bluuebunny/crossref_metadata_2025 huggingface dataset:
Predicting Intensive Care Delirium with Machine Learning: Model Development and External Validation
Authors: Gong Kirby D. , Lu Ryan , Bergamaschi Teya S. , Sanyal Akaash , Guo Joanna , Kim Han B. , Nguyen Hieu T. , Greenstein Joseph L. , Winslow Raimond L. , Stevens Robert D.
Published: December 2022

Background

Delirium poses significant risks to patients, but countermeasures can be taken to mitigate negative outcomes. Accurately forecasting delirium in intensive care unit (ICU) patients could guide proactive intervention. Our primary objective was to predict ICU delirium by applying machine learning to clinical and physiologic data routinely collected in electronic health records.

Methods

Two prediction models were trained and tested using a multicenter database (years of data collection 2014 to 2015), and externally validated on two single-center databases (2001 to 2012 and 2008 to 2019). The primary outcome variable was delirium defined as a positive Confusion Assessment Method for the ICU screen, or an Intensive Care Delirium Screening Checklist of 4 or greater. The first model, named “24-hour model,” used data from the 24 h after ICU admission to predict delirium any time afterward. The second model designated “dynamic model,” predicted the onset of delirium up to 12 h in advance. Model performance was compared with a widely cited reference model.

Results

For the 24-h model, delirium was identified in 2,536 of 18,305 (13.9%), 768 of 5,299 (14.5%), and 5,955 of 36,194 (11.9%) of patient stays, respectively, in the development sample and two validation samples. For the 12-h lead time dynamic model, delirium was identified in 3,791 of 22,234 (17.0%), 994 of 6,166 (16.1%), and 5,955 of 28,440 (20.9%) patient stays, respectively. Mean area under the receiver operating characteristics curve (AUC) (95% CI) for the first 24-h model was 0.785 (0.769 to 0.801), significantly higher than the modified reference model with AUC of 0.730 (0.704 to 0.757). The dynamic model had a mean AUC of 0.845 (0.831 to 0.859) when predicting delirium 12 h in advance. Calibration was similar in both models (mean Brier Score [95% CI] 0.102 [0.097 to 0.108] and 0.111 [0.106 to 0.116]). Model discrimination and calibration were maintained when tested on the validation datasets.

Conclusions

Machine learning models trained with routinely collected electronic health record data accurately predict ICU delirium, supporting dynamic time-sensitive forecasting.

Editor’s Perspective

What We Already Know about This Topic

What This Manuscript Tells Us That Is New
Distal Radial Access: Is There a Clinical Benefit?
Authors: Korotkikh A. V. , Babunashvili A. M. , Kazantsev A. N. , Annaev Z. S.
Published: December 2022

For decades, the femoral artery has been the most common vascular access for diagnostic and therapeutic endovascular procedures. However, over the past 20 years, radial access has been gaining popularity, as it is a safer and allows practical access with more benefits. Recently, the new distal radial access has proven to be an equal or perhaps even safer vascular access for diagnostic and therapeutic coronary and noncoronary interventions. Today, this access should be in the arsenal of every interventional surgeon.
Improved Prediction of Surgical Site Infection after Colorectal Surgery Using Machine Learning
Authors: Chen Kevin A. , Joisa Chinmaya U. , Stem Jonathan , Guillem Jose G. , Gomez Shawn M. , Kapadia Muneera R.
Published: December 2022

BACKGROUND:

Surgical site infection is a source of significant morbidity after colorectal surgery. Previous efforts to develop models that predict surgical site infection have had limited accuracy. Machine learning has shown promise in predicting post-operative outcomes by identifying non-linear patterns within large datasets.

OBJECTIVE:

We sought to use machine learning to develop a more accurate predictive model for colorectal surgical site infections.

DESIGN:

Patients who underwent colorectal surgery were identified in the American College of Surgeons National Quality Improvement Program database from years 2012-2019 and were split into training, validation, and test sets. Machine learning techniques included random forest, gradient boosting, and artificial neural network. A logistic regression model was also created. Model performance was assessed using area under the receiver operating characteristic curve.

SETTINGS:

A national, multicenter dataset.

PATIENTS:

Patients who underwent colorectal surgery.

MAIN OUTCOME MEASURES:

The primary outcome (surgical site infection) included patients who experienced superficial, deep, or organ-space surgical site infections.

RESULTS:

The dataset included 275,152 patients after application of exclusion criteria. 10.7% of patients experienced a surgical site infection. Artificial neural network showed the best performance with area under the receiver operating characteristic curve of 0.769 (95% CI 0.762 - 0.777), compared with 0.766 (95% CI 0.759 - 0.774) for gradient boosting, 0.764 (95% CI 0.756 - 0.772) for random forest, and 0.677 (95% CI 0.669 - 0.685) for logistic regression. For the artificial neural network model, the strongest predictors of surgical site infection were organ-space surgical site infection present at time of surgery, operative time, oral antibiotic bowel prep, and surgical approach.

LIMITATIONS:

Local institutional validation was not performed.

CONCLUSIONS:

Machine learning techniques predict colorectal surgical site infections with higher accuracy than logistic regression. These techniques may be used to identify patients at increased risk and to target preventative interventions for surgical site infection. See Video Abstract at http://links.lww.com/DCR/C88.
Single Port Endorobotic Rectal Mucosa Harvest For Urethral Reconstruction
Authors: Ozgur Ilker , Justiniano Carla F. , Wood Hadley M. , Gorgun Emre
Published: December 2022

BACKGROUND:

Colorectal mucosal grafts for substitution urethroplasty are alternatives for patients when buccal mucosa is not adequate for long urethral strictures.

