technique of creating images, graphs or animations to share knowledge. Different kinds of visualization methods and tools are available to envision the data in an efficient way. The visualization tools and techniques enable the user to understand the knowledge in an easy manner. Nowadays most of the information is presented semantically which provides knowledge based retrieval of the information. Knowledge based visualization tools are required to visualize semantic concepts. This article analyses the existing semantic based visualization tools and plug-ins. The features and characteristics of these tools and plug-ins are analyzed and tabulated.
Cerebral Blood Flow–Guided Manipulation of Arterial Blood Pressure Attenuates Hippocampal Apoptosis After Asphyxia‐Induced Cardiac Arrest in Rats
Authors: Wang Chih‐Hung , Chang Wei‐Tien , Huang Chien‐Hua , Tsai Min‐Shan , Liu Shing‐Hwa , Chen Wen‐Jone
Published: June 2020

Background

In most post–cardiac arrest patients, the autoregulation mechanism of cerebral blood flow (
CBF
) is dysregulated. We examined whether recovery of
CBF
by adjusting mean arterial pressure mitigates post–cardiac arrest neuronal damage.

Methods and Results

Wistar rats that underwent 8‐minute asphyxia‐induced cardiac arrest and resuscitation were computer‐randomized to norepinephrine or control groups. The
CBF
was measured at the dorsal hippocampal
CA
1 region of the left hemisphere. In the norepinephrine group, the mean arterial pressure was adjusted to recover
CBF
to 80% to 100% of baseline. Twenty‐four hours following resuscitation, neurological outcomes were assessed, and brain tissues and blood samples were harvested for neuronal apoptosis and injury assessment. Thirty resuscitated rats were randomized into 2 groups, each containing 12 rats that completed the experiments. Norepinephrine infusion effectively prevented posthyperemia hypoperfusion and recovered
CBF
to pre‐arrest baseline levels; a moderate positive linear correlation between mean arterial pressure and
CBF
during this period was also observed (
P
<0.001). There were no significant between‐group differences in neurological recovery. In the norepinephrine group compared with the control group, upregulated cleaved caspase‐3 protein expression in brain tissue determined by Western blot was reduced (
P
=0.02) and the densities of apoptotic cells in hippocampal
CA
1 and
CA
3 regions determined by terminal deoxynucleotidyl transferase‐mediated dUTP biotin nick‐end labeling were decreased (
P
<0.001). No significant differences in serum neuron‐specific enolase or S100β levels were detected between the 2 groups.

Conclusions

CBF
recovery demonstrated neuroprotective effects by reducing activation of cerebral apoptosis and number of apoptotic neurons. However, these effects did not significantly improve clinical neurological function, necessitating further investigation.
Assessing the Predictive Validity of Simple Dementia Risk Models in Harmonized Stroke Cohorts
Authors: Tang Eugene Y.H. , Price Christopher I. , Robinson Louise , Exley Catherine , Desmond David W. , Köhler Sebastian , Staals Julie , Yin Ka Lam Bonnie , Wong Adrian , Mok Vincent , Bordet Regis , Bordet Anne-Marie , Dondaine Thibaut , Lo Jessica W. , Sachdev Perminder S. , Stephan Blossom C.M. ,   for the STROKOG Collaboration
Published: June 2020

Background and Purpose:

Stroke is associated with an increased risk of dementia. To assist in the early identification of individuals at high risk of future dementia, numerous prediction models have been developed for use in the general population. However, it is not known whether such models also provide accurate predictions among stroke patients. Therefore, the aim of this study was to determine whether existing dementia risk prediction models that were developed for use in the general population can also be applied to individuals with a history of stroke to predict poststroke dementia with equivalent predictive validity.

Methods:

Data were harmonized from 4 stroke studies (follow-up range, ≈12–18 months poststroke) from Hong Kong, the United States, the Netherlands, and France. Regression analysis was used to test 3 risk prediction models: the Cardiovascular Risk Factors, Aging and Dementia score, the Australian National University Alzheimer Disease Risk Index, and the Brief Dementia Screening Indicator. Model performance or discrimination accuracy was assessed using the C statistic or area under the curve. Calibration was tested using the Grønnesby and Borgan and the goodness-of-fit tests.

Results:

The predictive accuracy of the models varied but was generally low compared with the original development cohorts, with the Australian National University Alzheimer Disease Risk Index (C-statistic, 0.66) and the Brief Dementia Screening Indicator (C-statistic, 0.61) both performing better than the Cardiovascular Risk Factors, Aging and Dementia score (area under the curve, 0.53).

Conclusions:

Dementia risk prediction models developed for the general population do not perform well in individuals with stroke. Their poor performance could have been due to the need for additional or different predictors related to stroke and vascular risk factors or methodological differences across studies (eg, length of follow-up, age distribution). Future work is needed to develop simple and cost-effective risk prediction models specific to poststroke dementia.
Urban-Rural Inequities in Acute Stroke Care and In-Hospital Mortality
Authors: Hammond Gmerice , Luke Alina A. , Elson Lauren , Towfighi Amytis , Joynt Maddox Karen E.
Published: June 2020

Background and Purpose:

The rural-urban life-expectancy gap is widening, but underlying causes are incompletely understood. Prior studies suggest stroke care may be worse for individuals in more rural areas, and technological advancements in stroke care may disproportionately impact individuals in more rural areas. We sought to examine differences and 5-year trends in the care and outcomes of patients hospitalized for stroke across rural-urban strata.

