bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Trauma System Evaluation before and after Level II Verification
Authors: Dixon Michael D. , Engum Scott
Published: June 2020

ACS-verified trauma centers show higher survival and improved mortality rates in states with ACS-verified Level I pediatric trauma centers. However, few significant changes are appreciated in the first two years after verification. Minimal research exists examining verification of ACS Level II pediatric trauma centers. We analyzed ACS Level II pediatric trauma verification at our institution. In 2014, Sanford Medical Center Fargo became the only Level II pediatric trauma center in North Dakota, as well as the only center between Spokane and Minneapolis. A retrospective review of the institution's pre-existing trauma database one year pre- and postverification was performed. Patients aged <18 years were included in the study ( P < 0.05). Patient number increased by 23 per cent, from 167 to 205 patients. A statistically significant increase occured in the three to six year old age group ( P = 0.0002); motorized recreational vehicle ( P = 0.028), violent ( P = 0.009), and other ( P = 0.0374) mechanism of injury categories; ambulance ( P = 0.0124), fixed wing ( P = 0.0028), and personal-owned vehicle ( P = 0.0112) modes of transportation. Decreased public injuries ( P = 0.0071) and advanced life support ambulance transportation ( P = 0.0397). The study showed a nonstatistically significant increase in mean Injury Severity Score (from 6.3 to 7) and Native American trauma (from 14 to 20 per cent). Whereas prolonged ACS Level I pediatric trauma center verification was found to benefit patients, minimal data exist on ACS Level II verification. Our findings are consistent with current Level I ACS pediatric trauma center data. Future benefits will require continued analysis because our Level II pediatric trauma center continues to mature and affect our rural and large Native American community.
Dr. Orvar Swenson and the Pull-Through
Authors: Newland John J. , Dukleska Katerina , Cowan Scott , Yeo Charles J. , Tholey Renee
Published: June 2020

Dr. Orvar Swenson is best remembered for developing the Swenson pull-through, a technique he developed to treat Hirschsprung's disease. After graduating from Harvard Medical School and beginning his residency at Peter Bent Brigham Hospital, Dr. Swenson observed that patients with Hirschsprung's disease and toxic megacolon resumed normal bowel function after placement of transverse colostomies. His observation led to studying the patency of his patients’ colons using barium enema contrast studies. At the collapsed portion of the colon, he performed rectal biopsies leading to the discovery that the cause of Hirschsprung's disease is that the collapsed portion of the colon lacks the Auerbach plexus. The Swenson pull-through removes this aganglionic portion of the colon and cures the patient. His career grew from there as he traveled to academic institutions teaching his technique. He is remembered fondly for his contributions to pediatric surgery through the restructuring of pediatric surgery departments, pediatric surgery research, and writing and editing multiple volumes of Pediatric Surgery, the standard textbook for pediatric surgeons. He died peacefully in 2012 at the age of 103 years.
Surgeons, Scholars, and Leaders Symposium: A 5-Year Experience
Authors: Morris Mackenzie C. , Baker Jennifer E. , Edwards Michael J.
Published: June 2020

The Department of Surgery at the University of Cincinnati developed the Surgeons, Scholars, and Leaders Symposium to address the underappreciated aspects of surgical education that are critical in the development of the academic surgeon. Surgical education has undergone many gaps since the beginning of a traditional surgical residency, first pioneered by Dr. Halsted in 1904; still, many gaps in surgical education remain. Topics such as research, financial planning, leadership, career development, and many others are not adequately addressed in formalized training. The Surgeons, Scholars, and Leaders Symposium was first held in January 2015 in Jackson Hole, WY, and has subsequently become an annual event. Recurrent themes addressed at the Symposium include global health, resident autonomy, research program development, leadership, mentorship, career development, and managing transitions. The annual Surgeons, Scholars, and Leaders Symposium has been instrumental in addressing these underappreciated aspects of surgeon development and will continue to be an important venue for the next generation of surgical leaders.
Mortality for Open Abdominal Aortic Aneurysm Repair before and after Endovascular Aortic Repair (EVAR)
Authors: Ammar Alex D.
Published: June 2020

The purpose of this study was to determine whether endovascular aortic repair (EVAR) has impacted inhospital mortality for patients undergoing open repair (OR). From 1982 through 2016, 1572 repairs were performed for abdominal aortic aneurysms (AAAs). Both ORs and EVARs were performed by the author at two large, tertiary-care, community-based hospitals. In Period I (1982–1999, n = 863), all AAA repairs were performed open. In Period II (2000–2016; n = 709), repairs were performed both by ORs and EVARs. Demographics were similar between study groups. Mortality for elective repairs in Periods I and II were as follows: I = 1.2 per cent (open, n = 9/756) versus II = 1.7 per cent (open, n = 4/241) versus II = 1.2 per cent (EVAR, n = 5/420). Mortality for patients with ruptured AAAs in Periods I and II were as follows: I = 31.8 per cent (open, n = 34/107) versus II = 32 per cent (open, n = 8/25) versus II = 13 per cent (EVAR, n = 3/23). The results of this study demonstrate that the introduction of EVARs has not negatively impacted the inhospital mortality for elective ORs or emergent AAAs for one vascular surgeon who completed training before EVARs became available.
The Impact of BMI on Adult Blunt Trauma Outcomes
Authors: Barry Rahman , Modarresi Milad , Aguilar Rodrigo , Sanabria Jacqueline , Wolbert Thao , Denning David , Thompson Errington , Sanabria Juan
Published: June 2020