IMPACT OF INNOVATION:

To presents the first cases of single port endorobotic rectal mucosa harvesting for urethral reconstruction.

TECHNOLOGY MATERIALS AND METHODS:

The patients are 43- and 57-year-old males with medical histories of lichen sclerosis. The urethrograms demonstrated panurethral strictures requiring long mucosal grafts. The single-port robot was docked under general anesthesia in modified lithotomy position. The procedure began with submucosal injection of lifting agent. After achieving an adequate lift of the mucosa, the dissection was started 2 cm proximal to the sphincter complex with a hook and continued cephalad. The semi-flexible robotic platform eased and facilitated the dissection providing the required traction and counter-traction. The injecting needle and aspiration device were directed with the help of a silk knot at the tip of the tools to create a handle for robot arms. The procedure was continued with a spatula tip thinner than the hook, which delivers less energy to the dissection field and creates a precise cut. The harvested graft was provided to the urology team after pinning it for measurement. The urologists prepared and completed the reconstruction of the urethra with the autograft.

PRELIMINARY RESULTS:

The patient had no complications related to his rectal mucosa harvest.

CONCLUSIONS:

We report the first two cases of single port robotic rectal mucosal harvesting for long panurethral strictures with single port endorobotic submucosal dissection technique.

FUTURE DIRECTIONS:

The technique seems promising to facilitate the precise submucosal dissection with meticulous control of traction and delivered energy.
Durable Response Seen in Patients With Refractory Fistulizing Perianal Crohn’s Disease Using Autologous Mesenchymal Stem Cells on a Dissolvable Matrix: Results from the Phase I Stem Cell on Matrix Plug (STOMP) Trial
Authors: Dozois Eric J. , Lightner Amy L. , Dietz Allan B. , Fletcher Joel G. , Lee Yong S. , Friton Jessica J. , Faubion William A.
Published: December 2022

BACKGROUND:

Refractory perianal Crohn’s disease remains notoriously difficult to treat. We developed a novel technology using a commercially available bioabsorbable fistula plug to deliver autologous adipose derived mesenchymal stem cells.

OBJECTIVE:

Assess therapeutic safety and feasibility in the completed STOMP trial.

DESIGN:

Prospective single-arm phase I clinical trial.

SETTING:

Tertiary academic medical center.

PATIENTS:

Adults (18-65) with complex single tract Crohn’s disease perianal fistula who have failed conventional therapy.

INTERVENTION:

Autologous adipose derived mesenchymal stem cells were isolated, ex vivo culture-expanded, and seeded onto a commercially available bioabsorbable fistula plug. Six weeks later, patients returned to the operating room for removal of the seton and placement of the stem cell-loaded plug.

MAIN OUTCOME MEASURES:

Patients were followed for a total of 8 visits through 12 months. Safety was the primary endpoint; clinical healing and MRI response were secondary endpoints.

RESULTS:

Twenty patients (12 female, mean age 36 years) were treated with the stem cell-loaded plug. Of the 20 patients enrolled, three were not included in the 12 month analysis due to study withdrawal. Through 12 months, no patient experienced a serious adverse event related to the stem cell-loaded plug. Four patients experienced 7 serious adverse events and 12 patients experienced 22 adverse events. Complete clinical healing occurred in 14 of 18 patients at 6 months and 13 of 17 patients at 12 months. MRI response was observed in 12 of 18 patients at 6 months.

LIMITATIONS:

The main limitations are the small sample size and restrictive inclusion criteria.

CONCLUSIONS:

A stem cell-loaded plug can safely and effectively deliver cell-based therapy for patients with single tract fistulizing perianal Crohn’s disease. See Video Abstract at http://links.lww.com/DCR/C70.
Re-do Continent Ileostomy in Inflammatory Bowel Disease Patients: Valuable Lessons Learned Over 25 years
Authors: Duraes Leonardo C. , Holubar Stefan D. , Lipman Jeremy M , Hull Tracy L. , Lightner Amy L. , Lavryk Olga A. , Kanters Arielle E. , Steele Scott R.
Published: December 2022

BACKGROUND:

Inflammatory bowel disease patients with continent ileostomies may require revision surgeries. There remains a paucity of data regarding outcomes after re-do continent ileostomy.

OBJECTIVE:

Evaluate the outcomes following re-do continent ileostomy.

DESIGN:

Retrospective cohort study.

SETTINGS:

High volume, specialized colorectal surgery department.

PATIENTS:

We identified patients who underwent re-do continent ileostomy (defined as neo-pouch construction or major operations changing the pouch configuration) for inflammatory bowel disease between 1994 and 2020.

MAIN OUTCOME MEASURES:

Patient demographics, short- and long-term outcomes, and quality-of-life.