Methods:

Retrospective cohort study using National Inpatient Sample data from 2012 to 2017. Rurality was classified by county of residence according to the 6-strata National Center for Health Statistics classification scheme.

Results:

There were 792 054 hospitalizations for acute stroke in our sample. Rural patients were more often white (78% versus 49%), older than 75 (44% versus 40%), and in the lowest quartile of income (59% versus 32%) compared with urban patients. Among patients with acute ischemic stroke, intravenous thrombolysis and endovascular therapy use were lower for rural compared with urban patients (intravenous thrombolysis: 4.2% versus 9.2%, adjusted odds ratio, 0.55 [95% CI, 0.51–0.59],
P
<0.001; endovascular therapy: 1.63% versus 2.41%, adjusted odds ratio, 0.64 [0.57–0.73],
P
<0.001). Urban-rural gaps in both therapies persisted from 2012 to 2017. Overall, stroke mortality was higher in rural than urban areas (6.87% versus 5.82%,
P
<0.001). Adjusted in-patient mortality rates increased across categories of increasing rurality (suburban, 0.97 [0.94–1.0],
P
=0.086; large towns, 1.05 [1.01–1.09],
P
=0.009; small towns, 1.10 [1.06–1.15],
P
<0.001; micropolitan rural, 1.16 [1.11–1.21],
P
<0.001; and remote rural 1.21 [1.15–1.27],
P
<0.001 compared with urban patients. Mortality for rural patients compared with urban patients did not improve from 2012 (adjusted odds ratio, 1.12 [1.00–1.26],
P
<0.001) to 2017 (adjusted odds ratio, 1.27 [1.13–1.42],
P
<0.001).

Conclusions:

Rural patients with stroke were less likely to receive intravenous thrombolysis or endovascular therapy and had higher in-hospital mortality than their urban counterparts. These gaps did not improve over time. Enhancing access to evidence-based stroke care may be a target for reducing rural-urban disparities.
Corticospinal Fibers With Different Origins Impact Motor Outcome and Brain After Subcortical Stroke
Authors: Liu Jingchun , Wang Caihong , Qin Wen , Ding Hao , Guo Jun , Han Tong , Cheng Jingliang , Yu Chunshui
Published: June 2020

Background and Purpose:

Motor deficit is the most common disability after stroke, and early prediction of motor outcome is critical for early interventions. Here, we constructed a fine map of the corticospinal tract (CST) for early prediction of motor outcome and for understanding the secondary brain changes after subcortical stroke.

Methods:

Diffusion spectrum imaging data from 50 healthy adults were used to reconstruct fine maps of CST with different origins, including primary motor area (M1), primary sensory area (S1), premotor cortex, and supplementary motor area (SMA). Their diffusion properties correlated with motor functions in healthy adults. The impacts of the impairments of different CST on motor outcomes and on structural and functional changes of brain were investigated in 136 patients with subcortical stroke by combining CST damage-symptom association study and voxel-based lesion-symptom mapping.

Results:

In healthy adults, the isotropy of M1 fiber correlated with walking endurance and that of SMA fiber with motor dexterity. In chronic stroke patients, the integrity of M1 and SMA fibers showed the most significant correlation with motor deficits. The percentage of early damage of M1 and SMA fibers correlated with that of chronic motor deficits. Voxel-based lesion-symptom mapping revealed that acute stroke lesions in the bilateral M1 and right SMA fibers were associated with chronic motor deficits. The early damage of M1 fiber negatively correlated with the integrity of M1-M1 fiber, and the early damage of SMA fiber negatively correlated with gray matter volume of the contralateral cerebellum in the chronic stage.

Conclusions:

The CST that originated from the M1 and SMA are closely associated with motor outcomes and brain structural changes, and the fine maps of CST from these 2 cortical areas are useful in assessing and predicting long-term motor outcome in patients with subcortical stroke.
How Furiously Can Colorless Green Ideas Sleep? Sentence Acceptability in Context
Authors: Lau Jey Han , Armendariz Carlos , Lappin Shalom , Purver Matthew , Shu Chang
Published: June 2020

We study the influence of context on sentence acceptability. First we compare the acceptability ratings of sentences judged in isolation, with a relevant context, and with an irrelevant context. Our results show that context induces a cognitive load for humans, which compresses the distribution of ratings. Moreover, in relevant contexts we observe a discourse coherence effect that uniformly raises acceptability. Next, we test unidirectional and bidirectional language models in their ability to predict acceptability ratings. The bidirectional models show very promising results, with the best model achieving a new state-of-the-art for unsupervised acceptability prediction. The two sets of experiments provide insights into the cognitive aspects of sentence processing and central issues in the computational modeling of text and discourse.
Learning Lexical Subspaces in a Distributional Vector Space
Authors: Arora Kushal , Chakraborty Aishik , Cheung Jackie C. K.
Published: June 2020