Traumatic injuries account for 10% of all mortalities in the United States. Globally, it is estimated that by the year 2030, 2.2 billion people will be overweight (BMI ≥ 25) and 1.1 billion people will be obese (BMI ≥ 30). Obesity is a known risk factor for suboptimal outcomes in trauma; however, the extent of this impact after blunt trauma remains to be determined. The incidence, prevalence, and mortality rates from blunt trauma by age, gender, cause, BMI, year, and geography were abstracted using datasets from 1) the Global Burden of Disease group 2) the United States Nationwide Inpatient Sample databank 3) two regional Level II trauma centers. Statistical analyses, correlations, and comparisons were made on a global, national, and state level using these databases to determine the impact of BMI on blunt trauma. The incidence of blunt trauma secondary to falls increased at global, national, and state levels during our study period from 1990 to 2015, with a corresponding increase in BMI at all levels ( P < 0.05). Mortality due to fall injuries was higher in obese patients at all levels ( P < 0.05). Analysis from Nationwide Inpatient Sample database demonstrated higher mortality rates for obese patients nationally, both after motor vehicle collisions and mechanical falls ( P < 0.05). In obese and nonobese patients, regional data demonstrated a higher blunt trauma mortality rate of 2.4% versus 1.2%, respectively ( P < 0.05) and a longer hospital length of stay of 4.13 versus 3.26 days, respectively ( P = 0.018). The obesity rate and incidence of blunt trauma secondary to falls are increasing, with a higher mortality rate and longer length of stay in obese blunt trauma patients.
Intraoperative Frozen Section Analysis for the Excision of Nonmelanoma Skin Cancer: A Single-Center Experience
Authors: Bilden Tylert , Benedict Katherine C. , Lamb Patrick W. , Mcmullin Jaron
Published: June 2020

Surgical resection of nonmelanoma skin cancer (NMSC) may be performed via Mohs micrographic surgery (MMS) or standard surgical excision with complete margin analysis. Whereas MMS may necessitate delayed reconstruction surgery, intraoperative frozen section analysis (IFSA) may be used to ensure clear surgical margins before proceeding with reconstruction. To achieve curative resection while optimizing aesthetic outcomes, surgeons may use surgical excision guided by IFSA to forego extensive or delayed reconstruction. Patients undergoing wide local excision for NMSC using IFSA from October 2008 to November 2016 were evaluated. Analysis included IFSA versus permanent section outcomes, the number of required excisions, and the recurrence rate. Our analysis contained 145 patients involving 162 lesions. IFSA demonstrated that 73.4 per cent of margins were negative after one excision and 26.5 per cent were re-excised until achieving negative margins. Analysis revealed one false-positive case (0.62%) and four false-negative cases (2.47%). Nine patients had local recurrence (5.56%). Frozen section sensitivity was 88.99 per cent and specificity 99.20 per cent. The positive predictive value was 96.97 per cent, and negative predictive value was 96.90 per cent. Mean follow-up time was 39 months. Both resection and recurrence data of excised NMSC lesions at our institution suggest that surgical excision using IFSA is a safe and effective alternative to MMS.
From Evidence to Practice: Are Low-Risk Breast Cancer Patients still Enduring Unnecessary Costs of Radiation?
Authors: Thornhill Rosanne , Chang Jenny , Selleck Matthew , Senthil Maheswari , Solomon Naveen , Namm Jukes P. , Garberoglio Carlos A. , Lum Sharon
Published: June 2020

Radiation is routinely recommended after conservative surgery for breast cancer, despite longstanding Level I evidence showing no survival benefit for elderly patients with favorable disease using endocrine therapy. We sought to evaluate radiation use and costs in patients eligible for omission of radiation. A retrospective single-institution review from 2005 to 2017 was performed of women aged ≥70 years, with cT1N0M0, who were ER/PR positive and HER-2 negative, and receiving breast-conserving surgery. Patient, tumor, and treatment characteristics were compared by use of radiation. Cost estimates used Medicare's 2019 fee schedule. Of 84 patients meeting the study criteria, 72.6 per cent received radiation and 56 per cent received endocrine therapy, with four recurrences (4.9% radiated and 4.4% not radiated, P = 0.9). Early and late grade I radiation toxicities occurred in 67.2 per cent and 26.2 per cent of radiated patients, respectively. Younger age ( P = 0.01), receipt of endocrine therapy ( P < 0.0001), and axillary surgery ( P < 0.0001) were significantly associated with radiation use. There were no significant differences in radiation use based on race/ethnicity, language, comorbidities, BMI, or pathologic tumor size. Estimated total radiation cost was $646,426. Radiation remains overused and endocrine therapy, underused in breast cancer patients eligible to avoid radiation. As gatekeepers for radiation oncology referrals, surgeons can diminish both physical and financial costs of radiation in eligible patients.
Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol
Authors: May L. Andrew , Harrell Kevin N. , Bell Christopher M. , Basham-Saif Angela , Barker Donald E. , Maxwell Robert A.
Published: June 2020