RESULTS:

A total of 168 patients met inclusion criteria; 102 (61%) were female, the mean age was 51 years (±13.1), and the mean BMI was 24.4 (±3.9). The median time between primary and re-do continent ileostomy was 16.8 years. One hundred twenty-two patients (73%) who underwent re-do surgery had ulcerative colitis, 36 (21%) had Crohn's disease, and 10 (6%) had indeterminate colitis. Slipped nipple valve and valve stricture were the most common indications for re-do continent ileostomy (86%). After a median follow-up of 4 years, 48 (29%) patients required a subsequent reoperation, and 27 (16%) had pouch failure requiring pouch excision. The pouch survival rate was 89% at 3 years, 84% at 5 years, and 79% at 10 years. On univariate analysis, a shorter time interval between the primary and re-do continent ileostomy was associated with long-term pouch failure (p = 0.003). Cox regression multivariate analysis confirmed that shorter interval between surgeries was independently associated with pouch failure (p = 0.014). The mean Global Quality-of-Life score was 0.61 (± 0.23) among the 70 patients who responded to the questionnaire.

LIMITATIONS:

Retrospective, single-center study. Low response rate for Quality-of-Life questionnaire.

CONCLUSION:

Re-do continent ileostomy surgery is associated with long-term pouch retention rate of 79% and satisfactory quality-of-life. Therefore, re-do surgery should be offered to patients who are motivated to keep their continent ileostomy. See Video Abstract at http://links.lww.com/DCR/C87.
Benefits of Healthcare Technology Management Input in Medical Product Safety Network Reports
Authors: Brown Cedric , Waheed Saphia
Published: December 2022

Healthcare technology management professionals play an important role in reporting medical device adverse events to the Food and Drug Administration by helping to identify and report device concerns, providing critical context to medical device reports, and mitigating safety concerns. The expert opinions and insights shared by healthcare technology management professionals are beneficial to the Food and Drug Administration and help the agency mitigate device-related problems and improve patient safety. This article is a case study that discusses how a medical device report involving infusion pump controllers was submitted to the Food and Drug Administration's Medical Product Safety Network reporting program and contributed to a voluntary class I recall affecting more than 800,000 devices nationwide. The details and context provided in the medical device report by the reporting team helped inform the investigation into, and resolution of, a device safety concern.
Normative reference values for Obstacles Test and Curb Test and their correlation with demographic characteristics: a cross-sectional study in Saudi children
Authors: Almass Banan A. , Algabbani Maha F. , Shaheen Afaf A.M. , Alqabbani Samiah
Published: December 2022

The Obstacles Test and Curb Test have been used to measure gait speed and functional balance in adults. Recently, they have been modified for use in children but the normative values have not been established. This requires correlating the sex, age, height, weight, and BMI% of children with the test results and developing prediction equations. In this cross-sectional study, the Obstacles Test and Curb Test were administered to a convenience sample of 240 typically developing children aged 6–11 years. The factors associated with the time to complete each test were studied and prediction equations were established. The completion times were 5.27 ± 0.81 s for the Obstacles Test and 2.82 ± 0.45 s for the Curb Test. The Obstacles Test showed a fair negative relationship with height (Pearson’s r = −0.41, P < 0.001), age (r = −0.35, P < 0.001), and weight (r = −0.32, P < 0.05). The Curb Test also had fair negative correlations with height (r = −0.42, P < 0.001), age (r = −0.39, P < 0.001), and weight (r = −0.31, P < 0.001). Both tests showed poor correlations with the sex [eta (η) = 0.15 and 0.12, respectively]. Nonetheless, age and sex emerged as the main predictors of both test scores, accounting for 14% and 17% of the total variance in the Obstacles Test and Curb Test times, respectively. Normative values and prediction equations for both tests in typically developing children may be used for individual comparisons and in clinical research for the evaluation of interventions targeting disabled children.
Walking Endurance and Oxygen Uptake On-Kinetics in Individuals With Parkinson Disease Following Overground Locomotor Training
Authors: Pechstein Andrew E. , Gollie Jared M. , Keyser Randall E. , Guccione Andrew A.
Published: December 2022

Background and Purpose:

Poor walking endurance in Parkinson disease (PD) may be attributable to both bioenergetic and biomechanical factors, but locomotor training methods addressing both these factors simultaneously are understudied. Our objective was to examine the effects of overground locomotor training (OLT) on walking endurance in individuals with mild-to-moderate PD, and to further explore potential cardiorespiratory contributions.

Methods:

A single-arm, longitudinal design was used to examine the effects of 24 biweekly sessions of OLT in people with mild-to-moderate PD (n = 12). Walking endurance was measured as total distance walked during a 10-minute walk test (10minWT). Oxygen uptake (V˙o
2) on-kinetic profiles were determined using a monoexponential function. Perceived fatigability was assessed following the 10minWT using a self-report scale. Magnitude of change in primary outcomes was assessed using Cohen's d and adjusted for sample size (Cohen's d
(unbiased)).

Results:

Participants executed 3036 (297) steps and maintained 65.5% (8%) age-predicted heart rate maximum in a typical session lasting 56.9 (2.5) minutes. Medium effects in total distance walked—885.9 (157.2) versus 969.5 (140.9); Cohen's d
(unbiased) = 0.54—and phase II time constant of the V˙o
2 on-kinetic profile—33.7 (12.3) versus 25.9 (15.3); Cohen's d
(unbiased) = 0.54—were observed alongside trivial effects for perceived fatigability—4.7 (1.4) versus 4.8 (1.5); Cohen's d
(unbiased) = 0.11—following OLT.

