bluuebunny/crossref_metadata_2025 huggingface dataset:
Patient Safety and Quality Improvement Initiatives in Cleft Lip and Palate Surgery: A Systematic Review
Authors: Grue Brendan , McGuire Connor , Hong Paul , Bezuhly Michael
Published: February 2023

Background:

Cleft lip and/or palate repair techniques require continued reevaluation of best practice through high-quality evidence. The objective of this systematic review was to highlight the existing evidence for patient safety and quality improvement (QI) initiatives in cleft lip and palate surgery.

Methods:

A systematic review of published literature evaluating patient safety and QI in patients with cleft lip and/or palate was conducted from database inception to June 9, 2022, using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using Methodological Index for Non-Randomized Studies, Cochrane, or a Measurement Tool to Assess Systematic Reviews (AMSTAR) 2 instruments, according to study type.

Results:

Sixty-one studies met inclusion criteria, with most published between 2010 and 2020 (63.9%). Randomized controlled trials represented the most common study design (37.7%). Half of all included studies were related to the topic of pain and analgesia, with many supporting the use of infraorbital nerve block using 0.25% bupivacaine. The second most common intervention examined was use of perioperative antibiotics in reducing fistula and infection (11.5%). Other studies examined optimal age and closure material for cleft lip repair, early recovery after surgery protocols, interventions to reduce blood loss, and safety of outpatient surgery.

Conclusions:

Patient safety and QI studies in cleft surgery were of moderate quality overall and covered a wide range of interventions. To further enhance PS in cleft repair, more high-quality research in the areas of perioperative pharmaceutical usage, appropriate wound closure materials, and optimal surgical timing are needed.
Alternative Path for Optic Nerve Decompression in Pseudotumor Cerebri With Full Endoscopic Lateral Transorbital Approach
Authors: Ozdogan Sibel , Beton Suha , Gungor Yigit , Comert Ayhan , Bakir Abdurrahman , Kahilogullari Gokmen
Published: February 2023

Endonasal endoscopic approaches are the most preferred surgical methods in patients with pseudotumor cerebri because of easy access to the optic nerve, but the choice of this technique may not apply to all endoscopic endonasal cases. Moreover, there may be difficulties in practice in some cases, including the coronavirus disease 2019 pandemic. This study aimed to suggest an alternative endoscopic approach by lateral orbitotomy for optic nerve decompression in patients with pseudotumor cerebri. The study was performed using 5 fresh-frozen cadaver heads (bilaterally, total of 10 sides) injected intravenously with colored silicone preserved in the cold chain. An average of 2.5 cm skin incision was made to fit the lateral orbitotomy. The lengths of the recurrent meningeal artery (mm), the meningo-orbital band (mm), and the optic nerve (mm) to the orbital margin were measured. After these morphometric measurements, optic nerve decompression was performed endoscopically, and the length of the decompression was measured (mm). The average length (mm) between the orbital rim and meningeal recurrent artery (or meningolacrimal branch) was 16.2 mm, between the orbital rim and the meningo-orbital band was 18.5 mm, and between the orbital rim and optic nerve was 44.1 mm. The average optic nerve decompression length was 4.4 mm. The endoscopic lateral orbitotomy approach provides easy access to the optic nerve by anatomically following the recurrent meningeal artery and the meningo-orbital band. It can be a safe second-line approach after endonasal approaches for optic nerve decompression in pseudotumor cerebri.
How do Plastic Surgeons use the Metaverse: A Systematic Review
Authors: Sun Pengfei , Zhao Shanbaga , Yang Yang , Liu Chao , Pan Bo
Published: February 2023

Objective:

In 2021, metaverse became a buzzword. The metaverse is a digital virtual world in which people can live as a digital virtual identity. In the metaverse, people can participate in making rules and create their own worlds. As plastic surgeons in the new era, we have been thinking about the application of the metaverse in plastic surgery. Therefore, we carried out this study to systematically review the current published articles on the application of metaverse in medicine, so as to provide a reference for the rational and effective application of metaverse by plastic surgeons in the future.

Methods:

The researchers searched the Wanfang, Weipu, China National Knowledge Infrastructure (CNKI), PubMed, the Cochrane Library, and the Embase database. The retrieval time was set from the database establishment to April 2022. All studies on the use of the metaverse in medicine were included in our study.

Results:

A total of 4 studies were included in this study. According to our study, the metaverse is mostly used for skill training for residents and medical students. The metaverse was used for the first time to train doctors in lung cancer surgery at Seoul National University Bundang Hospital, Korea. Augmented reality in the metaverse has also been used to aid surgery and to address a variety of medical and mental health problems for patients.