In this paper, we propose LexSub, a novel approach towards unifying lexical and distributional semantics. We inject knowledge about lexical-semantic relations into distributional word embeddings by defining subspaces of the distributional vector space in which a lexical relation should hold. Our framework can handle symmetric attract and repel relations (e.g., synonymy and antonymy, respectively), as well as asymmetric relations (e.g., hypernymy and meronomy). In a suite of intrinsic benchmarks, we show that our model outperforms previous approaches on relatedness tasks and on hypernymy classification and detection, while being competitive on word similarity tasks. It also outperforms previous systems on extrinsic classification tasks that benefit from exploiting lexical relational cues. We perform a series of analyses to understand the behaviors of our model. 1

Code available at https://github.com/aishikchakraborty/LexSub .
Efficacy of Laparoscopic Appendectomy in Appendicitis with Peritonitisa
Authors: Mancini Gregory J. , Mancini Matthew L. , Nelson Henry S.
Published: June 2020

Laparoscopic appendectomy (LA) is safe and effective in cases of peritonitis, perforation, and abscess. We investigated our conversion rate and clinical outcomes in this patient population, as well as preoperative factors that predict operative conversion. A retrospective nonrandomized cohort of 92 patients underwent LA for acute appendicitis with peritonitis, perforation, or abscess at our institution between 1997 and 2002. Thirty-six of the 92 were converted to open appendectomy (OA), yielding a conversion rate of 39 per cent. The presence of phlegmon (42%), nonvisualized appendix (44%), technical failures (8%), and bleeding (6%) were reasons for conversion. Preoperative data had no predictive value for conversion. CT scan findings of free fluid, phlegmon, and abscess did not correlate with findings at the time of surgery. Total complication rates were 8.9 per cent in the LA group as compared to 50 per cent in the converted cohort. Postoperative data showed LA patients stayed 3.2 days versus 6.9 days for converted patients ( P = 0.01). LA patients had less pneumonia ( P = 0.02), intra-abdominal abscess ( P = 0.01), ileus ( P = 0.01), and readmissions ( P = 0.01). LA is safe and effective in patients with appendicitis with peritonitis, perforation, and abscess, resulting in shorter hospital stays and less complication.
A Comparison of Continuous Renal Replacement Therapy to Intermittent Dialysis in the Management of Renal Insufficiency in the Acutely Ill Surgical Patient
Authors: Waldrop Jimmy , Ciraulo David L. , Milner Timothy P. , Gregori Douglas , Kendrick Aaron S. , Richart Charles M. , Maxwell Robert A. , Barker Donald E.
Published: June 2020

Acute renal failure (ARF) occurs in 10 per cent to 23 per cent of intensive care unit patients with mortality ranging from 50 per cent to 90 per cent. ARF is characterized by an acute decline in renal function as measured by urine output (UOP), serum creatinine, and blood urea nitrogen (BUN). Causes may be prerenal, intrarenal, or postrenal. Treatment consists of renal replacement therapy (RRT), either intermittent (ID) or continuous (CRRT). Indications for initiation of dialysis include oliguria, acidemia, azotemia, hyperkalemia, uremic complications, or significant edema. Overall, the literature comparing CRRT to ID is poor. No studies of only surgical/trauma patients have been published. We hypothesize that renal function and hemodynamic stability in trauma/surgical critical care patients are better preserved by CRRT than by ID. We performed a retrospective review of trauma/surgical critical care patients requiring renal supportive therapy. Thirty patients received CRRT and 27 patients received ID. The study was controlled for severity of illness and demographics. Outcomes assessed were survival, renal function, acid-base balance, hemodynamic stability, and oxygenation/ventilation parameters. Populations were similar across demographics and severity of illness. Renal function, measured by creatinine clearance, was statistically greater with CRRT ( P = 0.035). There was better control of azotemia with CRRT: BUN was lower ( P = 0.000) and creatinine was lower ( P = 0.000). Mean arterial blood pressure was greater ( P = 0.021) with CRRT. No difference in oxygenation/ventilation parameters or pH was found between groups. CRRT results in an enhancement of renal function with improved creatinine clearance at the time of dialysis discontinuation. CRRT provides better control of azotemia while preserving hemodynamic stability in patients undergoing renal replacement therapy. Prospective randomized controlled studies and larger sample sizes are needed to further evaluate these modalities.
Embolization of an Acute Renal Arteriovenous Fistula following a Stab Wound: Case Report and Review of the Literature
Authors: Benson David A. , Stockinger Zsolt T. , Mcswain Norman E.
Published: June 2020

