bluuebunny/crossref_metadata_2025 huggingface dataset:
Application Areas of Traditional Molecular Genetic Methods and NGS in relation to Hereditary Urological Cancer Diagnosis
Authors: Mikhaylenko Dmitry S. , Tanas Alexander S. , Zaletaev Dmitry V. , Nemtsova Marina V.
Published: June 2020

Next generation sequencing (NGS) is widely used for diagnosing hereditary cancer syndromes. Often, exome sequencing and extended gene panel approaches are the only means that can be used to detect a pathogenic germline mutation in the case of multiple primary tumors, early onset, a family history of cancer, or a lack of specific signs associated with a particular syndrome. Certain germline mutations of oncogenes and tumor suppressor genes that determine specific clinical phenotypes may occur in mutation hot spots. Diagnosis of such cases, which involve hereditary cancer, does not require NGS, but may be made using PCR and Sanger sequencing. Diagnostic criteria and professional community guidelines developed for hereditary cancers of particular organs should be followed when ordering molecular diagnostic tests for a patient. This review focuses on urological oncology associated with germline mutations. Clinical signs and genetic diagnostic laboratory tests for hereditary forms of renal cell cancer, prostate cancer, and bladder cancer are summarized. While exome sequencing, or, conversely, traditional molecular genetic methods are the procedure of choice in some cases, in most situations, sequencing of multigene panels that are specifically aimed at detecting germline mutations in early onset renal cancer, prostate cancer, and bladder cancer seems to be the basic solution for molecular genetic diagnosis of hereditary cancers.
Study of Vertical Characteristics with Changes in Prepressure of Rubber Pad Used by High‐Speed EMU
Authors: Xu Chuanbo , Chi Mao-Ru , Dai Liangcheng , Jiang Yiping , Guo Zhaotuan
Published: June 2020

Rubber spring plays an important role in improving train performance, so the study of rubber spring is one of the focuses of train dynamics. The vertical characteristic parameters of rubber spring are affected by prepressure significantly, as a result of varying parameters of static stiffness, dynamic stiffness, periodic energy consumption, damping coefficient, and so on. In order to use the theoretical method to calculate the precise static stiffness and predict the dynamic characteristics and to reduce the workload of the rubber spring performance test, this paper takes the annular rubber pad as an example to study with different prepressures. In this paper, the convexity coefficient correction formula (simply called the CCCF) for static stiffness calculation and the dynamic fiducial conversion coefficient (simply called the DFCC) method based on different prepressures are proposed. Through further analysis, the accuracy of CCCF and DFCC is proved both theoretically and experimentally. The results have shown precise prediction of the variation of prepressure on rubber spring parameters by using CCCF and DFCC and can be used as the reference of accurate vertical dynamic‐static characteristics of the rubber spring.
Research on Friction Stir Spot Welding Brazing Process and Properties of Dissimilar Metals DP590 and 6061
Authors: Xu Kai , Zhang Shu-quan
Published: June 2020

Friction stir welding (FSW) is the most popular and efficient method for solid‐state joining of similar or dissimilar metals and alloys. This technology is mostly applied in aerospace, rail, automotive, and marine industries. In order to reduce the weight of special auto parts, friction stir spot welding (FSSW) was proposed by some researchers for the connection of steel‐aluminium dissimilar metals. However, the steel‐aluminium joints welded by FSSW are prone to brittle fracture and have lower shear load although they have high mechanical connection strength. The friction stir spot welding brazing process integrates the brazing effects with the friction welding effects by the addition of solder. A study of FSSW of DP590 and 6061 with the filler metal added was carried out in this paper. The orthogonal test was performed to optimize the process parameters in order to achieve the best shear load of the joint. The shear strength of the joint was studied by the shear test. The fracture morphology was investigated by optical microscopy (OM), scanning electron microscope (SEM), and energy dispersive spectrometer (EDS). The results showed that the shear load of the joint could reach 13.239 kN when the rotating speed, depth, and residence time of the mixing head were 1000 r/min, 0.2 mm, and 90 s, respectively. The aluminium‐zinc solder added could well wet the interface between aluminium and steel and promote the metallurgical bonding, thereby improving the shear load of the joint. The temperature field of DP590/6061 FSSW process was simulated by ANSYS software to verify the rationality of the optimal process parameters. The simulation results were confirmed to be basically consistent with the data measured by the thermocouple.
The Utility and Efficacy of Laparoscopic Radical Cystectomy in Patients with Muscle-Invasive Bladder Cancer at a Single Institution
Authors: Nakane Keita , Enomoto Torai , Hishida Seiji , Tomioka Masayuki , Taniguchi Tomoki , Kato Daiki , Takai Manabu , Iinuma Koji , Muramatsu Maekawa Yuka , Horie Kengo , Mizutani Kosuke , Tsuchiya Tomohiro , Yokoi Shigeaki , Koie Takuya
Published: June 2020