Conclusion:

At present, the application of metaverse is still in the preliminary stage of exploration, and the practical effect of metaverse on plastic surgery needs to be observed and evaluated. Although there are still many problems in the metaverse, the new medical model of plastic surgery supported by the metaverse is worth looking forward to.
Temporomandibular Joint Disk Displacement: Etiology, Diagnosis, Imaging, and Therapeutic Approaches
Authors: Minervini Giuseppe , D’Amico Cesare , Cicciù Marco , Fiorillo Luca
Published: February 2023

An estimated 8 to 15% of women, and 3 to 10% of men currently suffer from Temporomandibular disorders, and it has been reported that sounds are a common finding and have been observed in 28% to 50% of the adult population; sounds are almost always connected to “internal derangements” a condition in which the articular disk displaced from its position on the mandibular condyle. Due to the multifactorial etiology of temporomandibular joint dysfunction, any accurate diagnosis based on clinical examination alone often proves to be difficult, so a clinical examination should be utilized together with other imaging methods to determine the relationship between the disk and condyle before and after treatment. In general, management of temporomandibular joint-related conditions is necessary when pain or dysfunction is present, so many surgical or nonsurgical methods of treatment have been reported. The Occlusal splint is 1 of the most widespread treatment it induces a slight vertical condylar distraction and eliminates the occlusal factor, which can be responsible for Temporomandibular joint disturbances, removing the influence of the teeth on the joint position by the slight distraction of the joint which, in turn, enables damaged connective tissue to heal.
Prefabrication—a Vascularized Skin Flap Using an Arteriovenous LoopPrefabricated Flap With Arteriovenous Loop
Authors: Liu Pingping , Wang Weixin , Ma Ning , Li Yangqun , Yang Zhe , Tang Yong
Published: February 2023

Background:

Arteriovenous loops have a high potency to induce angiogenesis and are promising to solve the problem of scarce implanted pedicle sources and insufficient neovascularization in flap prefabrication. But there is a lack of large animal experiments to support their clinical application. Therefore, we aimed to explore the feasibility of prefabricating large flaps based on arteriovenous loops in pigs.

Methods:

Five minipigs were used. In the experimental group, a 10-cm-long ear vein graft was microanastomosed with the saphenous artery and vein to form an arteriovenous loop and implanted under the medial thigh flap. A month later, a 10×10 cm prefabricated flap pedicled with the arteriovenous loop was elevated and sutured in situ. In the control group, a 10×10 cm flap with no vascular pedicle was elevated completely and sutured in situ in the same position. The patency of the arteriovenous loop was evaluated by angiography 30 days after implantation, and the viability of flaps was assessed by macroscopic analysis 10 days after elevation. Three animals received arteriovenous loop flaps unilaterally and no-pedicle flaps unilaterally. Two animals received arteriovenous loop flaps bilaterally.

Results:

In the experimental group, no thrombi were exhibited in any arteriovenous loop. All 7 prefabricated flaps survived uneventfully. In the control group, 3 flaps were completely necrotic.

Conclusion:

The arteriovenous loops with long interpositional venous grafts can be used as vascular pedicles to prefabricated large area and well-vascularized flaps. This approach can greatly expand the application of flap prefabrication.
Needle Removal in the Deep Maxillofacial Region Assisted by Computerized Navigation Technique and Digital Guiding Plate
Authors: Cheng Yuet , Li Qian , Li Zhi , Cheng Gu
Published: February 2023

Retention of foreign bodies frequently happened in the region of oral and maxillofacial. In very rare cases, the positions of the foreign objects moved with the movement of muscles in the oral and maxillofacial regions. Precise locations of moving objects and minimally invasive surgeries pose a great challenge to surgeons. The case of a 44-year-old female patient diagnosed with retention of the fractured needle is reported in this study. A digital guide plate was manufactured to locate the precise position of the fractured needle and preoperatively mimic the surgery processes. The computerized navigation system guided us to make an incision and precisely target the fractured needle during the surgery. Combing the technologies of the digital guiding plate and navigation system, removing the moving foreign bodies becomes objective, time-saving, and minimally invasive.
Patient-specific Composite Anatomic Models: Improving the Foundation for Craniosynostosis Repair
Authors: Marques Mitchell A. , Purnell Chad A. , Zhao Linping , Patel Pravin K. , Alkureishi Lee W.T.
Published: February 2023