Discussion and Conclusions:

These preliminary findings may demonstrate the potential for moderate-intensity OLT to improve walking endurance and enhance cardiorespiratory adjustments to walking activity in adults with mild-to-moderate PD.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A407).
A Hybrid Assessment of Clinical Mobility Test Items for Evaluating Individuals With Mild Traumatic Brain Injury
Authors: Fino Peter C. , Michielutti Patrick G. , Pelo Ryan , Parrington Lucy , Dibble Leland E. , Hoppes Carrie W. , Lester Mark E. , Weightman Margaret M. , King Laurie A.
Published: December 2022

Background and Purpose:

The Functional Gait Assessment (FGA) and High Level Mobility Assessment Tool (HiMAT) are clinical batteries used to assess people with mild traumatic brain injury (mTBI). However, neither assessment was specifically developed for people with mTBI; the FGA was developed to evaluate vestibular deficits, and the HiMAT was developed for individuals with more severe TBI. To maximize the sensitivity and reduce the time burden of these assessments, the purpose of this study was to determine the combination of FGA and HiMAT items that best discriminates persons with persistent symptoms from mTBI from healthy controls.

Methods:

Fifty-three symptomatic civilians with persistent symptoms from mTBI (21% male, aged 31 (9.5) years, 328 [267] days since concussion) and 57 healthy adults (28% male, aged 32 (9.6) years) participated across 3 sites. The FGA and HiMAT were evaluated sequentially as part of a larger study. To determine the best combination of items, a lasso-based generalized linear model (glm) was fit to all data.

Results:

The area under the curve (AUC) for FGA and HiMAT total scores was 0.68 and 0.66, respectively. Lasso regression selected 4 items, including FGA Gait with Horizontal Head Turns and with Pivot Turn, and HiMAT Fast Forward and Backward Walk, and yielded an AUC (95% confidence interval) of 0.71 (0.61-0.79) using standard scoring.

Discussion and Conclusions:

The results provide initial evidence supporting a reduced, 4-Item Hybrid Assessment of Mobility for mTBI (HAM-4-mTBI) for monitoring individuals with mTBI. Future work should validate the HAM-4-mTBI and investigate its utility for tracking progression throughout rehabilitation.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A409).
Diagnostic Discrepancies in Small-volume Biopsy for the Initial Diagnosis, Recurrence, and Transformation of Follicular Lymphoma
Authors: Volaric Ashley K. , Lin Oscar , Balassanian Ronald , Cook Stephen , Falchi Lorenzo , Fitzpatrick Megan J. , Frank Annabel K. , Gupta Srishti , Hasserjian Robert P. , Long Steven , Ly Amy , Menke Joshua R. , Mou Eric , Natkunam Yasodha , Reed Daniel R. , Ruiz-Cordero Roberto , Wang Linlin , Wen Kwun Wah , Xie Yi , Zadeh Sara L. , Gratzinger Dita ,   the Cyto-Heme Institutional Collaborative (CHIC) Consortium
Published: December 2022

Small-volume biopsies (SVBs) including fine-needle aspiration (FNA), cell block, and needle core biopsies (NCB) are increasingly utilized to diagnose and guide the clinical management of lymphoma. We established a multi-institutional interdisciplinary collaboration of cytopathologists, hematopathologists, and oncologists focused on the role of SVB in the management of patients with follicular lymphoma (FL). To assess the performance characteristics of SVB in this setting, we evaluated all consecutive SVBs performed for clinical indications of initial diagnosis, recurrence, or transformation of FL over a 5-year period and focused on the 182 that had at least one subsequent biopsy within 3 months as part of the same clinical work-up. The most common outcome of a subsequent biopsy as part of the same clinical work-up was a more specific diagnosis usually assigning the pathologic grade (111/182, 61%), followed by a complete agreement with the SVB (24/182, 13%), and change from nondiagnostic on initial biopsy to diagnostic on subsequent biopsy (21/182, 12%). A minority resulted in a diagnostic change from benign to lymphoma (17/182, 9%), a change in FL grade (5/182, 3%), or change in the lymphoma diagnostic category (4/182, 2%). There were no cases where an initial diagnosis of lymphoma was overturned. The distribution of discrepancies was similar across initial SVB types (FNA, FNA + cell block, NCB with or without FNA). Tissue limitations were noted in a minority of cases (53/182, 29%) and were enriched among initially nondiagnostic biopsies (16/21, 76%). Flow cytometry immunophenotyping was performed in the majority of cases both at the first and last biopsy (147/182, 81%). SVB can be a powerful method to detect FL in various clinical indications, with discrepant cases mostly resulting from a refinement in the initial diagnosis.
Nationwide Validation Study of the Prognostic Significance of Stratification Using Pathological Stage and Response to Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma
Authors: Matsuda Satoru , Kitagawa Yuko , Okui Jun , Okamura Akihiko , Kawakubo Hirofumi , Takemura Ryo , Muto Manabu , Kakeji Yoshihiro , Takeuchi Hiroya , Watanabe Masayuki , Doki Yuichiro
Published: December 2022

Objective:

This study aimed to validate the prognostic significance of stratification using pathological stage and response to neoadjuvant chemotherapy with a nationwide database from an authorized institute by the Japan Esophageal Society.

Background:

We proposed the combined criteria using pStage and pathological response. Conducting a validation study using an expanded cohort in the clinical setting would be valuable since it was developed using retrospective data collection.

Methods:

Patients with esophageal squamous cell carcinoma who underwent subtotal esophagectomy at 85 authorized institutes were retrospectively reviewed for esophageal cancer between 2010 and 2015. The prognostic value of the pathological response was evaluated within the same pStage. Moreover, risk stratification was developed to predict cancer-specific survival (CSS).