Background: The aim of this study was to compare the surgical and oncological outcomes and complications of laparoscopic radical cystectomy (LRC) to those of open radical cystectomy (ORC) in patients with muscle-invasive bladder cancer (MIBC). Methods: Our study focused on patients with histologically confirmed stage T2–T4a urothelial carcinoma of the bladder without distant metastases, who underwent LRC (LRC group) or ORC (ORC group). The primary endpoints in this study were the overall survival (OS) and recurrence-free survival (RFS) rates. Results: In this study, 59 patients, 17 underwent LRC and 42 underwent ORC, were enrolled. The 2-year OS rate was 100% in the LRC group and 88.0% in the ORC group (p = 0.85). The 2-year RFS rate was 63.5% in the LRC group and 69.5% in the ORC group (p = 0.321). On multivariate analysis, the histological type, positive lymph node, and positive resection margin were significantly associated with the OS rates. Conclusions: This study suggested that LRC may achieve similar oncological outcomes and fewer perioperative complications and less blood loss compared to ORC. Therefore, LRC should be considered as one of the treatment options for patients with MIBC.
Left Atrial Volume Index Predicts New-Onset Atrial Fibrillation and Stroke Recurrence in Patients with Embolic Stroke of Undetermined Source
Authors: Tan Benjamin Y.Q. , Ho Jamie Sin Ying , Sia Ching-Hui , Boi Yushan , Foo Anthia S.M. , Dalakoti Mayank , Chan Mark Y. , Ho Andrew F.W. , Leow Aloysius S. , Chan Bernard P.L. , Teoh Hock Luen , Seow Swee Chong , Kojodjojo Pipin , Seet Raymond C.S. , Sharma Vijay K. , Yeo Leonard Leong L.
Published: June 2020

Introduction: It is unclear which surrogate of atrial cardiopathy best predicts the risk of developing a recurrent ischemic stroke in embolic stroke of undetermined source (ESUS). Left atrial diameter (LAD) and LAD index (LADi) are often used as markers of left atrial enlargement in current ESUS research, but left atrial volume index (LAVi) has been found to be a better predictor of cardiovascular outcomes in other patient populations. Objective: We aim to compare the performance of LAVi, LAD, and LADi in predicting the development of new-onset atrial fibrillation (AF) and stroke recurrence in ESUS. Methods: Between October 2014 and October 2017, consecutive patients diagnosed with ESUS were followed for new-onset AF, ischemic stroke recurrence, and a composite outcome of occult AF and stroke recurrence. LAVi and LADi were measured by transthoracic echocardiogram; “high” LAVi was defined as ≥35 mL/m2 in accordance with American Society of Echocardiography guidelines. Results: 185 ischemic stroke patients with ESUS were recruited and followed for a median duration of 2.1 years. Increased LAVi was associated with new-onset AF detection (aOR 1.08; 95% CI 1.03–1.14; p = 0.003) and stroke recurrence (aOR 1.05; 95% CI 1.01–1.10; p = 0.026). Patients with “high” LAVi had a higher likelihood of developing a composite of AF detection and stroke recurrence (HR 3.45; 95% CI 1.55–7.67; p = 0.002). No significant association was observed between LADi and either occult AF or stroke recurrence. Conclusions: LAVi is associated with new-onset AF and stroke recurrence in ESUS patients and may be a better surrogate of atrial cardiopathy.
On the performance of switching methods in space division multiplexing based optical networks
Authors: Iyer Sridhar
Published: June 2020

In the current work, for Space Division Multiplexing based Optical Networks (SDM-b-OTNs), we investigate the performance of various switching methods with a variation in traffic evolution over different time frame periods. Initially, comparison of the existing methods viz., independent switching (InSw), frequency switching (FqSw), and space switching (SpSw) demonstrates that (i) over longer periods of time frame, FqSw provisions low network usage, and (ii) SpSw offers low network usage for shorter periods of time frame; however, as time frame increases to longer periods, SpSw starts to outperform InSw. Next, we investigate a hybrid switching (HySw) method which begins by implementing InSw and then shifts to the use of SpSw after the activation of specific numbers of space channels. HySw is observed to provision substantial savings on the costs incurred for switching, and with lower space channel values it also offers a balance in the trade-off which occurs between the costs associated for activating the space channels and that incurred for switching. Lastly, a comparison of InSw, SpSw, and HySw considering mixed line rate (MLR) demands shows that the space channels assigned in the ‘in-between’ periods of time frame can be reduced by shifting from InSw to SpSw in the starting periods of time frame.Overall, from the results it is inferred that the network performance only slightly depends on the MLR traffic, and over longer periods of time frame, in comparison to InSw, the significant benefits of SpSw and HySw remains conserved.
Imagem	sobrevivente
Authors: Barbosa Paulo Eduardo
Published: June 2020

Proponho neste artigo a necessidade de se atualizar questões ao se expor em espaço museal conjunto de imagens ampliadas, considerando a expografia como uma das determinantes da possibilidade de análise e fruição da imagem.
Bovine Arch and Stroke Laterality
Authors: Matakas Jason D. , Gold Menachem M. , Sterman Jonathan , Haramati Linda B. , Allen Michael T. , Labovitz Daniel , Slasky Shira E.
Published: June 2020

Background

Left‐hemispheric strokes are more frequent and often have a worse outcome than their right‐hemispheric counterparts. This study aimed to evaluate whether cardioembolic stroke laterality is affected by anatomical characteristics of the aortic arch. We hypothesized that laterality varies between patients with bovine versus standard arch.