Preoperative surgical planning incorporating computer-aided design and manufacturing is increasingly being utilized today within the fields of craniomaxillofacial, orthopedic, and neurosurgery. Application of these techniques for craniosynostosis reconstruction can include patient-specific anatomic reference models, “normal” reference models or patient-specific cutting/marking guides based on the presurgical plan. The major challenge remains the lack of tangible means to transfer the preoperative plan to the operating table. We propose a simple solution to utilize a digitally designed, 3D-printed “composite model” as a structural template for cranial vault reconstruction. The composite model is generated by merging the abnormal patient cranial anatomy with the “dural surface topography” of an age-matched, sex-matched, and ethnicity-matched normative skull model. We illustrate the applicability of this approach in 2 divergent cases: 22-month-old African American male with sagittal synostosis and 5-month-old White male with metopic synostosis. The aim of this technical report is to describe our application of this computer-aided design and modeling workflow for the creation of practical 3D-printed skulls that can serve as intraoperative frameworks for the correction of craniosynostosis. With success in our first 2 cases, we believe this approach of a composite model is another step in reducing our reliance on subjective guesswork, and the fundamental aspect of the workflow has a wider application within the field of craniofacial surgery for both clinical patient care and education.
Examination of Facial Convexity and Concavity Values With Reference to the External Acoustic Pore: A Retrospective Study
Authors: Tuncel Cini Nilgun , Babacan Serdar , Guner Sak Nazan , Isiklar Sefa , Ari Ilknur , Gokalp Gokhan
Published: February 2023

The human skull serves as an essential material for facial reconstruction. In particular, the petrous part of the temporal bone is vital due to its compact structure, which can resist mechanical forces. The study aims to give descriptive values to estimate the face shape and produce regression formulas through the external acoustic pore as a reference point. The study was carried out on 3-dimensional computed tomography images, a total of 83 adult images (45 females and 38 males) in the Department of Radiology of Bursa Uludag University Medical Faculty. The distances between the imaginary vertical line passing through the porion and the anthropometric points revealing the facial features were measured for the soft and hard tissue. The vertical distances between the soft and hard tissue landmarks were also measured for both sexes. Measurements were performed with the Image J program, and for the statistical analysis, SPSS 25.0 was used (P < 0.005). Linear simple regression analysis was used to produce formulas to estimate the soft tissue thickness using hard tissue. Also, discriminant function analysis was performed to determine sex in the presence of an unknown skull. The descriptive values of the variables on the axial and vertical planes and the differences between sexes are given. Also, all formulas make accurate predictions of 90% or more. The authors tried to estimate the anatomical points that roughly reveal the facial features with the regression formulas developed using anthropometric measurements. The authors think that the shape of the face, which is more specific to the individual, can be reached more clearly using mathematical models, and the authors believe that this study will set an example for future studies.
MICROGLIA AND INFILTRATING T-CELLS ADOPT LONG-TERM, AGE-SPECIFIC, TRANSCRIPTIONAL CHANGES AFTER TRAUMATIC BRAIN INJURY IN MICE
Authors: Chen Zhangying , Islam Mecca B.A.R. , Ford Kacie P. , Zhao Guangyuan , Chen Shang-Yang , Wang Yidan , Davis Booker T. , Mentis Alexios-Fotios A. , Schwulst Steven J.
Published: February 2023

Aged traumatic brain injury (TBI) patients suffer increased mortality and long-term neurocognitive and neuropsychiatric morbidity compared with younger patients. Microglia, the resident innate immune cells of the brain, are complicit in both. We hypothesized that aged microglia would fail to return to a homeostatic state after TBI and adopt a long-term injury-associated state within aged brains compared with young brains after TBI. Young and aged male C57BL/6 mice underwent TBI via controlled cortical impact versus sham injury and were sacrificed 4 months post-TBI. We used single-cell RNA sequencing to examine age-associated cellular responses after TBI. Brains were harvested, and CD45+ cells were isolated via fluorescence-activated cell sorting. cDNA libraries were prepared using the 10x Genomics Chromium Single Cell 3′ Reagent Kit, followed by sequencing on a HiSeq 4,000 instrument and computational analyses. Post-injury, aged mice demonstrated a disparate microglial gene signature and an increase in infiltrating T cells compared with young adult mice. Notably, aged mice post-injury had a subpopulation of age-specific, immune-inflammatory microglia resembling the gene profile of neurodegenerative disease-associated microglia with enriched pathways involved in leukocyte recruitment and brain-derived neurotrophic factor signaling. Meanwhile, post-injury, aged mice demonstrated heterogeneous T-cell infiltration with gene profiles corresponding to CD8 effector memory, CD8 naive-like, CD8 early active T cells, and Th1 cells with enriched pathways, such as macromolecule synthesis. Taken together, our data showed that the aged brain had an age-specific gene signature change in both T-cell infiltrates and microglia, which may contribute to its increased vulnerability to TBI and the long-term sequelae of TBI.
Variables Influencing the Differential Host Response to Burns in Pediatric and Adult Patients
Authors: Barrios Evan L. , Polcz Valerie E. , Moldawer Lyle L. , Rincon Jaimar C. , Efron Philip A. , Larson Shawn D.
Published: February 2023