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007–2015) or TNCs (2015–2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.
After Elective Sigmoid Colectomy for Diverticulitis, Does Recurrence-Free Mean Symptom-Free?
Authors: Choi Karmina K. , Krautsak Kevin , Martinolich Jessica , Canete Jonathan J. , Valerian Brian T. , Chismark A. David , Lee Edward C.
Published: June 2020

After elective sigmoidectomy for diverticulitis, patients may experience persistent abdominal symptoms. This study aimed to determine the incidence and characteristics of persistent symptoms (PSs) and their risk factors in patients who had no reported recurrence after elective sigmoidectomy. Patients who underwent elective sigmoidectomy for diverticulitis from 2002 to 2016 at a tertiary academic colorectal surgery practice were included. After retrospective review of medical records, patients were contacted with a questionnaire to inquire about recurrence of diverticulitis and persistent abdominal symptoms since resection. Outcomes examined were prevalence of and risk factors for PSs after elective sigmoidectomy. Of 662 included patients, 346 completed the questionnaire and had no recurrent diverticulitis. PSs were reported by 43.9 per cent of the patients. The mean follow-up was 87 months. Female gender and preoperative diagnosis of irritable bowel syndrome were independent risk factors for PSs (Relative Risk 1.65, P < 0.001 and Relative Risk 1.41, P = 0.014). Previous IVantibiotics treatment was associated with PSs ( P = 0.034) but not with a significant risk factor. As the follow-up interval increased, prevalence of PSs decreased ( P = 0.006). More than 40 per cent of patients experienced persistent abdominal symptoms after sigmoidectomy for diverticulitis. Female patients and those with irritable bowel syndrome were at significantly increased risk.
Mark M. Ravitch: A Staple in Surgical History and Innovation
Authors: Abeshouse Marnie , Goldstein Scott , Phillips Benjamin
Published: June 2020

Mark M. Ravitch is a surgeon worth acknowledging. He is credited for revolutionizing pediatric surgery as a subspecialty, mastering chest wall deformities and introducing the surgical stapler to the United States, to name a few. Above all, he was a notable leader, teacher, and author. This historical vingette is a brief snapshot of his biography and various achievements.
Bracketed Radioactive Seed Localization for Breast Conservation Surgery
Authors: Dixon Jordan , Jasra Bharti , Ankola Anita , Sharma Smita , Letter Haley
Published: June 2020

We aimed to evaluate the surgical margin outcomes and re-excision rates in patients undergoing bracketed seed localization of biopsy-proven breast cancer detected on screening mammogram. After approval by our Institutional Review Board, we retrospectively identified patients who had undergone iodine-125 seed localized lumpectomy at our institution from January 2010 to June 2017 by one of two fellowship-trained breast surgeons. Of those patients, a subset of 25 patients were identified who had undergone bracketed seed localization, defined as two or more seeds used to delineate the radiographic borders of the area of concern. All patients had originally presented with calcifications identified on screening mammogram that were subsequently diagnosed as ductal carcinoma in situ and/or invasive ductal carcinoma by image-guided biopsy performed at our institution. Eight patients had one positive margin on final surgical pathology and required re-excision (32%). One patient was converted to mastectomy. Of the patients requiring re-excision, the average maximum linear extent of calcifications was 3.4 cm (SD 0.97), whereas it was 3.1 cm (SD 1.2) in patients with negative surgical margins ( P = 0.5). Bracketing calcifications with radioactive seeds can potentially allow more patients to undergo breast conservation surgery.
Predicting Postthyroidectomy Hypocalcemia: Improving Predictive Ability of Parathyroid Hormone Level
Authors: Strajina Veljko , Dy Benzon M. , Mckenzie Travis J. , Thompson Geoffrey B. , Lyden Melanie L.
Published: June 2020

We performed a retrospective study of our large patient cohort aiming to examine the ability to predict postthyroidectomy hypocalcemia. A retrospective review of patients who underwent total or near-total thyroidectomy at our institution between 2008 and 2018 was performed. Postoperative hypocalcemia was defined as Ca level <8.0 mg/dL (reference range: 8.9–10.1 mg/dL) within 30 days of operation. Logistic regression was used to develop models for prediction of the occurrence of postoperative hypocalcemia. Inclusion criteria were met by 1463 patients. Hypocalcemia was documented in 223 patients (15%). Models based on parathyroid hormone (PTH) levels alone had an associated receiver operator characteristic with an areas under the curve (AUC) of 0.79. There was an inverse relationship between time of measurement and PTH levels within the first two hours after thyroidectomy ( P < 0.01). When measured two to six hours after closure, the predictive ability of PTH compared favorably (AUC = 0.82) with either earlier (within the first two hours after closure, AUC = 0.79) or later measurement (6–24 hours after closure, AUC = 0.77). When measured between two and six hours postoperatively, PTH < 19 pg/mL had a sensitivity of 90 per cent and negative predictive value of 96 per cent for postoperative hypocalcemia. The model that included the PTH level, concurrently measured total blood calcium level, and time of measurement had an improved predictive ability with an AUC of 0.87. PTH level of 19 pg/mL measured two to six hours after thyroidectomy had a sensitivity of 90 per cent and a negative predictive value of 96 per cent in our cohort. The model including postoperative PTH level, calcium level, and time of measurement may further improve the ability to predict postthyroidectomy hypocalcemia.
Factors Associated with Reconstruction in Patients Undergoing Mastectomy
Authors: Huang Julian , Wang Melinda , Chagpar Anees
Published: June 2020