Results:

The pathological response showed significant stratification of CSS in 3761 patients included in this analysis. We classified the patients into 7 groups as survival was significantly different between responders and nonresponders under the stratification with pStage, excluding pStage I comprising pStage 0–I/II responder/II nonresponder/III responder/III nonresponder/IV responder/IV nonresponder with the 5-year CSS of 83.7%/75.8%/68.9%/59.8%/44.4%/40.7%/23.1%, respectively. Furthermore, the area under the curve was significantly higher under the new classification than in the pStage alone (P<0.001).

Conclusions:

The prognostic value of classification using pStage and the pathological response was successfully validated using real-world data in Japan. This result would guide appropriate treatment for patients with esophageal squamous cell carcinoma who received neoadjuvant chemotherapy followed by esophagectomy.
Health System Structure
Authors: Brooks Ezra S. , Mavroudis Catherine L. , Tong Jason , Wirtalla Christopher J. , Friedman Ari , Kelz Rachel R.
Published: December 2022

Objective:

To examine the role of hub-and-spoke systems as a factor in structural racism and discrimination.

Background:

Health systems are often organized in a “hub-and-spoke” manner to centralize complex surgical care to 1 high-volume hospital. Although the surgical health care disparities are well described across health care systems, it is not known how they seem across a single system’s hospitals.

Methods:

Adult patients who underwent 1 of 10 general surgery operations in 12 geographically diverse states (2016–2018) were identified using the Healthcare Cost and Utilization Project’s State Inpatient Databases. System status was assigned using the American Hospital Association dataset. Hub designation was assigned in 2 ways: (1) the hospital performing the most complex operations (general hub) or (2) the hospital performing the most of each specific operation (procedure-specific hub). Independent multivariable logistic regression was used to evaluate the risk-adjusted odds of treatment at hubs by race and ethnicity.

Results:

We identified 122,236 patients across 133 hospitals in 43 systems. Most patients were White (73.4%), 14.2% were Black, and 12.4% Hispanic. A smaller proportion of Black and Hispanic patient underwent operations at general hubs compared with White patients (B: 59.6% H: 52.0% W: 62.0%, P<0.001). After adjustment, Black and Hispanic patients were less likely to receive care at hub hospitals relative to White patients for common and complex operations (general hub B: odds ratio: 0.88 CI, 0.85, 0.91 H: OR: 0.82 CI, 0.79, 0.85).

Conclusions:

When White, Black, and Hispanic patients seek care at hospital systems, Black and Hispanic patients are less likely to receive treatment at hub hospitals. Given the published advantages of high-volume care, this new finding may highlight an opportunity in the pursuit of health equity.
Understanding How Experts Do It
Authors: Grover Karan , Korenblit Nechama , Babu Archana , Podolsky Dina , Carbonell Alfredo , Orenstein Sean , Pauli Eric M. , Novitsky Yuri , Madani Amin , Sullivan Maura , Nieman Dylan
Published: December 2022

Background:

The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based.

Methods:

Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed.

Results:

A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44–78)]. Subject matter experts practiced a median of 6.5 years (1.5–16) and have completed a median of 300 (60–500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling.

Conclusion:

This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.
Transfusion-free Strategies in Liver and Pancreatic Surgery
Authors: Kulkarni Sujit , Parina Ralitza , Henderson Randy , Derek Elika , Selby Taylor , Kwon Yong , Emamaullee Juliet , Sher Linda , Genyk Yuri , Selby Rick
Published: December 2022

Objective:

The objective of this study is to (1) describe the techniques and prove the feasibility of performing complex hepatobiliary and pancreatic surgery on a Jehovah Witness (JW) population.  (2) Describe a strategy that offsets surgical blood loss by the manipulation of circulating blood volume to create reserve whole blood upon anesthesia induction.

Background:

Major liver and pancreatic resections often require operative transfusions. This limits surgical options for patients who do not accept major blood component transfusions. There is also growing recognition of the negative impact of allogenic blood transfusions.

Methods:

A 23-year, single-center, retrospective review of JW patients undergoing liver and pancreatic resections was performed. We describe perioperative management and patient outcomes. Acute normovolemic hemodilution (ANH) is proposed as an important strategy for offsetting blood losses and preventing the need for blood transfusion. A quantitative mathematical formula is developed to provide guidance for its use.

Results:

One hundred one major resections were analyzed (liver n=57, pancreas n=44). ANH was utilized in 72 patients (liver n=38, pancreas n=34) with median removal of 2 units that were returned for hemorrhage as needed or at the completion of operation. There were no perioperative mortalities. Morbidity classified as Clavien grade 3 or higher occurred in 7.0% of liver resection and 15.9% of pancreatic resection patients.

Conclusions:

Deliberate perioperative management makes transfusion-free liver and pancreatic resections feasible. Intraoperative whole blood removal with ANH specifically preserves red cell mass, platelets, and coagulation factors for timely reinfusion. Application of the described JW transfusion-free strategy to a broader general population could lessen blood utilization costs and morbidities.
A Step Toward Personalized Surgical Decision Making
Authors: Meneveau Max O. , Vavolizza Rick D. , Mohammad Anwaruddin , Kumar Pankaj , Manderfield Joseph T. , Callahan Colleen , Lynch Kevin T. , Abbas Tarek , Slingluff Craig L. , Bekiranov Stefan
Published: December 2022

Objective:

Develop a predictive model to identify patients with 1 pathologic lymph node (pLN) versus >1 pLN using machine learning applied to gene expression profiles and clinical data as input variables.