Methods and Results

We retrospectively identified 1598 acute cardioembolic strokes in patients with atrial fibrillation from our institutional stroke database (2009–2017). Inclusion criteria were acute anterior circulation ischemic infarct and availability of both arch and brain imaging (magnetic resonance imaging or computed tomography). Alternative causes of stroke and anomalous arch were excluded. Imaging was reviewed for stroke characterization and laterality and arch branching pattern. Bovine arch denotes a common origin of the brachiocephalic trunk and left common carotid artery. Strokes were classified as bilateral (left or right). Univariate analysis was performed using chi‐square tests. The final cohort comprised 615 patients, mean age 77 years (
SD
11.8 years) with 376 women (61%) and 33% white, 30% black, and the remainder mixed/Hispanic. Standard arch (n=424) stroke distribution was left 43.6% (185), right 45.1% (191), and bilateral 11.3% (48). Bovine arch (n=191) stroke distribution was left 51.3% (98), right 35.6% (68), and bilateral 13.1% (25). Bovine arches were associated with more left‐sided strokes compared with standard arches (
P
=0.018). There was an association between black race and bovine arch (
P
=0.0001).

Conclusions

Bovine aortic arch configuration is associated with left hemispheric laterality of cardioembolic stroke. This study enriches the understanding that arch anatomy influences stroke laterality and highlights the need for further research into the causative hemodynamic factors.
3K3A-Activated Protein C Variant Does Not Interfere With the Plasma Clot Lysis Activity of Tenecteplase
Authors: Mukherjee Purba , Lyden Patrick , Fernández José A. , Davis Thomas P. , Pryor Kent E. , Zlokovic Berislav V. , Griffin John H.
Published: June 2020

Background and Purpose:

A recombinant engineered variant of APC (activated protein C), 3K3A-APC, lacks anticoagulant properties (<10%) while preserving APCs anti-inflammatory, anti-apoptotic, and neuroprotective functions and is very promising in clinical trials for ischemic stroke. Therapeutic intervention with single bolus administration of the third-generation tPA (tissue-type plasminogen activator), tenecteplase, is anticipated to be widely adopted for treatment of acute ischemic stroke. 3K3A-APC is well-tolerated in stroke patients dosed with alteplase, and in vitro studies show 3K3A-APC does not interfere with alteplase-induced clot lysis. The purpose of this in vitro study was to assess the influence of 3K3A-APC on tenecteplase-induced clot lysis.

Methods:

Tenecteplase-mediated lysis of thrombin generated plasma clots of human normal pooled plasma was monitored in the presence of varying doses of 3K3A-APC. The effects on fibrinolysis by tenecteplase and alteplase were compared.

Results:

The presence of 3K3A-APC shortened the time for clot lysis induced by tenecteplase at very low levels but not at higher therapeutic concentrations of tenecteplase. Comparisons of alteplase-mediated clot lysis to tenecteplase clot lysis showed that both thrombolytic agents behaved similarly in the presence of 3K3A-APC.

Conclusions:

These results indicate that 3K3A-APC does not interfere with tenecteplase’s clot lysis function.
Quantitative Histogram Analysis on Intracranial Atherosclerotic Plaques
Authors: Shi Zhang , Li Jing , Zhao Ming , Peng Wenjia , Meddings Zakaria , Jiang Tao , Liu Qi , Teng Zhongzhao , Lu Jianping
Published: June 2020

Background and Purpose:

Intracranial atherosclerosis is one of the main causes of stroke, and high-resolution magnetic resonance imaging provides useful imaging biomarkers related to the risk of ischemic events. This study aims to evaluate differences in histogram features between culprit and nonculprit intracranial atherosclerosis using high-resolution magnetic resonance imaging.

Methods:

Two hundred forty-seven patients with intracranial atherosclerosis who underwent high-resolution magnetic resonance imaging sequentially between January 2015 and December 2016 were recruited. Quantitative features, including stenosis, plaque burden, minimum luminal area, intraplaque hemorrhage, enhancement ratio, and dispersion of signal intensity (coefficient of variation), were analyzed based on T2-, T1-, and contrast-enhanced T1-weighted images. Step-wise regression analysis was used to identify key determinates differentiating culprit and nonculprit plaques and to calculate the odds ratios (ORs) with 95% CIs.

Results:

In total, 190 plaques were identified, of which 88 plaques (37 culprit and 51 nonculprit) were located in the middle cerebral artery and 102 (57 culprit and 45 nonculprit) in the basilar artery. Nearly 90% of culprit lesions had a degree of luminal stenosis of <70%. Multiple logistic regression analyses showed that intraplaque hemorrhage (OR, 16.294 [95% CI, 1.043–254.632];
P
=0.047), minimum luminal area (OR, 1.468 [95% CI, 1.032–2.087];
P
=0.033), and coefficient of variation (OR, 13.425 [95% CI, 3.987–45.204];
P
<0.001) were 3 significant features in defining culprit plaques in middle cerebral artery. The enhancement ratio (OR, 9.476 [95% CI, 1.256–71.464];
P
=0.029), intraplaque hemorrhage (OR, 2.847 [95% CI, 0.971–10.203];
P
=0.046), and coefficient of variation (OR, 10.068 [95% CI, 2.820–21.343];
P
<0.001) were significantly associated with plaque type in basilar artery. Coefficient of variation was a strong independent predictor in defining plaque type for both middle cerebral artery and basilar artery with sensitivity, specificity, and accuracy being 0.79, 0.80, and 0.80, respectively.