Postmastectomy reconstruction has been shown to be oncologically safe, but few studies have investigated factors influencing the type of reconstruction chosen, if at all. Records of female patients with stages 0 to 3 breast cancer undergoing mastectomy at a large academic institution between January 2010 and March 2018 were reviewed. Nine hundred sixty patients were included in this cohort; 784 patients had reconstruction. Younger age, earlier disease stage, private insurance, no history of diabetes, and bilateral mastectomy (BM) were associated with reconstruction. On multivariate analysis, younger age, BM, private insurance, and earlier disease stage predicted reconstruction. Of reconstruction patients, 453 had implants. Race, BMI, and later disease stage influenced the type of reconstruction; on multivariate analysis, higher BMI and later disease stage predicted flap reconstruction. Younger age, BM, private insurance, and earlier disease stage were associated with reconstruction, but the type of reconstruction was affected primarily by BMI and disease stage.
Health-Care Workers’ Perception of Reimbursement for Complex Surgical Oncology Procedures
Authors: Levi Shoshana , Alberto Emily , Urban Dakota , Petrelli Nicholas , Tiesi Gregory
Published: June 2020

Perception of physician reimbursement for surgical procedures is not well studied. The few existing studies illustrate that patients believe compensation to be higher than in reality. These studies focus on patient perceptions and have not assessed health-care workers’ views. Our study examined health-care workers’ perception of reimbursement for complex surgical oncology procedures. An anonymous online survey was distributed to employees at our cancer center with descriptions and illustrations of three oncology procedures—hepatectomy, gastrectomy, and pancreaticoduodenectomy. Participants estimated the Medicare fee and gave their perceived value of each procedure. Participants recorded their perception of surgeon compensation overall, both before and after revealing the Medicare fee schedule. Most of the 113 participants were physicians (33.6%) and nurses (28.3%). When blinded to the Medicare fee schedules, most felt that reimbursements were too low for all procedures (60–64%) and that surgeons were overall undercompensated (57%). Value predictions for each procedure were discordant from actual Medicare fee schedules, with overestimates up to 374 per cent. After revealing the Medicare fee schedules, 55 per cent of respondents felt that surgeons were undercompensated. Even among health-care workers, a large discrepancy exists between perceived and actual reimbursement. Revealing actual reimbursements did not alter perception on overall surgeon compensation.
Measured versus Estimated Blood Loss: Interim Analysis of a Prospective Quality Improvement Study
Authors: Thomas Samantha , Ghee Lauren , Sill Anne M. , Patel Shirali T. , Kowdley Gopal C. , Cunningham Steven C.
Published: June 2020

Estimated blood loss (EBL) is an increasingly important factor used to predict outcomes, such as morbidity and mortality, length of stay, and readmissions, after major abdominal operations. However, blood loss is difficult to estimate, with frequent under- and overestimations, consequences of which can be potentially dangerous for individual patients and confounding for scoring systems relying on EBL. We hypothesized that EBL is often inaccurate and have pro-spectively enrolled consecutive patients undergoing major elective intra-abdominal operations. Actual hemoglobin levels were measured and used to calculate the measured blood loss (MBL), which was compared with the EBL, as estimated both by surgeons (sEBL) and anesthesiologists (aEBL). Of 23 eligible cases at interim analysis, pancreaticoduodenectomy (n = 8) was the most common, followed by colectomy (n = 3), hepatectomy (n = 3) and gastrectomy (n = 2), biliary excision and reconstruction (n = 2), combined gastrectomy + colectomy (n = 1), radical nephrectomy (n = 1), open cholecystectomy (n = 1), pancreatic debridement (n = 1), and exploratory laparotomy (n = 1). aEBL overestimated MBL by 192 mL (143%) on average. The aEBL was significantly greater than the MBL ( P = 0.004), whereas the sEBL was significantly less than the MBL ( P = 0.009). In conclusion, surgeons significantly underestimate and anesthesiologists significantly overestimate EBL. This finding impacts not only immediate patient care but also the interpretation of scoring systems relying on EBL.
Robotic versus Laparoscopic Sigmoid Colectomy: Analysis of Healthcare Cost and Utilization Project Database
Authors: Alharthi Samer , Reilly Margaret , Arishi Abdulaziz , Ahmed Amin Mohamed , Chulkov Maria , Qu Weikai , Ortiz Jorge , Nazzal Munier , Pannell Stephanie
Published: June 2020

Minimally invasive sigmoid colectomy via the laparoscopic approach (LA) has numerous benefits. We seek to compare outcomes between laparoscopic and robotic sigmoid colectomies. We analyzed the data using the National Inpatient Sample database between 2008 and 2014. Utilization and outcome measures were compared. The seven-year average number of patients who underwent elective sigmoid colectomy in the United States from 2008 to 2014 was estimated to be 197,053. Of these, 95.1 per cent were conducted using the LA. The mean age was 58.33 + 13.6 years and 58.23 + 12.8 years in laparoscopic and robotic approaches, respectively. No significant differences existed in respect to morbidities. Postoperative complications were comparable with respect to other complications. Length of hospital stay was statistically significantly shorter in the robot-assisted approach compared with the LA (mean 4.8 + 4 vs 5.7 + 5 days, respectively, P < 0.001). Patients who underwent robotic surgery had significantly higher total hospital charges than those who underwent laparoscopic surgery (median $45,057 vs $57,871 USD, P < 0.001). The advent of robot-assisted surgery has provided more options for patients and surgeons. Compared with laparoscopy, robot-assisted sigmoid colectomy has no clinical advantages in morbidity and mortality. However, the robotic approach has a significantly higher total charge to the patient.
Is it Rational to Perform Liver Resection for Patients with Intermediate and Advanced Stages of Hepatocellular Carcinoma?
Authors: Tomas Kadir , Oguz Sukru , Topaloglu Serdar , Calik Adnan , Arslan Mehmet , Dinç Hasan , Ozdemir Feyyaz , Kucukaslan Hakan , Cobanoglu Umit , Karabulut Erdem , ÖZtÜRk Mehmet Halil
Published: June 2020