Background:

Standard management for clinically detected melanoma lymph node metastases is complete therapeutic LN dissection (TLND). However, >40% of patients with a clinically detected melanoma lymph node will only have 1 pLN on final review. Recent data suggest that targeted excision of just the single enlarged LN may provide excellent regional control, with less morbidity than TLND. The selection of patients for less morbid surgery requires accurate identification of those with only 1 pLN.

Methods:

The Cancer Genome Atlas database was used to identify patients who underwent TLND for melanoma. Pathology reports in The Cancer Genome Atlas were reviewed to identify the number of pLNs. Patients were included for machine learning analyses if RNA sequencing data were available from a pLN. After feature selection, the top 20 gene expression and clinical input features were used to train a ridge logistic regression model to predict patients with 1 pLN versus >1 pLN using 10-fold cross-validation on 80% of samples. The model was then tested on the remaining holdout samples.

Results:

A total of 153 patients met inclusion criteria: 64 with one pLN (42%) and 89 with >1 pLNs (58%). Feature selection identified 1 clinical (extranodal extension) and 19 gene expression variables used to predict patients with 1 pLN versus >1 pLN. The ridge logistic regression model identified patient groups with an accuracy of 90% and an area under the receiver operating characteristic curve of 0.97.

Conclusions:

Gene expression profiles together with clinical variables can distinguish melanoma metastasis patients with 1 pLN versus >1 pLN. Future models trained using positron emission tomography/computed tomography imaging, gene expression, and relevant clinical variables may further improve accuracy and may predict patients who can be managed with a targeted LN excision rather than a complete TLND.
Factors Associated With Provision of Nonbeneficial Surgery
Authors: Zaza Sarah I. , Zimmermann Christopher J. , Taylor Lauren J. , Kalbfell Elle L. , Stalter Lily , Brasel Karen , Arnold Robert M. , Cooper Zara , Schwarze Margaret L.
Published: December 2022

Objective:

We tested the association of systems factors with the surgeon’s likelihood of offering surgical intervention for older adults with life-limiting acute surgical conditions.

Background:

Use of surgical treatments in the last year of life is frequent. Improved risk prediction and clinician communication are solutions proposed to improve serious illness care, yet systems factors may also drive receipt of nonbeneficial treatment.

Methods:

We mailed a national survey to 5200 surgeons randomly selected from the American College of Surgeons database comprised of a clinical vignette describing a seriously ill older adult with an acute surgical condition, which utilized a 2×2 factorial design to assess patient and systems factors on receipt of surgical treatment to surgeons.

Results:

Two thousand one hundred sixty-one surgeons responded for a weighted response rate of 53%. For an 87-year-old patient with fulminant colitis and advanced dementia or stage IV lung cancer, 40% of surgeons were inclined to offer an operation to remove the patient’s colon while 60% were inclined to offer comfort-focused care only. Surgeons were more likely to offer surgery when an operating room was readily available (odds ratio: 4.05, P<0.001) and the family requests “do everything” (odds ratio: 2.18, P<0.001).

Conclusions:

Factors outside the surgeon’s control contribute to nonbeneficial surgery, consistent with our model of clinical momentum. Further characterization of the systems in which these decisions occur might expose novel strategies to improve serious illness care for older patients and their families.
Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States
Authors: Mao Jialin , Behrendt Christian-Alexander , Falster Michael O. , Varcoe Ramon L. , Zheng Xinyan , Peters Frederik , Beiles Barry , Schermerhorn Marc L. , Jorm Louisa , Beck Adam W. , Sedrakyan Art
Published: December 2022

Objective:

To examine long-term outcomes after endovascular (EVAR) and open repairs (OAR) for intact abdominal aortic aneurysms in Australia, Germany, and the United States, using a unified study design.

Background:

Similarities and differences in long-term outcomes after EVAR versus OAR across countries remained unclear, given differences in designs across existing studies.

Methods:

We identified patients aged >65 years undergoing intact abdominal aortic aneurysm repairs during 2010-2017/2018. We compared long-term patient mortality and reintervention after EVAR and OAR using Kaplan-Meier analyses and Cox regressions. Propensity score matching was performed within each country to adjust for differences in baseline patient characteristics between procedure groups.

Results:

We included 3311, 4909, and 145363 patients from Australia, Germany, and the United States, respectively. The median patient age was 76 to 77 years, and most patients were males (77%–84%). Patient mortality was lower after EVAR than OAR within the first 60 days and became similar at 3-year follow-up (Australia 14.7% vs 16.5%, Germany 18.2% vs 19.7%, United States: 24.4% vs 24.4%). At the end of follow-up, patient mortality after EVAR was higher than OAR in Australia [ hazard ratio (HR) 95% CI: 1.21 (0.96-1.54)] but similar to OAR in Germany [HR 95% CI: 0.92 (0.80-1.07)] and the United States [HR 95% CI: 1.02 (0.99-1.05)]. The risk of reintervention after EVAR was more than twice that after OAR in Australia [HR 95% CI: 2.60 (1.09-6.15)], Germany [HR 95% CI: 4.79 (2.56-8.98)], and the United States [HR 95% CI: 2.67 (2.38-3.00)]. The difference in reintervention risk appeared early in German and United States patients.