Conclusions:

Features characterized by high-resolution magnetic resonance imaging provided complementary values over luminal stenosis in defined lesion type for intracranial atherosclerosis; the dispersion of signal intensity in histogram analysis was a particularly effective predictive parameter.
Leveraging Pre-trained Checkpoints for Sequence Generation Tasks
Authors: Rothe Sascha , Narayan Shashi , Severyn Aliaksei
Published: June 2020

Unsupervised pre-training of large neural models has recently revolutionized Natural Language Processing. By warm-starting from the publicly released checkpoints, NLP practitioners have pushed the state-of-the-art on multiple benchmarks while saving significant amounts of compute time. So far the focus has been mainly on the Natural Language Understanding tasks. In this paper, we demonstrate the efficacy of pre-trained checkpoints for Sequence Generation. We developed a Transformer-based sequence-to-sequence model that is compatible with publicly available pre-trained BERT, GPT-2, and RoBERTa checkpoints and conducted an extensive empirical study on the utility of initializing our model, both encoder and decoder, with these checkpoints. Our models result in new state-of-the-art results on Machine Translation, Text Summarization, Sentence Splitting, and Sentence Fusion.
Addition to the taxonomic and distribution records of Abernessia Arlé (Hymenoptera: Pompilidae)
Authors: OLIVEIRA NATHÁLIA S. , DECKER BRENNA L. , PITTS JAMES P. , WAICHERT CECILIA
Published: June 2020

Species of spider wasps (Hymenoptera: Pompilidae) are diverse in the tropical regions. The Neotropical genus Abernessia Arlé, 1947 was described from São Paulo and later found in Espírito Santo, Bahia and Minas Gerais, Brazil. Herein, we establish a neotype for the type-species A. irmgardae Arlé, discuss the previous distribution records of Abernessia in South America, add new records for Brazil, and expand the recorded distribution to San Pedro, Paraguay. The male of Abernessia giga is described and illustrated. Finally, an updated key to species known from males is provided.
Taxonomic reconsideration of the subspecific complex of Laemostenus (Antisphodrus) cazorlensis (Mateu, 1953) (Coleoptera, Carabidae, Platyninae)
Authors: MUÑOZ-SANTIAGO JOSÉ , ORTUÑO VICENTE M.
Published: June 2020

In this article we present a comparative study between the three subspecies of Laemostenus (Antisphodrus) cazorlensis (Mateu, 1953) (Coleoptera, Carabidae), a representative carabid of the cave fauna of Jaén and Albacete (southern Spain). The aim of this work was to examine the validity of the characters typically used to distinguish the subspecies L. (A.) c. cazorlensis (Mateu, 1953), L. (A.) c. divergens (Mateu, 1953) and L. (A.) c. seguranus (Vives & Vives, 1982) and check if they support the actual subspecific classification. For this purpose, a morphometric study of the pronotum and a morphological study of the male and female genitalia were carried out on 161 individuals of the three subspecies from the different geographic territories within the known distribution range of the species. An ANOVA analysis was run to support the results of the morphometric study developed with the total of studied samples. The results suggest that none of the studied characters can be used to characterize any of the subspecific taxa. Besides, the karstic profile of the ground in where this species inhabits could facilitate the genetic flow between its populations, so it is possible that they are not completely isolated. We conclude that the observable differences between individuals of Laemostenus (Antisphodrus) cazorlensis for the studied characters reflect intraspecific variability, and do not support a subspecific classification of the species. We propose the synonymization of the two non-typical subspecies of Laemostenus (Antisphodrus) cazorlensis with the typical one and, therefore, with the specific taxa.
Laparoscopic Revision of Bariatric Procedures: Is it Feasible?
Authors: Khaitan Leena , Van Sickle Kent , Gonzalez Rodrigo , Lin Edward , Ramshaw Bruce , Smith C. Daniel
Published: June 2020

Reoperative bariatric surgery is required in 10 per cent to 20 per cent of patients secondary to weight regain or complications of the previous procedure. This study evaluates the feasibility of performing the revision procedure laparoscopically. A retrospective review of all patients undergoing revision of a previous weight loss procedure between October 1998 and November 2003 was conducted. Demographics, indications for surgery, operative findings, and complications were reviewed. Thirty-nine revisions were performed in 37 patients. Indications for revision were failure to lose weight (22), gastric outlet stricture (10), refractory gastroesophageal reflux (GERD) (6), and blind loop syndrome (1). All 39 procedures were revised to Roux- en-Y gastric bypass (RYGBP), with 18 open revisions (OR) and 21 laparoscopic revisions (LR). Ten of the 21 LR (48%) were converted to an open procedure due to adhesions or unclear anatomy. Early complications requiring operation were noted in five procedures (two OR, three LR). Nine patients (seven OR, two LR) required surgery at least 3 months following their revision. One patient died (LR). The difference in body mass index (kg/m2) (BMI) pre- and post-op was 43.3 ± 9.9 versus 37.4 ± 9.2, P = 0.01 (follow-up 5 months), but no significant BMI differences between LR and OR patients were seen. Revisional bariatric surgery is associated with more complications requiring surgery early in the laparoscopic population versus more late complications in those approached open. Revisional bariatric surgery can be approached laparoscopically and with acceptable morbidity comparable to patients whose revision is approached open.
Correlation between Perceptual, Visuo-spatial, and Psychomotor Aptitude to Duration of Training Required to Reach Performance Goals on the MIST-VR Surgical Simulator
Authors: McClusky D.A. , Ritter E.M. , Lederman A.B. , Gallagher A.G. , Smith C.D.
Published: June 2020