Surgery has traditionally been the definitive form of invasive management for renal vascular injuries. There is a growing trend in the use of endovascular techniques as an alternative to surgery in the trauma setting. We present the case of a 24-year-old woman with an acute renal arteriovenous fistula caused by a stab wound in the left flank, which was successfully managed with selective arterial embolization. This represents only the second reported case of such an approach in the acute setting.
The Economic Impact of Early Enteral Feeding in Gastrointestinal Surgery: A Prospective Survey of 51 Consecutive Patients
Authors: Lucha Paul A. , Butler Ralph , Plichta Jessica , Francis Michael
Published: June 2020

Early postoperative oral feeding has been demonstrated to be safe and not increase postoperative morbidity. There are conflicting reports about its effect on postoperative length of stay. Some patients will fail attempts at early postoperative feeding and may be relegated to a longer postoperative course. Few studies to date have attempted to identify cost savings associated with early oral support, and those identified address nasoenteric support only. Fifty-one consecutive patients were randomized into either a traditional postoperative feeding group or an early postoperative feeding group after their gastrointestinal surgery. Length of hospital stay, hospital costs (excluding operating room costs), morbidity, and time to tolerance of a diet were compared. There was a tendency toward increased nasogastric tube use in the early feeding arm, but the morbidity rates were similar. Length of hospital stay and costs were similar in both arms. Early postoperative enteral support does not reduce hospital stay, nursing workload, or costs. It may come at a cost of higher nasogastric tube use, however, without an increase in postoperative morbidity.
Myofibrosarcoma of the Adrenal Gland
Authors: Mclaughlin S.A. , Schmitt T.M. , Huguet K.L. , Menke D.M. , Nguyen J.H.
Published: June 2020

Adrenal masses have varying presentations. Most commonly, adrenal masses are discovered incidentally on CT or MRI during an evaluation for an unrelated complaint. Although the majority of these are nonfunctional cortical adenomas, hormonally active tumors and adrenocortical carcinoma must also be considered in the differential diagnosis. Rarely, retroperitoneal tumors may mimic an adrenal mass. We report a case of a 49-year-old man with anemia and weight loss who was found to have a large retroperitoneal mass arising from the adrenal gland. Surgical treatment involved en bloc resection of the right kidney, adrenal gland, segments 7 and 8 of the liver, and a portion of the right hemidiaphragm. Final pathology revealed a low-grade myofibrosarcoma. We believe that this is the first case report of a myofibrosarcoma of the adrenal gland. Myofibrosarcomas are rare malignant tumors composed of myofibroblasts that arise from the deep soft tissues. These tumors have a predilection for the head and neck, trunk, or extremities. Myofibrosarcomas can be differentiated from other sarcomas by immunohistochemical staining and pathologic features. We will briefly discuss the workup of an adrenal mass and focus on the diagnosis of myofibrosarcoma.
Small Bowel Ischemia after Roux-en-Y Gastric Bypass Complicated by Pregnancy: A Case Report
Authors: Charles Anthony , Domingo Shirley , Goldfadden Aaron , Fader Jason , Lampmann Richard , Mazzeo Robert
Published: June 2020

Small bowel obstruction is an unusual complication of pregnancy. Its occurrence after Roux- en-Y gastric bypass (RYGB) for morbid obesity complicated by pregnancy is rare. Morbid obesity describes body weight at least 100 lb over the ideal weight, or a body mass index (BMI) ≥40. Surgery offers the only viable treatment option with long-term weight loss and maintenance. This case report involves a 23-year-old female at 25 weeks gestation with a 1-day history of diffuse abdominal pain and vomiting. She had a RYGB with a 15 cc micropouch 6 months prior to the commencement of this pregnancy. All radiologic investigations were normal. Esophagogastroscopy was performed revealing an ischemic Roux limb of the gastric bypass. At laparotomy, an internal hernia involving the afferent limb was identified at the site of the Roux anastomosis compromising portions of both the afferent and Roux limbs. Nonviable portions of both the afferent and Roux limbs were resected. Gastrointestinal continuity was achieved by fashioning a gastro-gastrostomy and a jejuno-jejunostomy, thus reversing the original gastric bypass procedure. The immediate postoperative period was complicated by fetal demise. With the increase in bariatric surgery, small bowel ischemia after Roux- en-Y gastric bypass will most likely become more prevalent, particularly in women of childbearing age.
Splanchnic Hypoperfusion-Directed Therapies in Trauma: A Prospective, Randomized Trial
Authors: Cohn Stephen M. ,   THE MIAMI TRAUMA CLINICAL TRIALS GROUP Investigators: Principal Investigators:, Cohn Stephen M. , Kirton Orlando , Brown Margaret , Hameed S. Morad , Cohn Stephen M. , Barquist Erik , Duncan Robert , Majetshak Mathias , Popkin C. , Augenstein J. , Byers P. , Ginzburg E. , Mckenney M. , Namias N. , Shatz D. , Sleeman D.
Published: June 2020