Conclusions:

This multinational study demonstrated important similarities in long-term outcomes after EVAR versus OAR across 3 countries. Variation in long-term mortality and reintervention comparisons indicates possible differences in patient profiles, surveillance, and best medical therapy across countries.
Pancreas and Islet Transplantation: Comparative Outcome Analysis of a Single-centre Cohort Over 20-years
Authors: Marfil-Garza Braulio A. , Hefler Joshua , Verhoeff Kevin , Lam Anna , Dajani Khaled , Anderson Blaire , O’Gorman Doug , Kin Tatsuya , Bello-Chavolla Omar Yaxmehen , Grynoch Donald , Halpin Anne , Campbell Patricia M. , Senior Peter A. , Bigam David , Shapiro A.M. James
Published: December 2022

Objective:

To provide the largest single-center analysis of islet (ITx) and pancreas (PTx) transplantation.

Summary Background Data:

Studies describing long-term outcomes with ITx and PTx are scarce.

Methods:

We included adults undergoing ITx (n=266) and PTx (n=146) at the University of Alberta from January 1999 to October 2019. Outcomes include patient and graft survival, insulin independence, glycemic control, procedure-related complications, and hospital readmissions. Data are presented as medians (interquartile ranges, IQR) and absolute numbers (percentages, %) and compared using Mann-Whitney and χ
2 tests. Kaplan-Meier estimates, Cox proportional hazard models and mixed main effects models were implemented.

Results:

Crude mortality was 9.4% and 14.4% after ITx and PTx, respectively (P=0.141). Sex-adjusted and age-adjusted hazard-ratio for mortality was 2.08 (95% CI, 1.04–4.17, P=0.038) for PTx versus ITx. Insulin independence occurred in 78.6% and 92.5% in ITx and PTx recipients, respectively (P=0.0003), while the total duration of insulin independence was 2.1 (IQR 0.8–4.6) and 6.7 (IQR 2.9–12.4) year for ITx and PTx, respectively (P=2.2×10-22). Graft failure ensued in 34.2% and 19.9% after ITx and PTx, respectively (P=0.002). Glycemic control improved for up to 20-years post-transplant, particularly for PTx recipients (group, P=7.4×10-7, time, P=4.8×10-6, group*time, P=1.2×10-7). Procedure-related complications and hospital readmissions were higher after PTx (P=2.5×10-32 and P=6.4×10-112, respectively).

Conclusions:

PTx shows higher sex-adjusted and age-adjusted mortality, procedure-related complications and readmissions compared with ITx. Conversely, insulin independence, graft survival and glycemic control are better with PTx. This study provides data to balance risks and benefits with ITx and PTx, which could improve shared decision-making.
Viral infectivity in pediatric SARS-CoV-2 clinical samples does not vary by age
Authors: Schmidt Madaline M , Despres Hannah W , Shirley David J , Bose Michael E , McCaul Kate C , Crothers Jessica W , Henrickson Kelly J , Lee Benjamin , Bruce Emily A
Published: December 2022

At the start of the SARS-CoV-2 pandemic, there was much uncertainty about the role of children in infection and transmission dynamics. Through the course of the pandemic, it became clear that children were susceptible to SARS-CoV-2 infection, however they were experiencing a notable lack of severe disease outcomes as compared to the adult population. This trend held true with the emergence of new SARS-CoV-2 variants, even in pediatric populations that were ineligible to be vaccinated. The difference in disease outcomes has prompted questions about the virologic features of SARS-CoV-2 infection in this population. In order to determine if there was any difference in the infectivity of the virus produced by children infected with COVID-19, we compared viral RNA levels (clinical RT-qPCR CTs) and infectious virus titers from 144 SARS-CoV-2 positive clinical samples collected from children ages 0 to 18 years old. We found that age had no impact on the infectiousness of SARS-CoV-2 within our cohort, with children of all ages able to produce high levels of infectious virus.
Insights into the phylogenetic inconsistencies of the genus Amazonocrinis and description of epilithic Amazonocrinis malviyae sp. nov. (Cyanobacteria, Nostocales) from Jammu and Kashmir, India
Authors: Kumar Naresh , Saraf Aniket , Pal Sagarika , Mishra Deeksha , Singh Prashant
Published: December 2022

A dark-coloured thin film of cyanobacteria growing on the bottom of a submerged stone was isolated from Basantgarh village in Udhampur district, Jammu and Kashmir, India. The isolated strain (designated 19C-PST) was characterized using a polyphasic approach. The strain exhibited typical

Nostoc

-like morphology with a characteristic feature of having heterocytes in series. The 16S rRNA gene phylogeny placed the strain at a well-supported and distinct node. Notably, the recently described genus,

Amazonocrinis

, on the addition of more 16S rRNA gene sequences, reflected a critical split, which proved to be stable and well supported in all phylogenetic analyses of the 16S rRNA gene. Interestingly,

Amazonocrinis nigriterrae

CENA67T (type species of the genus) clustered together with our strain 19C-PST in the 16S rRNA gene phylogenetic analysis while the rest of the members of the genus

Amazonocrinis

were placed at a separate and distant node. This clearly indicated that strain 19C-PST is a member of Amazonocrinis sensu stricto. However, the results of phylogenetic analysis of ITS sequences only, in strains purported to belong to