Given the dynamic nature of modern surgical education, determining factors that may improve the efficiency of laparoscopic training is warranted. The objective of this study was to analyze whether perceptual, visuo-spatial, or psychomotor aptitude are related to the amount of training required to reach specific performance-based goals on a virtual reality surgical simulator. Sixteen MS4 medical students participated in an elective skills course intended to train laparoscopic skills. All were tested for perceptual, visuo-spatial, and psychomotor aptitude using previously validated psychological tests. Training involved as many instructor-guided 1-hour sessions as needed to reach performance goals on a custom designed MIST-VR manipulation-diathermy task (Mentice AB, Gothenberg, Sweden). Thirteen subjects reached performance goals by the end of the course. Two were excluded from analysis due to previous experience with the MIST-VR (total n = 11). Perceptual ability (r = -0.76, P = 0.007) and psychomotor skills (r = 0.62, P = 0.04) significantly correlated with the number of trials required. Visuo-spatial ability did not significantly correlate with training duration. The number of trials required to train subjects to performance goals on the MIST-VR manipulation diathermy task is significantly related to perceptual and psychomotor aptitude.
A Case and Review of Bowel Perforation Secondary to Metastatic Lung Cancer
Authors: Garwood Robert A. , Sawyer Mark D. , Ledesma E.J. , Foley Eugene , Claridge Jeffrey A.
Published: June 2020

Gastrointestinal tract perforation (GITP) secondary to metastatic lung cancer is extremely rare. We present a case of small bowel perforation secondary to metastatic lung cancer. The objective of this study was to review the current literature and further characterize the incidence, histology, and risk of GITP secondary to lung cancer metastasis. A Medline search was done to identify all the cases of GITP attributed to metastatic lung cancer reported in the literature. Data was collected and analyzed from a collection of cases in the medical literature since 1960. We identified 98 cases of perforated lung cancer metastasis to the small intestine. Four gastric perforations, three colonic perforations, and one appendiceal perforation were also identified but not analyzed. The mean age was 64.5 years. There was a male predominance of 89 per cent versus 11 per cent female. Perforations occurred most often in the jejunum (53%) followed by ileum (28%). Combined jejunum-ileum lesions accounted for 4 per cent of perforations. No duodenal perforations were reported, though a specific site was not determined in 13 per cent of cases. Small bowel perforations were most often caused by adenocarcinoma (23.7%), squamous cell carcinoma (22.7%), large cell carcinoma (20.6%), and small cell carcinoma (19.6%). The prevalence of small bowel perforation secondary to a given primary lung cancer histology varied by region. The mean survival was 66 days with 50 per cent of patients not surviving past 30 days. Despite a high incidence of lung cancer, small bowel perforation secondary to lung cancer metastasis remains relatively rare. Perforated metastases occur more often in men and are found more commonly in the jejunum. Small bowel perforations are caused most often by adenocarcinoma; however, squamous cell and large cell carcinoma metastases are more likely to result in perforation. Small bowel perforation in this setting has a significant impact on mortality, decreasing 1-year survival to less than 3 per cent.
Hospital and Long-Term Outcome of Trauma Patients with Tracheostomy for Respiratory Failure
Authors: Engoren Milo , Arslanian-Engoren Cynthia
Published: June 2020

Studies of tracheostomy for respiratory failure have suggested a poor prognosis, however, trauma patients may have a better outcome. Data from 113 trauma patients were retrospectively analyzed for comorbidities, laboratory values, and hospital course. Long-term survival was determined from the Social Security Death Index. Trauma patients were young, overwhelmingly male, relatively healthy, and frequently uninsured. Seventy-five per cent of trauma patients were liberated from mechanical ventilation by hospital discharge. Timing of tracheostomy had no effect on days of mechanical ventilation or hospital length of stay. Hospital survival was 98 per cent, and 3-year Kaplan-Meier survival was 80 per cent. Older age and higher admission creatinine levels were predictive of late death. Trauma patients who undergo tracheostomy are likely to survive and be liberated from mechanical ventilation.
Trends in Breast Cancer at a County Hospital
Authors: Hoehne Francesca M. , Taylor Edward
Published: June 2020

Breast cancer mortality has changed dramatically with improvements in screening techniques. Mammography is essential for early detection; however, its contribution to the survival benefit in young women is questionable. We report our experience in breast biopsies at a county teaching hospital with a traditionally younger patient population. Institutional review board approval was obtained prior to data collection. A total of 550 breast biopsies were conducted between 1995 and 2000. Data regarding age, method of breast biopsy, and pathology was reviewed. One hundred twenty of 550 patients (21.8%) had breast carcinoma detected on breast biopsies with the predominant histologic subtype being invasive ductal carcinoma. The mean age of patients with carcinoma was 52.8 years, whereas that of patients with benign breast disease was 43.6 years ( P < 0.05). Forty-three per cent of all breast cancers occurred in women under the age of 50 years. During the study period, there was neither an increase in the number of breast biopsies performed per year nor a decrease in the average age of women with breast cancer. However, observing a significant percentage of breast cancer patients under 50 years old, our data suggest the importance of strict adherence to current screening recommendations including self–breast examination and yearly mammography.
Recombinant Human Coagulation Factor VIIa in Jehovah's Witness Patients Undergoing Liver Transplantation
Authors: Jabbour Nicolas , Gagandeep Singh , Cheng Peilin Alice , Boland Brendan , Mateo Rod , Genyk Yuri , Selby Rick , Zeger Gary
Published: June 2020