This study aimed to investigate clinical characteristics of hepatocellular carcinoma and the outcome of our aggressive treatment policy which follows the Barcelona Clinic Liver Cancer (BCLC) guidance. In this study, we retrospectively analyzed data of 102 patients who were treated for hepatocellular carcinoma between January 2007 and October 2016. Male predominance (81.4%) and a median age of 61 years were observed. Cirrhosis was evident in 88.2 per cent of patients. Viral hepatitis (77.5%) was the most common underlying etiology. The majority of our patients (71.6%) were in BCLC B and C stages. Liver resection was performed in 53.4 per cent of patients in those stages. Transarterial chemoembolization was the leading interventional treatment. Overall survival rates at three and five years were 75 per cent and 75 per cent in BCLC 0, 69 per cent and 58 per cent in BCLC A, 50 per cent and 41 per cent in BCLC B, and 11 per cent and 11 per cent in BCLC C, respectively. The BCLC treatment algorithm should consider the role of liver resection also for intermediate stages.
Significance of Amylase Monitoring in Peritoneal Drainage Fluid after Splenectomy: A Clinical Analysis of Splenectomy in 167 Patients with Hepatolenticular Degeneration
Authors: Shen Yi , Guo Binbin , Wang Laiyong , Peng Hui , Pan Jinfang , Zhang Qi , Huang Long , Zhou Fuhai , Yu Qingsheng
Published: June 2020

Different kinds of complications after splenectomy in hepatolenticular degeneration patients with hypersplenism have been reported in the past decades, but studies on pancreatic fistula and the corresponding targeted prevention and treatment after splenectomy still remain much unexplored. The present work investigated the pathogenic factors of pancreatic fistula after splenectomy and the variation tendency of amylase in drainage fluid, aiming to verify the significance of monitoring amylase in the abdominal drainage fluid in the early diagnosis of pancreatic fistula after splenectomy. One hundred sixty-seven patients with hepatolenticular degeneration and hypersplenism who underwent splenectomy in the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine from January 2016 to August 2018 were selected and analyzed. The amylase in the abdominal drainage fluid was monitored routinely after splenectomy. We also conducted the statistics on the incidence of different types of pancreatic fistula and analyzed the influence factors of pancreatic fistula formation. After splenectomy, biochemical fistula occurred in 11 patients (6.6%), grade B fistula in six patients (3.6%), grade C fistula in one patient (0.6%), and the incidence of pancreatic fistula was 4.2 per cent (biochemical fistula excluded). The amylase in the peritoneal drainage fluid was closely concerned with the incidence of pancreatic fistula according to our statistics. Furthermore, by analyzing the different influence factors of pancreatic fistula, Child-Pugh grading of liver function ( P = 0.041), pancreatic texture ( P = 0.029), degree of splenomegaly ( P = 0.003), and operative method ( P = 0.001) were supposed to be closely related to the formation of pancreatic fistula. Monitoring of amylase in peritoneal drainage fluid is regarded as an important physiological parameter in the early diagnosis of pancreatic fistula after splenectomy, which provides effective clinical reference and plays a significant role in preventing the occurrence and development of pancreatic fistula.
Early Anti-Xa Assay-Guided Low Molecular Weight Heparin Chemoprophylaxis is Safe in Adult Patients with Acute Traumatic Brain Injury
Authors: Rodier Simon G. , Kim Mirhee , Moore Samantha , Frangos Spiros G. , Tandon Manish , Klein Michael J. , Berry Cherisse D. , Huang Paul P. , Dimaggio Charles J. , Bukur Marko
Published: June 2020

This study evaluated the safety of early anti-factor Xa assay–guided enoxaparin dosing for chemoprophylaxis in patients with TBI. We hypothesized that assay-guided chemoprophylaxis would be comparable in the risk of intracranial hemorrhage (ICH) progression to fixed dosing. An observational analysis of adult patients with blunt traumatic brain injury (TBI) was performed at a Level I trauma center from August 2016 to September 2017. Patients in the assay-guided group were treated with an initial enoxaparin dose of 0.5 mg/kg, with peak anti-factor Xa activity measured four hours after the third dose. Prophylactic range was defined as 0.2 to 0.5 IU/mL with a dose adjustment of ± 10 mg based on the assay result. The assay-guided group was compared with historical fixed-dose controls and to a TBI cohort from the most recent Trauma Quality Improvement Project dataset. Of 179 patients included in the study, 85 were in the assay-guided group and 94 were in the fixed-dose group. Compared with the fixed-dose group, the assay-guided group had a lower Glasgow Coma Score and higher Injury Severity Score. The proportion of severe (Abbreviated Injury Score, head ≥3) TBI, ICH progression, and venous thromboembolism rates were similar between all groups. The assay-guided and fixed-dose groups had chemoprophylaxis initiated earlier than the Trauma Quality Improvement Project group. The assay-guided group had the highest percentage of low molecular weight heparin use. Early initiation of enoxaparin anti-factor Xa assay–guided venous thromboembolism chemoprophylaxis has a comparable risk of ICH progression to fixed dosing in patients with TBI. These findings should be validated prospectively in a multicenter study.
Meta-analysis on the Effect of Pasireotide for Prevention of Postoperative Pancreatic Fistula
Authors: Dalton Elissa C. , Johns Michael S. , Rhodes Lori , Merritt William T. , Petrelli Nicholas J. , Tiesi Gregory G.
Published: June 2020