Splanchnic hypoperfusion as reflected by gastric intramucosal acidosis has been recognized as an important determinant of outcome in shock. A comprehensive splanchnic hypoperfusion-ischemia reperfusion (IRP) protocol was evaluated against conventional shock management protocols in critical trauma patients. The study was a prospective randomized trial comparing three therapeutic approaches to hypoperfusion after severe trauma in 151 trauma patients admitted to the intensive care unit. Group 1 patients received hemodynamic support based on conventional indicators of hypoperfusion. In group 2, resuscitation was further guided by gastric tonometry-derived estimates of splanchnic hypoperfusion and included more invasive hemodynamic monitoring and additional administration of colloid or crystalloid solutions, or inotropic support. Group 3 patients additionally received therapies specifically aimed at optimizing splanchnic perfusion and minimizing oxidant-mediated damage from reperfusion. The three groups were similar based on age, Injury Severity Score, and Acute Physiology and Chronic Health Evaluation II Scores. There were no statistically significant differences in mortality rates, organ dysfunction, ventilator days, or length of stay between any of the interventions. Techniques of optimization of splanchnic perfusion and minimization of oxidant-mediated reperfusion injury evaluated in this study were not advantageous relative to standard resuscitation measures guided by conventional or tonometric measures of hypoperfusion in the therapy of occult and clinical shock in trauma patients.
“Most Brilliant in Judgment”: Alexander the Great and Aristotle
Authors: Lainas Panagiotis , Panutsopulos Dimitrios , Skandalakis Panagiotis N. , Zoras Odysseas , Skandalakis John E.
Published: June 2020

From historical sources, it is evident that Alexander the Great was indebted to one of his teachers, Aristotle of Stagira. It was the teaching of Aristotle that evoked all the nascent talents of young Alexander and turned him into a great man. Alexander was extremely interested in the secrets of medicine and considered it an art. The medical knowledge he acquired from Aristotle may have saved his life and the lives of his troops on many occasions. If Alexander did not possess medical knowledge and if his everyday life had not been so greatly influenced by medicine, he might never have been able to create his empire.
Long-Term Follow-up after Robotic Cholecystectomy
Authors: Bodner Johannes , Hoeller Elisabeth , Wykypiel Heinz , Klingler Paul , Schmid Thomas
Published: June 2020

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30–35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.
Cadaveric Kidney Transplant Complicated by Rupture of Native Kidney Angiomyolipoma: A Case Report and Review of the Literature
Authors: Garcia-Covarrubias Lisardo , Mcgee Jennifer , Landes Joshua , Florman Sander S. , Slakey Douglas P.
Published: June 2020

Kidneys with angiomyolipomas have been used for transplantation, but we are unaware of postoperative hemorrhage from a native kidney angiomyolipoma. A 49-year-old male who underwent a cadaveric renal transplant complicated by postoperative hemorrhage from a native kidney angiomyolipoma is presented. Evaluation and current management strategies are discussed.
Assessment of Nonoperative Management of Blunt Spleen and Liver Trauma
Authors: Sharma Om P. , Oswanski Michael F. , Singer Daniel , Raj Shekhar S. , Daoud Yahya A.H.
Published: June 2020

An 8-year analysis of nonoperative management (NOM) of spleen and liver trauma was done in a level 1 trauma center. Spleen and liver trauma was diagnosed in 279 patients: 93 children (<18), 137 younger adults (18–54), and 49 older adults (≥ 55). Nineteen patients who failed resuscitations died within 0–60 minutes of arrival and were excluded from treatment analysis. Operative management (OM) was done in 39 (15%) and NOM in 221 (85%) patients with failure (NOMF) in 11 (5%). NOM and NOMF was 82 per cent and 5.6 per cent in spleen, 74 per cent and 14.3 per cent in combined spleen/liver, and 96 per cent and 1.5 per cent in liver trauma ( P value <0.001). NOM was done in 99 per cent of children, 81 per cent of younger adults, and 68 per cent of older adults with 0 per cent, 8 per cent, and 10 per cent NOMF. Higher grades of splenic trauma and CT fluid had higher OM rate. NOM success rates were 93.8 per cent in grade 3 and 90.3 per cent in higher grades of spleen trauma. There was no NOMF in higher grades of liver trauma. CT fluid grade had no impact on NOMF. Female patients had higher mean injury severity score, age, and mortality compared to cohorts. NOM should be attempted in hemodynamically stable patients. Age over 55, higher grades of injury, and large hemoperitoneum were not predictors of failure of NOM.
CT-Angiography for the Detection of a Lower Gastrointestinal Bleeding Source
Authors: Duchesne J. , Jacome T. , Serou M. , Tighe D. , Gonzales A. , Hunt J.P. , Marr A.B. , Weintraub S.L.
Published: June 2020