Indisputably, liver transplantation is among the most technically challenging operations in current practice and is compounded by significant coagulopathy and portal hypertension. Recombinant human coagulation factor VIIa (rFVIIa) is a new product that was initially described to treat bleeding in hemophilia patients. We present in this paper 10 liver transplants in Jehovah's Witness patients using this novel product at University of Southern California–University Hospital. The subject population included nine males and one female with an average age of 50 years. Six patients underwent cadaveric and four live donor liver transplantation. Surgeries were conducted following our established protocol for transfusion-free liver transplantation, which includes preoperative blood augmentation, intraoperative blood salvage, acute normovolemic hemodilution, and postoperative blood conservation. Factor rFVIIa was used at a dose of 80 μg/kg intravenously just prior to the incision in all patients, and a second intraoperative dose was used in 3 patients. All living donor liver transplantation (LDLT) recipients did well and were discharged uneventfully with normal liver functions. Two of the six cadaveric recipients died. One patient died intraoperatively from acute primary graft nonfunction, and the other died 38 hours postoperatively from severe anemia. This report suggests factor rFVIIa might have a much broader application in surgery in the control of bleeding associated with coagulopathy.
Diverticular Abscess Presenting as an Incarcerated Inguinal Hernia
Authors: Greenberg Josh , Arnell Tracey D.
Published: June 2020

Acute diverticulitis may present with an abscess that is usually pericolonic or pelvic and can be treated with urgent surgery or percutaneous drainage. We present a case of a diverticular abscess presenting as a left inguinal hernia. This is analogous to an Amyand's hernia in which an inflamed appendix is found in a right inguinal hernia. The patient presented was managed with open drainage of the hernia and subsequent laparoscopic sigmoid resection in the same hospitalization.
Role of Repeat Computerized Tomography in Nonoperative Management of Solid Organ Trauma
Authors: Sharma Om P. , Oswanski Michael F. , Singer Daniel
Published: June 2020

Nonoperative management (NOM) of blunt spleen and liver trauma is currently well accepted. CT imaging is helpful in selecting treatment options and to evaluate resolution of solid organ trauma. This 8-year study was undertaken to assess the role of repeat CT scans in NOM by analyzing indications of surgery in NOM failures. NOM was undertaken in 221 patients with spleen/liver trauma. After initial CT scans, 82 (37%) scans were repeated in 65 patients. There was failure of NOM (NOMF) in 11 patients. Follow-up imaging was done prior to delayed surgery in 4 (36%) patients, 4.9 per cent of repeat scans. Two of these patients had hemodynamic instability and, in the other two, there were clinical signs of peritonitis. The remaining seven patients had delayed surgery due to hemodynamic instability. There is a limited role of repeat CT scans in NOM of spleen and liver trauma. Repeat CT should be done more liberally in patients with suspected intestinal and mesenteric trauma, unexplained blood loss, complex hepato-biliary trauma, and in patients with neurological or pharmacological paralysis.
Mucinous Cystadenoma of the Pancreas Associated with Acute Pancreatitis and Concurrent Pancreatic Pseudocyst
Authors: Russell Robert T. , Sharp Kenneth W.
Published: June 2020

We report an unusual occurrence of a recurrent pancreatic pseudocyst caused by an underlying mucinous cystadenoma of the distal pancreas. A 54-year old female was admitted for acute pancreatitis. Her only risk factors included the use of hydrochlorothiazide and two or three glasses of wine daily. Abdominal computed tomography (CT) done a week after onset of her symptoms showed a 5-cm cystic lesion in the tail of the pancreas suspected to be a pseudocyst. Her symptoms subsequently resolved. One month later, she had another episode of pancreatitis and an abdominal CT showed an 11 x 16 cm pseudocyst along with the previously mentioned cystic lesion. Approximately 6 weeks after her initial presentation, she was taken to the operating room for an exploratory laparotomy and cyst gastrostomy for a symptomatic pseudocyst. An intraoperative frozen section of the cyst wall showed a fibrous wall with acute and chronic inflammation without an epithelial lining. Six weeks after her cyst gastrostomy, she returned with abdominal pain, early satiety, and anorexia. Abdominal CT showed reaccumulation of fluid within the pseudocyst and endoscopic retrograde cholangiopancreatography (ERCP) revealed a normal caliber pancreatic duct with an abrupt cutoff at the distal duct. She underwent exploratory laparotomy with drainage of 3 L of fluid from the pancreatic pseudocyst. After gaining access to the lesser sac, a 6-cm cystic lesion was identified in the tail of the pancreas. She underwent a distal pancreatectomy and splenectomy. The intraoperative and final pathology confirmed the presence of a benign mucinous cystadenoma. The patient had an uneventful recovery, began to tolerate oral intake, and was discharged 7 days after surgery. The differentiation between a pancreatic pseudocyst and benign cystic neoplasms of the pancreas is crucial to determine treatment options. Cystic neoplasms of the pancreas, whether mucinous or serous, have the potential to harbor malignancy, and resection is recommended.
Management of Subclavian and Axillary Artery Injuries: Spanning the Range of Current Therapy
Authors: Franga Dion L. , Hawkins Michael L. , Mondy J. Sheppard
Published: June 2020