Background

A randomized controlled trial (RCT) of routine administration of pasireotide demonstrated decreased incidence of clinically significant postoperative pancreatic fistula (POPF). Recent studies have not replicated these results. A meta-analysis was performed to evaluate its efficacy in this setting.

Methods

Prospective trials utilizing pasireotide prophylactically after pancreatectomy were reviewed. The primary outcome was clinically significant POPF. Secondary outcomes included length of stay (LOS), readmission rates, and mortality. Study heterogeneity was assessed.

Results

Five studies totaling 1571 patients were identified. There was no difference in age, sex, or cancer rates. Pasireotide patients had smaller pancreatic ducts ( P ≤.001) and softer glands ( P = .04). For all pancreatectomies, there was no difference in POPF rates (OR 0.84; 95% CI 0.60-1.16, P = .29). Patients undergoing distal pancreatectomy (OR 0.70; 95% CI 0.30-1.63, P = .41) had similar rates of POPF versus pancreaticoduodenectomy (PD) patients that experienced a lower incidence of POPF (OR 0.60; 95% CI 0.42-0.86, P = .006). Mortality rates and LOS were similar. Readmission rates were decreased with pasireotide (OR 0.61; 95% CI 0.44-0.85).

Conclusions

Routine administration of pasireotide did not decrease POPF rates for all pancreatectomies, but was associated with lower rates for PD and decreased readmission rates. Further prospective, randomized studies are warranted.
Racial Disparities at Mixed-Race and Minority Hospitals: Treatment of African American Males With High-Grade Splenic Injuries
Authors: Tignanelli Christopher J. , Watarai Bradly , Fan Yunhua , Petersen Ashley , Hemmila Mark , Napolitano Lena , Jarosek Stephanie , Charles Anthony
Published: June 2020

Introduction

Racial and socioeconomic disparities in health access and outcomes for many conditions are well known. However, for time-sensitive high-acuity diseases such as traumatic injuries, disparities in access and outcomes should be significantly diminished. Our primary objective was to characterize racial disparities across majority, mixed-race, and minority hospitals for African American (AA) versus white males with high-grade splenic injuries.

Methods

Data from the National Trauma Data Bank was utilized from 2007 to 2015. A total of 24 855 AA or white males with high-grade splenic injuries were included. Multilevel mixed effects regression analysis was used to evaluate disparities in outcomes and resource allocation.

Results

Mortality was significantly higher for AA males at mixed-race (odds ratio [OR] 1.6; 95% CI 1.3-2.1; P < .001) and minority (OR 2.1; 95% CI 1.5-3.0; P < .001) hospitals, but not at majority hospitals. At minority hospitals, AA males were significantly less likely to be admitted to the intensive care unit (OR 0.7; 95% CI 0.49-0.97; P = .04) and experienced a significantly longer time to surgery (IRR 1.5; P = .02). Minority hospitals were significantly more likely to have failures from angiographic embolization requiring operative intervention (OR 2.2; P = .009). At both types of nonmajority hospitals, AA males with penetrating injuries were more likely to be managed with angiography (mixed-race hospitals: OR 1.7; P = .046 vs minority hospitals: OR 1.6; P = .08).

Discussion

While multiple studies have shown that minority hospitals have increased mortality compared to majority hospitals, this study found this disparity only existed for AAs.
Efforts to Improve Appropriate Trauma Activation for Patients Transferred to a Level 1 Trauma Center From Outside Hospitals
Authors: Seegert Sara , Redfern Roberta E. , Chapman Bethany , Benson Daniel
Published: June 2020

Trauma centers monitor under- and overtriage rates to comply with American College of Surgeons Committee on Trauma verification requirements. Efforts to maintain acceptable rates are often undertaken as part of quality assurance. The purpose of this project was to improve the institutional undertriage rate by focusing on appropriately triaging patients transferred from outside hospitals (OSHs). Trauma physicians received education and pocket cards outlining injury severity score (ISS) calculation to aid in prospectively estimating ISS for patients transferred from OSHs, and activate the trauma response expected for that score. Under- and overtriage rates before and after the intervention were compared. The postintervention period saw a significant decrease in overall overtriage rate, with simultaneous trend toward lower overall undertriage rate, attributable to the significant reduction in undertriage rate of patients transferred from OSHs. Prospectively estimating ISS to assist in determining trauma activation level shows promise in managing appropriate patient triage. However, questions arose regarding the necessity for full trauma activation for transferred patients, regardless of ISS. It may be necessary to reconsider how patients transferred from OSHs are evaluated. Full trauma activation can be a financial and resource burden, and should not be taken lightly.
A Dinucleotide Deletion in the CD24 Gene Is a Potential Risk Factor for Colorectal Cancer
Authors: Segev Lior , Naboishchikov Ilana , Kazanov Diana , Bernstein Ezra , Shaked Meital , Arber Nadir , Shapira Shiran
Published: June 2020