The evaluation of lower gastrointestinal bleeding (LGIB) often involves the collaborative efforts of the gastroenterologist, radiologist, and surgeon. Efforts to localize the acute LGIB have traditionally involved colonoscopy, technetium-labeled red blood cell (RBC) scintigraphy, angiography, or a combination of these modalities. The sensitivity of each method of diagnosis is limited, with the most common cause of a negative study the spontaneous cessation of hemorrhage. Other technical factors include vasospasm, lack of adequate contrast volume or exposure time, a venous bleeding source, and a large surface bleeding area. We report the use of multidetector computed tomography (MDCT), or CT-angiography (CT-A), in the initial evaluation of LGIB, and speculate on the incorporation of this technique into a diagnostic algorithm to treat LGIB. MDCT may offer a very sensitive means to evaluate the source of acute LGIB, while avoiding some of the morbidity and intense resource use of contrast angiography, and may provide unique morphologic information regarding the type of pathology. Screening with the more rapid and available MDCT, followed by either directed therapeutic angiography or surgical management, may represent a reasonable algorithm for the early evaluation and management of acute LGIB in which an active bleeding source is strongly suspected.
Percutaneous Endoscopic Gastrostomy in ICU Patients with Previous Laparotomy
Authors: Guzzo James L. , Bochicchio Grant V. , Haan James , Bochicchio Kelly , Kole Kerry , Scalea Thomas M.
Published: June 2020

To our knowledge, there is an absence of data evaluating the safety and efficacy of percutaneous endoscopic gastrostomy (PEG) placement in ICU patients with previous abdominal surgery. Our goals were to determine the complication rate of PEG in ICU patients who either had a recent or prior laparotomy compared to patients without any prior abdominal surgery. Prospective data was collected on 42 consecutive patients with prior abdominal surgery who underwent PEG placement in a university ICU setting during a 3-year period. These patients were further stratified by time of previous abdominal surgery: recent = abdominal surgery during the current hospitalization; old = abdominal surgery done prior to the current hospitalization and >30 days. Complications were defined as technical problems, local infection, tube dislodgment, and bleeding. This data was compared to results of 75 consecutive PEG placements in ICU patients with no previous abdominal surgery (NPAS) at the same institution. A total of 117 patients were included in the study. Sixty-two (58%) of the patients were trauma patients and 45 (42%) had other pathology. The mean age of the study population was 53 ± 15 years and they were primarily male (75%). The overall complication rates were as follows: local wound = 18.7 per cent, technical problems = 4 per cent, PEG dislodgment = 7.4 per cent, and bleeding = 3 per cent. Of the 42 patients with prior abdominal surgery, 22 were recent, and 20 were old. Local wound complications were the most common complication when stratified by PEG category (virgin = 17.3%, recent = 18%, and old = 15%) followed by dislodgment (virgin = 6.7%, recent = 9%, and old = 5%). There were no significant differences in complication rates when comparing specific complications by PEG category as analyzed by χ2 analysis. PEG should be considered in all patients with previous laparotomy in need for long-term enteral access.
A Retroperitoneal Bleed Induced by Enoxaparin Therapy
Authors: Ernits Martin , Mohan Pradeep S. , Fares Louis G. , Hardy Howard
Published: June 2020

Retroperitoneal bleeding is one of the most serious, potentially lethal complications of antico-agulation therapy. Although well documented in fully heparinized and coumadinized patients, there are only few reports of life-threatening hemorrhages in low-molecular-weight heparin (LMWH)-treated patients. We present a case of almost fatal spontaneous retroperitoneal bleeding in a 71-year-old woman with pneumonia and acute coronary syndrome. After receiving combination therapy with Lovenox (enoxaparin), aspirin, and Plavix for 5 days, she developed acute hemorrhagic shock and possible intra-abdominal compartment syndrome. Urgent computed tomography scan of the abdomen and pelvis was performed and showed a left retroperitoneal hematoma. The patient's condition continued to deteriorate, which prompted emergent exploration. After evacuating 3 L of free blood from the peritoneal cavity, we managed to stabilize the patient. Our case of spontaneous retroperitoneal bleeding adds to the growing number of cases in which enoxaparin has been associated with severe bleeding. A high index of suspicion is necessary if the patient displays any of the signs and symptoms that suggest major hemorrhage. It appears that those at highest risk receive doses approaching 1 mg/kg subcutaneously every 12 hours, have renal impairment, are of advanced age, and receive concomitant medications that can affect hemostasis. On average, a retroperitoneal hematoma occurs within 5 days of therapy with enoxaparin. In high-risk patients, enoxaparin activity (anti-factor Xa) should be carefully monitored.
The Association between Chance Fractures and Intra-abdominal Injuries Revisited: A Multicenter Review
Authors: Tyroch Alan H. , Mcguire Emmett L. , Mclean Susan F. , Kozar Rosemary A. , Gates Keith A. , Kaups Krista L. , Cook Charles , Cowgill Sarah M. , Griswold John A. , Sue Larry A. , Craun Michael L. , Price Jan
Published: June 2020

The association between Chance fractures and intra-abdominal injuries is reported to be as high as 89 per cent. Because prior studies were small series or case reports, we conducted a multicenter review to learn the true association between Chance fractures and intra-abdominal injuries as well as diagnostic trends. Trauma registry data, medical records, and radiology reports from 7 trauma centers were used to characterize 79 trauma patients with Chance fractures. Initial methods of abdominal assessment were computed tomography (CT) scan (79%), clinical examination (16%), and diagnostic peritoneal lavage (DPL) (5%). Twenty-six (33%) patients had intraabdominal injuries of which hollow viscus injuries predominated (22%). Twenty patients (25%) underwent laparotomy. The presence of an abdominal wall contusion and automobile restraint use were highly predictive of intra-abdominal injury and the need for laparotomy. The association between a Chance fracture and intra-abdominal injury is not as high as previously reported. CT scan has become the primary modality to assess the abdominal cavity of patients with Chance fractures, whereas the role of DPL has diminished.
A Case of Cushing Syndrome Secondary to Ectopic Adrenocorticotropic Hormone Producing Carcinoid of the Duodenum
Authors: Uecker John M. , Janzow Matthew T.
Published: June 2020