Injuries of the subclavian and proximal axillary arteries are potentially devastating but account for a minority of vascular injuries presenting to trauma centers in the United States. We have reviewed our recent experience with management of subclavian and axillary artery injuries in a state-designated level 1 academic trauma center and report four cases that illustrate the typical arterial injury patterns and the entire therapeutic armamentarium in its current iteration. Sub-clavian and proximal axillary artery injuries present as interesting surgical problems. A high index of suspicion for vascular injuries should be maintained given the mechanism and proximity to major vasculature. Consideration should always be given to the least invasive treatment options in stable patients. Awareness of multiple therapeutic modalities and indications for each should be an integral part of every surgeon's armamentarium. As with all vascular intervention, eventual failure is the rule rather than the exception; therefore, plans for longitudinal surveillance should be made independent of the technique used to treat the injury.
Upper Gastrointestinal Bleeding Caused by a “Hypophrenic” Diverticulum of the Distal Esophagus
Authors: Sam Albert D. , Chaer Rabih A. , Cintron Jose , Teresi Miguel , Massad Malek G.
Published: June 2020

Distal esophageal diverticula are uncommon acquired anomalies of the distal thoracic esophagus. We report a case of an elderly man presenting with a history of upper gastrointestinal bleeding secondary to a distal esophageal diverticulum arising from the intra-abdominal portion of the esophagus. To our knowledge, this is the first report of upper gastrointestinal bleeding from a subdiaphragmatic esophageal diverticulum. We propose the term “hypophrenic diverticulum of the esophagus” for this disease entity, and we would like to bring it to the attention of readers of The American Surgeon.
Role of Leukocyte Count, Neutrophil Percentage, and C-Reactive Protein in the Diagnosis of Acute Appendicitis in the Elderly
Authors: Yang Horng-Ren , Wang Yu-Chun , Chung Ping-Kuei , Chen Wei-Kung , Jeng Long-Bin , Chen Ray-Jade
Published: June 2020

Leukocyte count, neutrophil percentage, and C-reactive protein (CRP) have been shown to give valuable information in the diagnosis of acute appendicitis. However, whether these laboratory tests have the same clinical applicability in the elderly as in young patients remains unclear. This retrospective study aimed to clarify the role of these tests in the diagnosis of acute appendicitis in patients aged 60 years or over. Eighty-five consecutive elderly patients underwent appendectomy for suspected acute appendicitis during a 30-month period. Histologically verified appendicitis was found in 77 of the 85 patients (90.6%). There was no significant difference in leukocyte counts or CRP values between patients with acute appendicitis and those with a normal appendix. The sensitivities of leukocyte count, neutrophil percentage, and CRP in the diagnosis of acute appendicitis were 71.4 per cent, 88.3 per cent, and 90 per cent, respectively, while the specificities were 37.5 per cent, 25 per cent, and 37.5 per cent, respectively. Of 77 patients with acute appendicitis, only two had all three tests simultaneously normal. In conclusion, patients with normal results in all three tests are highly unlikely to have acute appendicitis and should be evaluated with extra caution before surgery.
Restorative Proctocolectomy and Ileal Pouch–Anal Anastomosis for Ulcerative Colitis after Liver Transplant for Primary Sclerosing Cholangitis: Case Report and Review of Literature
Authors: Grucela Alexis L. , Steinhagen Randolph M.
Published: June 2020

Primary sclerosing cholangitis (PSC) is present in 5 per cent of patients with ulcerative colitis (UC). Conversely, as many as 90 per cent of patients with PSC have been found to have UC. The accepted treatment for advanced PSC is orthotopic liver transplant, and the treatment of ulcerative colitis with concomitant PSC is restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA). A small number of studies have shown that there is an increased risk of pouchitis in UC patients with PSC after ileal pouch-anal anastomosis. We report a case of a 45-year-old male who underwent a two-stage restorative proctocolectomy with IPAA after previous orthotopic liver transplant for PSC. We have reviewed the available literature concerning restorative proctocolectomy after liver transplantation, giving special attention to postoperative complications and subsequent development of pouchitis. It is important to be aware of the possibility of increased risk for development of pouchitis and to follow these patients closely to prevent complications.
Single-Stage Reconstruction of Perforated Choledochal Cyst: Case Report and Review of the Literature
Authors: Franga Dion L. , Howell Charles G. , Mellinger John D. , Hatley Robyn M.
Published: June 2020

Choledochal cysts represent a rare disease in the Western world. We reviewed our recent experience with a case of perforated choledochal cyst, define the currently accepted treatment options, and review the literature of this unusual disease. An 11-month-old girl presented with abdominal pain and distention as well as non-bilious vomiting. Subsequent workup included endoscopic retrograde cholangiopancreatography revealing a perforated type I choledochal cyst. She underwent single-stage excision and reconstruction with a Roux- en-Y hepaticojejunostomy. Perforated choledochal cyst is a rare event, and prompt surgical intervention is warranted. Single-stage cystectomy and Roux- en-Y reconstruction is possible in select patients. A thorough understanding of the pathophysiology, management, and follow-up is required.
National Analysis of Adverse Patient Safety Events in Bariatric Surgery
Authors: Poulose Benjamin K. , Griffin Marie R. , Zhu Yuwei , Smalley Walter , Richards William O. , Wright J. Kelly , Melvin Willie , Holzman Michael D.
Published: June 2020