Background

CD24 is a sialoglycoprotein anchored to the cell surface via glycosylphosphatidylinositol and is involved in intracellular signaling processes. It plays an important role in the early stages of the multistep process of colorectal carcinogenesis. Several single nucleotide polymorphisms in the CD24 gene are reported to exert a diverse effect on cancer risk. We aimed to elucidate whether CD24 TG/del genetic variants are associated with susceptibility to colorectal cancer (CRC).

Methods

The study included 179 subjects, 36 with CRC (prior to surgery) and 143 healthy control subjects. Deoxyribonucleic acid was purified from peripheral blood leukocytes, and by using restriction fragment length polymorphism analysis, the CD24 gene was genotyped for the specific genetic variant, TG deletion. Additionally, CD24 protein expression levels were determined by Western blotting analysis.

Results

The incidence of the TG/del was higher among the CRC patients compared with healthy controls, 14% and 10%, respectively ( P = .54). CD24 protein levels were significantly higher among CRC patients. There were no significant differences in CD24 expression between CRC patients at different stages of the disease or between patients who carry the mutation and those who did not.

Conclusions

CD24 genetic variant might be of clinical value for risk assessment as part of cancer prevention programs. Further study on larger populations is needed to validate the importance of this dinucleotide deletion in CRC development. Overexpression of CD24 protein occurs early along the multistep process of CRC carcinogenesis, and a simple blood sample based on CD24 expression on peripheral blood leukocytes can contribute to early diagnosis.
Peripheral Vascular Function in Dilated Cardiomyopathy of Different Etiology
Authors: Bosso Giorgio , Valvano Antonio , Apuzzi Valentina , Mercurio Valentina , Di Simone Valeria , Cittadini Antonio , Napoli Raffaele , Oliviero Ugo
Published: June 2020

Vascular function in dilated cardiomyopathy of different etiology has been poorly investigated. Moreover, reference values of flow-mediated dilation (FMD) in chronic heart failure (CHF) need to be updated according to the new standardized protocols. We characterized the vascular impairment in different stages of post-ischemic dilated cardiomyopathy (PI-DC) or idiopathic dilated cardiomyopathy (I-DC). Eighty consecutive outpatients with CHF in different New York Heart Association (NYHA) classes (45 PI-DC, 35 I-DC) and 50 control subjects underwent FMD and brachial distensibility coefficient measurement. Patients with CHF showed a marked impairment in FMD compared with controls that worsened from classes NYHA I-II to III-IV, independently of etiology ( P < .05). New York Heart Association I-II PI-DC patients showed a worse FMD compared with NYHA I-II I-DC patients ( P < .05). Brachial distensibility coefficient values were significantly lower in patients with CHF compared with controls ( P < .001) without differences between PI-DC and I-DC. In conclusion, advanced CHF is characterized by vascular impairment that is independent of etiology. In the early stages of CHF, endothelial dysfunction is more severe in patients with PI-DC compared with I-DC probably due to the high cardiovascular risk profile. In I-DC, vascular function impairment is independent of cardiovascular risk factors and could participate in the pathogenesis of I-DC.
The Effect of Ibuprofen Dosing Interval on Post-Tonsillectomy Outcomes in Children: A Quality Improvement Study
Authors: Mast Grayson , Henderson Krysta , Carr Michele M.
Published: June 2020

Objective:

In this Quality Improvement (QI project) it was hypothesized that an increase in dosing intervals for postoperative analgesia when alternating Ibuprofen and Acetaminophen would reduce post-tonsillectomy hemorrhage (PTH) rates for those undergoing tonsillectomies with or without adenoidectomy, while maintaining the standard of postoperative analgesia and reducing visits to the Emergency Room (ER) for reasons other than PTH. Data was collected from 353 children. Utilizing run chart analysis, it was determined that patients experiencing the 4-hour dosing interval had lower rates of PTH, fewer ER visits, and no increase in postoperative phone calls from caregivers.

Patients and Methods:

Patients were treated with standing Acetaminophen 15 mg/kg q6h and Ibuprofen 10 mg/kg q6h for postoperative analgesia from July of 2017 until January of 2018. Starting January of 2018 through November of 2018, the dosage interval was lengthened 1 hour. Data relating to PTH, ER visits for reasons other than bleeding, and phone calls from caregivers was collected.

Results:

Run charts were used to assess outcomes regarding PTH, postoperative visits to the ER for reasons other than PTH, and phone calls from caregivers. Our results suggest that a standing protocol of alternating Acetaminophen and Ibuprofen given every 4 hours improves the post-tonsillectomy hemorrhage rate without increasing ER visits or calls about pain.