Amazonocrinis

did not agree with the 16S rRNA gene results and placed our strain 19C-PST in a sister clade to three strains that have not yet been speciated, UHCC 0702, NIES-4103 and SA22, with

A. nigriterrae

falling into a separate clade. Further, folded secondary structures of the D1–D1′, V2, BoxB and V3 helices of strain 19C-PST were found to be significantly different from those of all the phylogenetically related taxa. The study revealed an interesting case where low taxon sampling and phylogenomic interpretations came across as points of attention in cyanobacterial taxonomy. Based on the morphological, phylogenetic, 16S–23S ITS secondary structure analyses, we describe our strain as Amazonocrinis malviyae sp. nov. in accordance with the International Code of Nomenclature for algae, fungi and plants. This work also illuminates the need for further research to resolve the taxonomic discrepancies among

Amazonocrinis

strains.
Levilactobacillus humaensis sp. nov. and Lapidilactobacillus luobeiensis sp. nov., isolated from traditional Chinese pickle
Authors: Zhang Hong Xia , Gu Chun Tao
Published: December 2022

Two Gram-stain-positive bacterial strains, designated 213-9(3)T and 30-1(2)T, were isolated from traditional Chinese pickle, and were characterized using a polyphasic taxonomic approach. Results of 16S rRNA gene sequence analysis indicated that strain 213-9(3)T was most closely related to

Levilactobacillus paucivorans

TMW 1.1424T,

Levilactobacillus huananensis

151-2BT and

Levilactobacillus lindianensis

220-4T, having 99.7–99.9 % 16S rRNA gene sequence similarities; strain 30-1(2)T was most closely related to

Lapidilactobacillus achengensis

247-4T, with 99.4 % 16S rRNA gene sequence similarity. Strain 213-9(3)T shared the highest pheS (93.9 %), rpoA (99.3 %) and concatenated pheS and rpoA (97.5 %) sequence similarities to

L. paucivorans

TMW 1.1424T. Strain 30-1(2)T had the highest pheS (82.4 %), rpoA (95.5 %) and concatenated pheS and rpoA (91.2 %) sequence similarities to

L. achengensis

247-4T. The phylogenetic relationships based on concatenated pheS and rpoA sequences and whole genome sequences were identical to those based on 16S rRNA gene sequences. Strain 213-9(3)T exhibited the highest average nucleotide identity (ANI) and digital DNA–DNA hybridization (dDDH) values (92.7 and 48.8 %, respectively) to

L. paucivorans

DSM 22467T. Strain 30-1(2)T had the highest ANI (84.4 %) and dDDH (32.8 %) values with

L. achengensis

247-4T. Acid production from d-galactose, d-glucose, d-mannose, N-acetyl-β-glucosaminidase, arbutin, salicin, cellobiose, maltose, gentiobiose, d-tagatose and gluconate, hydrolysis of aesculin, and activity of cystine arylamidase could differentiate strain 213-9(3)T from

L. paucivorans

DSM 22467T. Acid production from l-arabinose, d-ribose, d-xylose and d-galactose, and activity of alkaline phosphatase, esterase (C4), α-mannosidase and α-fucosidase could differentiate strain 30-1(2)T from

L. achengensis

247-4T. Based upon the data obtained in the present study, two novel species, Levilactobacillus humaensis sp. nov. and Lapidilactobacillus luobeiensis sp. nov., are proposed and the type strains are 213-9(3)T (=CCM 9241T=CCTCC AB 2022115T=JCM 35554T) and 30-1(2)T (=CCM 9240T=CCTCC AB 2022114T=JCM 35553T), respectively.
Anaeropeptidivorans aminofermentans gen. nov., sp. nov., a mesophilic proteolytic salt-tolerant bacterium isolated from a laboratory-scale biogas fermenter, and emended description of Clostridium colinum
Authors: Köller Nora , Hahnke Sarah , Zverlov Vladimir , Wibberg Daniel , Klingl Andreas , Busche Tobias , Klocke Michael , Pühler Alfred , Schlüter Andreas , Liebl Wolfgang , Maus Irena
Published: December 2022

An anaerobic bacterial strain, designated strain M3/9T, was isolated from a laboratory-scale biogas fermenter fed with maize silage supplemented with 5 % wheat straw. Cells were straight, non-motile rods, which stained Gram-negative. Optimal growth occurred between 30 and 40°C, at pH 7.5–8.5, and up to 3.9 % (w/v) NaCl was tolerated. When grown on peptone from casein and soymeal, strain M3/9T produced mainly acetic acid, ethanol, and isobutyric acid. The major cellular fatty acids of the novel strain were C16 : 0 and C16 : 0 DMA. The genome of strain M3/9T is 3757  330 bp in size with a G+C content of 38.45 mol%. Phylogenetic analysis allocated strain M3/9T within the family

Lachnospiraceae

with

Clostridium colinum

DSM 6011T and

Anaerotignum lactatifermentans

DSM 14214T being the most closely related species sharing 57.86 and 56.99% average amino acid identity and 16S rRNA gene sequence similarities of 91.58 and 91.26 %, respectively. Based on physiological, chemotaxonomic and genetic data, we propose the description of a novel species and genus Anaeropeptidivorans aminofermentans gen. nov., sp. nov., represented by the type strain M3/9T (=DSM 100058T=LMG 29527T). In addition, an emended description of

Clostridium colinum

is provided.