Cushing syndrome caused by adrenocorticotropic hormone (ACTH) production from solid tumors can result in life-threatening hypercortisolemia. Ectopic ACTH production is most commonly associated with bronchial carcinoids and squamous cell carcinoma of the lung. We report a case of Cushing syndrome caused by ectopic ACTH production from a carcinoid of the duodenum. The patient presented to an outside hospital in hypertensive crisis and diabetic ketoacidosis. After stabilization, diagnostic studies including a serum cortisol level, and computed tomography (CT) scans of the head, chest, abdomen, and pelvis revealed hypercortisolemia and a large mass in the head of the pancreas. Pancreaticoduodenectomy was performed. Pathologic investigation revealed a 1-cm carcinoid of the duodenum with two large metastatic lymph nodes near the head of the pancreas. This is the first reported case in the English literature of Cushing syndrome caused by ectopic ACTH production from a carcinoid of the duodenum.
Extended Right Hepatectomy with Total Caudate Lobe Resection and Biliary Tree Resection for a Large Colorectal Liver Metastasis Involving both the Right and Left Hepatic Lobes and the Umbilical Fissure: A Case Report
Authors: Chedid Aljamir D. , Chedid Marcio F. , Kruel Cleber R.P. , Girardi FÁbio M. , Kruel Cleber D.P.
Published: June 2020

Very large right-sided liver tumors may grow up to the base of the umbilical fissure and involve the left hepatic duct and can occasionally reach the bile duct confluence. This kind of involvement has often been considered a contraindication to resection. We report a patient who presented with a large hepatic metastasis from colorectal cancer that reached the umbilical fissure and involved the left hepatic duct just above the bile duct confluence. An extended right hepatectomy including complete resection of caudate lobe was performed. We resected the left and common hepatic ducts, as well as both the entire hepatic and the proximal third of common bile duct. A long jejunal limb Roux-en-Y (45 cm) single-layer left intrahepatic hepaticojejunostomy was constructed. She is still well 14 months postoperatively. To the best of our knowledge, this is the first report of such a procedure employed for the treatment of a liver metastasis from colorectal cancer. Extended right hepatectomy including complete caudate lobe resection can be feasible even when the majority of the extrahepatic biliary system needs to be resected. Our approach probably offers the only chance to prevent early death from liver failure in these patients.
Laparoscopic Resection of Periaortic Paragangliomas
Authors: Whitson Bryan A. , Tuttle Todd M.
Published: June 2020

Paragangliomas are extra-adrenal pheochromocytomas that are often located in the retroperitoneum along the aorta. Although laparoscopic resection is recommended for adrenal pheochromocytomas, few laparoscopic resections for paragangliomas have been reported. We describe the presentation and imaging findings of four patients with periarotic paraganglioma. Laparoscopic resection was successfully performed in three of the four patients; the fourth patient required conversion to an open procedure. This report adds to a growing number of cases documenting that laparoscopic resection of paragangliomas is safe and feasible.
Two Distinct Phenotypes of Rat Vascular Smooth Muscle Cells: Growth Rate and Production of Tumor Necrosis Factor-α
Authors: Groves Joshua , Wang Zhongbiao , Newman Walter H.
Published: June 2020

The monoclonal theory of atherosclerosis postulates that a subpopulation of vascular smooth muscle cells (VSMCs) is selectively expanded in response to pathologic stimuli and accumulates in vascular intima. The purpose of this research was to clone VSMC, determine growth rates of the clones and their ability to release the mitogenic cytokine tumor necrosis factor-α (TNF-α). With approval of the institutional animal care and use committee, VSMCs were isolated and cultured from the thoracic aortas of three rats. To confirm that the cells in primary culture were of smooth muscle origin, they were immunostained with anti-α-smooth muscle-actin antibodies. Single cell-derived individual colonies with uniform appearance were surrounded by cloning rings, released with trypsin, and expanded. Growth rates of the clones were assessed by the mitochondrial dependent reduction of methyltetrazolium (MTT) to formazan after 24-hour stimulation with 10 per cent serum. Additionally, cloned cells were stimulated with 0.1, 1,10, and 20 μg/mL lipopolysaccharide (LPS) for 24 hours, and TNF-α was determined in the culture medium. Data were analyzed by ANOVA. Two clones were isolated that could be divided into categories based on distinctly different morphology: 1) spindle-shaped (SP) or 2) epithelioid-shaped (EP) VSMCs. The SP clone had a growth rate that was 25 per cent higher than the EP clone ( P < 0.05). Also, the SP clone had significantly higher release of TNF-α in response to LPS. For instance, TNF-α released in response to 0.1 μg/mL of LPS in the SP clone was 157 ± 45 pg/mL versus 21 ± 8.5 pg/mL in the EP clone ( P < 0.05). Primary cultures of rat VSMCs are heterogeneous and consist of at least two morphologically distinct cell types. These clones are different in growth rate and cytokine production. It is possible that selective expansion of one of these clones contributes to formation of stenotic vascular lesions.
Effect of the 80-Hour Work Week on Cases Performed by General Surgery Residents
Authors: Mcelearney Shannon Tierney , Saalwachter Alison R. , Hedrick Traci L. , Pruett Timothy L. , Sanfey Hilary A. , Sawyer Robert G.
Published: June 2020