Conclusions:

This data shows promise in reducing PTH and ER visits with a longer dose interval when alternating Acetaminophen and Ibuprofen for postoperative analgesia in tonsillectomy patients. A randomized clinical trial should be carried out to further validate these claims.
Claude Lefort as interpreter of Machiavellian social conflict
Authors: Alagna Luana M
Published: June 2020

Claude Lefort, French philosopher and activist, exponent of the anti-totalitarian moment in France, has developed an original theoretical proposal on democracy and totalitarianism. When he distanced himself from the creed of the proletarian revolution as an instrument of understanding of human action, he focused on the understanding of the political as a space in which the social emerges, in which it takes shape. The idea that society acquired a unity through the revolutionary project was overturned by the knowledge that the social cannot be contained; it cannot be the object of appropriation and unification through action or knowledge without threatening freedom and the existence of society itself. Democratic political society can only be heterogeneous, in which the conflict cannot be resolved precisely because the various interests in society are irreducible and asymmetrical. Machiavelli, in the Lefortian thinking, had identified the sense of the political at the beginning of his institution, in which the division and disagreement between classes are the foundation of social relations. This view is opposed to the classical conception of dissent as a moment of collision between passions and reason, where the disorder compromises the political structure. Social conflict indeed is an irreducible resource for the existence of human relations, public space and political society. In the clash between two realisms, Lefort shelved the Marxist one to deepen the turmoil of the ‘divine Machiavelli’, replacing in his theoretical vision the Machiavellian idea of the political as a social dimension to the Marxist dominance of the production forces; the political is the way in which society represents its legitimacy and presupposes conflict as inescapable, a way to guarantee political freedom. Plurality and irrepressible diversity will be instruments for guaranteeing democracy.
The Interaction Between Rosuvastatin and Ticagrelor Leading to Rhabdomyolysis: A Case Report and Narrative Review
Authors: Sibley Rachel A. , Katz Alyson , Papadopoulos John
Published: June 2020

Objective

Drug interactions are a common cause of morbidity and mortality and may require prompt discontinuation of therapeutic regimens due to harmful side effects. Patients with acute coronary syndromes are likely to be prescribed multiple medications that are metabolized through the cytochrome P450 system, increasing the probability for drug interaction. Atorvastatin and simvastatin are both well known to interact with the oral P2Y12 agent ticagrelor. The purpose of this paper is to describe the interaction of ticagrelor with rosuvastatin leading to rhabdomyolysis, which is less clearly defined in the literature.

Method

We report a case of a 74-year-old male who presented with bilateral lower extremity weakness and difficulty ambulating for one month after being prescribed ticagrelor for a drug eluting stent, in the setting of already being on rosuvastatin. His clinical picture and laboratory findings were consistent with a diagnosis of rhabdomyolysis. His medications were adjusted to a regimen of clopidogrel and alirocumab. One month later, he returned to his baseline status.

Results

The mechanism of interaction between rosuvastatin and ticagrelor appears to be multifactorial. It may be caused by CYP450-mediated metabolism from a small amount of crossover between isoenzymes. Ticagrelor may also cause acute kidney injury, increasing the concentration of rosuvastatin. Other mechanisms of interaction include genetic differences in the organic anion transporter polypeptides and transportation through p-glycoprotein.

Conclusion

Future pharmacokinetic studies are warranted to better understand the interaction.
Autophagy
Authors: Peterson Victor
Published: June 2020

What follows is a proof as to why, at its origin, the articulation of any doctrine of racial supremacy harbors an internal contradiction. The notion of racial supremacy suffers from its own predicament for, by its inconsistency, Whites cannot be “White.” This proof has the added benefit of illustrating that it is precisely because of the unattainability of “White”-ness that there is so much animosity. This essay’s framework explains why this animosity is externalized toward those, who by the terms of that system, and by name alone, are barred access to this transcendent category—transcendent, thus, not of this world. With outstretched hands, attempts to enact supremacist notions in the world make for a hell of definitions. White is somehow defined as a noncolor color that has no means of defining or justifying itself, save by or through others. As such, its distinction from others falls apart, devouring itself by the very terms of its articulation.
Toward postmigrant realities in Leila Aboulela’s Elsewhere, Home
Authors: Englund Lena
Published: June 2020

The number of migration narratives published in recent years in the form of short stories, novels, poetry, and nonfiction has been considerable, particularly by writers connected with the African continent. Previous studies on this body of work have included investigations of identity and otherness, transnational connections, and cosmopolitan aspirations. Despite this abundance of perspectives on the literature, there have also been urgent calls for new ways of theorizing migration (Fasselt, 2019; Kraler, 2011; Edmunds, 2006). Postmigration is just such an intervention, a concept that aims to go beyond previous meanings of migrant and migration, to critique instances of othering and the gap between the margins and the majority society (Römhild, 2017), and to focus explicitly on trajectories relating to the future. Postmigration, as outlined by Roger Bromley (2017: 39), is not a concept solely tied to temporal distinctions, but is also ideological in its attempts to construct “a new set of emergent spaces of plurality”. The present article argues that Leila Aboulela’s short story collection Elsewhere, Home (2018) manifests such spaces, particularly through its representations and negotiations of gender, family practices, generation, and religious belief and practice. My analysis shows that Aboulela subverts tropes regarding gendered and religious identity and mobility. Elsewhere, Home is no longer primarily occupied with the displacement of individual characters but moves toward seeing migration as interaction and participation instead of integration (Moslund and Petersen, 2019), and as transcultural (Petersen and Schramm, 2017) instead of transnational.