Identifying risk factors for adverse events after bariatric surgery (BaS) can help define high-risk groups to improve patient safety. We calculated cumulative incidence of adverse events and identified risk factors for these events using validated surgical patient safety indicators (PSIs) developed by the Agency for Healthcare Research and Quality. BaS patients ≥18 years old were identified using the 2002 Nationwide Inpatient Sample. Cumulative incidence at discharge was calculated for accidental puncture or laceration (APL), pulmonary embolus or deep venous thrombosis (PE/DVT), and postoperative respiratory failure (RF). Factors predictive of these PSIs were identified. From 7,853,982 discharges, a national cohort of 69,490 BaS patients was identified. During BaS hospitalization, the cumulative incidences per 1000 discharges of APL, PE/DVT, and RF were 12.6, 3.4, and 7.3, respectively. Risk factors for APL included male gender (odds ratio [OR] 1.6, 95% confidence interval 1.1–2.3, P < 0.05) and age of 40–49 years (OR 1.6 [1.1–2.3], P < 0.05) compared to ages 18–39 years. Patients aged 50–59 years (OR 3.5 [1.6–7.7], P < 0.05) had a higher chance of PE/DVT compared to those 18–39 years. Male gender (OR 1.8 [1.1–2.9], P < 0.05), ages 40–49 (OR 2.1 [1.1–4.2], P < 0.05) and 50–59 (OR 3.8 [2.1–6.9], P < 0.05), a history of chronic lung disease (OR 1.7 [1.1–2.7], P < 0.05), and Medicare coverage compared to private insurance (OR 2.2 [1.2–3.8], P < 0.05) were predictive of RF. This study established national measures for BaS adverse events. Further, risk factors associated with adverse events varied by gender, age, insurance status, and comorbidity. Evaluation of these higher risk BaS groups is needed to improve patient safety.
A Jehovah's Witness with Complex Abdominal Trauma and Coagulopathy: Use of Factor VII and a Review of the Literature
Authors: Haan James , Scalea Thomas
Published: June 2020

Management of acute bleeding in patients who are Jehovah's Witnesses remains a challenge. Clearly, the most important concept is meticulous and early hemostasis to minimize ongoing blood loss. This is generally followed by supportive measures. Dilutional coagulopathy can present a real challenge, as therapeutic options are quite limited in this group of patients. We present a patient who arrived in hemorrhagic shock, and despite early surgical therapy, his significant blood loss caused dilutional coagulopathy that we treated with activated factor VIIa. While use of factor VIIa after injury is gaining popularity, data on its use in patients who are Jehovah's Witnesses is quite limited. In this case, we believe the product was life-saving. Most importantly, there were no religious objections to its use. In appropriate patients, when surgical bleeding is controlled and there is still evidence of dilutional coagulopathy, factor VIIa may have a real role in patients, particularly those who are Jehovah's Witnesses.
Initial Chest Tube Management after Pulmonary Resection
Authors: Antanavicius G. , Lamb J. , Papasavas P. , Caushaj P.
Published: June 2020

Tube thoracostomy management with suction or water seal after anatomical pulmonary resection remains somewhat controversial. Initial chest tube management may influence the duration of pleural fluid drainage, duration of tube thoracostomy, and/or hospital length of stay following pulmonary resection. We hypothesized that initial chest tube management with water seal decreases time for chest tube removal and decreases time of hospital stay. A retrospective chart review was performed on 109 consecutive patients who underwent lobectomy or segmentectomy in Western Pennsylvania Hospital between December 1999 and December 2003. Comparison was made between chest tube management of water seal or suction in patients with and without air leak. Of the 109 patients, 78 (72%) had no air leak at the completion of surgery, and 31 (28%) had air leak. In the group without air leak (n = 78), water seal was used in 32 (41%) patients and suction in 46 (59%). In patients placed to water seal initially after surgery (n = 32), removal of chest tubes was on postoperative day (POD) 3.19 ± 0.24 and hospital discharge was on POD 5.13 ± 0.61. In patients placed to suction initially (n = 46), chest tubes were removed on POD 4.52 ± 0.40. Hospital discharge was on POD 6.74 ± 0.5. Both duration of chest tube ( P < 0.007) and length of hospital stay ( P < 0.04) were significantly lower in the water seal group. In the air leak group (n = 31), 7 (23%) patients were managed with water seal and 24 (77%) patients with suction. Both duration of chest tube ( P = 0.001) and length of hospital stay ( P < 0.05) were significantly lower in the water seal group. In patients without air leak, chest tubes should be managed with water seal following anatomical pulmonary resection, resulting in significantly shorter chest tube duration and hospital length of stay.
Age Affects Presenting Symptoms of Achalasia and Outcomes after Myotomy
Authors: Rakita Steven , Bloomston Mark , Villadolid Desiree , Thometz Donald , Boe Brian , Rosemurgy Alexander
Published: June 2020

Older patients with achalasia presumably have had a longer, more indolent course than younger patients. This study was undertaken to determine the impact of patient age and duration of symptoms on symptom severity and outcome after Heller myotomy. Two hundred sixty-two patients (142 men and 120 women), of average age 49 years ± 17.7 (SD), have undergone laparoscopic Heller myotomy. Patients scored their symptoms using a Likert scale and subjectively rated their overall outcome. Data are presented as median, mean ± SD, when appropriate. Follow-up is 25 months, 32 months ± 28.7. Symptom severity scores improved after myotomy ( P < 0.001 for all, paired Student's t test). Before myotomy, older patients had less dysphagia, regurgitation, choking, and chest pain ( P < 0.05). Duration of preoperative symptoms did not correlate with frequency of symptoms. After myotomy, older patients had lower scores for dysphagia, chest pain, choking, and heartburn ( P < 0.01); patients with prolonged durations of symptoms had lower dysphagia and choking scores. Neither age nor duration of symptoms had a significant effect on overall subjective outcomes. All patients should expect significant reductions in symptoms of achalasia following myotomy. Age and duration of symptoms impact symptoms before and after myotomy, but neither seem to impact subjective measure of outcome.