The Accreditation Council for Graduate Medical Education (ACGME) implemented mandatory work week hours restrictions in 2003. Due to the traditionally long hours in general surgery, the effect of restrictions on surgical training and case numbers was a matter of concern. Data was compiled retrospectively from ACGME logs and operating room (OR) records at a university hospital for 2002 and 2003. Work week restrictions began in January 2003. This data was reviewed to determine resident case numbers, both in whole and by postgraduate year (PGY). Mean case numbers per resident-month in 2002 were 8.8 ± 8.2 for PGY1s, 16.2 ± 15.7 for PGY2s, 31.4 ± 12.9 for PGY3s, 31.5 ± 17.6 for PGY4s, and 31.5 ± 17.6 for PGY5s. In 2003, they were 8.8 ± 5.2 for PGY1s, 16.6 ± 13.9 for PGY2s, 27.8 ± 12.5 for PGY3s, 38.2 ± 18.8 for PGY4s, and 26.1 ± 9.6 for PGY5s. PGY1s, PGY2s, PGY3s, PGY4s, or all classes were not statistically different. PGY5s did have statistically fewer cases in 2003 ( P = 0.03). PGY5s did have statistically fewer cases after the work-hours restriction, which likely represented shifting of postcall afternoon cases to other residents. Comparing other classes and all PGYs, case numbers were not statistically different. Operative training experience does not appear to be hindered by the 80-hour work week.
Surgeon-Performed Ultrasound Improves Localization of Abnormal Parathyroid Glands
Authors: Solorzano Carmen C. , Lee Theresa M. , Ramirez Marcela C. , Carneiro Denise M. , Irvin George L.
Published: June 2020

With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy (LPX). We investigated whether ultrasonography in the hands of the surgeon (SUS) could improve the localization of abnormal parathyroids when sestamibi scans (MIBI) were negative or equivocal. One hundred eighty patients with sporadic primary hyperparathyroidism (SPHPT) underwent preoperative SUS and MIBI scans before LPX guided by intraoperative parathormone assay. When the sestamibi scans were negative, SUS was used to localize the parathyroid, distinguish parathyroid from thyroid tissue, and to guide the intraoperative jugular venous sampling for differential elevation of parathyroid hormone (PTH). Operative findings, intraoperative hormone dynamics, and postoperative calcium levels determined successful localization. MIBI was negative or equivocal in 36/180 (20%) patients: 1) showed no parathyroid gland in 22 patients, 2) suggested an incorrect location for the abnormal gland in 9, and 3) was insufficient in recognizing multiglandular disease in 5. In these 36 patients, the addition of SUS led to the successful identification of the abnormal tissue in 19/36 (53%). In the remaining 17 patients with negative/equivocal scans, the parathyroid could not be clearly visualized by SUS. In these patients, SUS facilitated LPX by aiding preoperative transcutaneous jugular venous sampling for differentially elevated PTH (n = 3) and identifying questionable thyroid nodule versus parathyroid tissue (n = 1). Overall, SUS was useful in 23/36 (67%) patients with nonlocalizing MIBI scans, thus improving the rate of localization from 80 per cent to 93 per cent ( P < 0.01). Surgeon-performed cervical ultrasonography improved the localization of abnormal parathyroids by MIBI scan, adding to the success of limited parathyroidectomy.
Mesenteric Venulitis in a 71-Year-Old Man after Acute Appendicitis
Authors: Charron Paul , Smith Jeff
Published: June 2020

Mesenteric inflammatory veno-occlusive disease (MIVOD) is a clinicopathological entity recently described for a case series of patients with intestinal ischemia of unknown etiology. MIVOD is characterized as a venulitis with lymphocytic, necrotizing, or mixed granulomatous morphology. The disease seems to be self-limiting with resolution of symptoms after surgical resection. We describe a 71-year-old man who developed focal intestinal ischemia in the postoperative period after laparoscopic appendectomy. At re-exploration, a 20-cm segment of grossly ischemic jejunum was identified and resected. The excised specimen demonstrated early ischemic mucosal injury and necrotizing mesenteric venulitis with thrombosis, consistent with verso-occlusive disease. The etiology of this rare vasculitis is currently unknown. We present our case report, which is followed by a review of the literature of MIVOD.