Burn injury is a significant source of morbidity and mortality in the pediatric population. Although 40,000 pediatric patients in the United States are admitted to the hospital with burn wounds annually, significant differences exist in the management and treatment of these patients, even among highly specialized burn centers. Some aspects of pediatric burn research, such as metabolic changes and nutritional support following burn injury have been studied extensively; however, in many aspects of burn care, pediatric research lags behind the study of adult populations. This review compares and contrasts a wide array of physiologic and immune responses between children and adults after burn injury. Such a review elucidates where robust research has been conducted, where adult research is applicable to pediatric patients, and where additional pediatric burn research needs to be conducted.
Automated Video Debriefing Using Computer Vision Techniques
Authors: VanVoorst Brian R. , Walczak Nicholas R. , Hackett Matthew G. , Norfleet Jack E. , Schewe Jon P. , Fasching Joshua S.
Published: February 2023

Introduction

Within any training event, debriefing is a vital component that highlights areas of proficiency and deficiency, enables reflection, and ultimately provides opportunity for remediation. Video-based debriefing is desirable to capture performance and replay events, but the reality is rife with challenges, principally lengthy video and occlusions that block line of sight from camera equipment to participants.

Methods

To address this issue, researchers automated the editing of a video debrief, using a system of person-worn cameras and computer vision techniques. The cameras record a simulation event, and the video is processed using computer vision. Researchers investigated a variety of computer vision techniques, ultimately focusing on the scale invariant feature transform detection method and a convolutional neural network. The system was trained to detect and tag medically relevant segments of video and assess a single exemplar medical intervention, in this case the application of a tourniquet.

Results

The system tagged medically relevant video segments with 92% recall and 66% precision, resulting in an F1 (harmonic mean of precision and recall) of 72% (N = 23). The exemplar medical intervention was successfully assessed in 39.5% of videos (N = 39).

Conclusion

The system showed suitable accuracy tagging medically relevant video segments, but requires additional research to improve medical intervention assessment accuracy. Computer vision has the potential to automate video debrief creation to augment existing debriefing strategies.
Association Between Distress at Diagnosis and Disease-free Survival Among Patients With Resectable Colon Cancer: A Large Cohort Study
Authors: Shin Jung Kyong , Kang Danbee , Kim Soohyun , Choi Youngeun , Lee Woo Yong , Yun Seong Hyeon , Cho Yong Beom , Huh Jung Wook , Park Yoon Ah , Cho Juhee , Kim Hee Cheol
Published: February 2023

Objective:

This study aimed to evaluate the association between distress at initial diagnosis and disease-free survival in patients with resectable colon cancer.

Summary Background Data:

Considerable research has examined the psychological impact of having a confirmed diagnosis of cancer, but relatively limited research has examined the impact of distress during the diagnostic phase on oncological outcomes.

Methods:

This is a retrospective cohort study. We included newly diagnosed colon cancer patients who had resectable surgery and underwent distress screening between July 2014 and July 2021 (N=1,362). The Korean versions of the Distress Thermometer were used to assess distress and related problems. Patients were categorized into 3 groups based on distress score: low (<4), moderate (4–7), and severe (≥8). The primary outcome was disease-free survival.

Results:

The mean distress was 5.1 (SD=2.4) and 61%, and 15% of patients had moderate and severe distress at diagnosis, respectively. The severe distress group was more likely to report fear, sadness, and concerns regarding insurance/finance, work, and childcare than the low distress group. Compared with the low distress group, the severe distress group had worse disease-free survival (Hazard Ratio=1.84, 95% CI=1.03, 3.29). The association was more evident in patients with stage IV disease (Hazard Ratio=2.53, 95% CI=1.02, 6.25).

Conclusions:

A substantial number of patients with colon cancer experience distress at diagnosis, and severe distress has a negative impact on oncologic outcomes. Active monitoring and appropriate management of distress at diagnosis should be adopted at clinical settings.
Comparative Outcomes of Groin Hernia Repair by Sex Among Medicare Beneficiaries
Authors: Ehlers Anne P. , Rob Farizah , Thumma Jyothi , Howard Ryan , Davidson Giana H. , Waljee Jennifer F. , Dimick Justin B. , Telem Dana A.
Published: February 2023

Objective:

To compare the rates of operative recurrence between male and female patients undergoing groin hernia repair.

Background Data:

Groin hernia repair is common but understudied in females. Limited prior work demonstrates worse outcomes among females.

Methods:

Using Medicare claims, we performed a retrospective cohort study of adult patients who underwent elective groin hernia repair between January 1, 2010 and December 31, 2017. We used a Cox proportional hazards model to evaluate the risk of operative recurrence up to 5 years following the index operation. Secondary outcomes included 30-day complications following surgery.

Results:

Among 118,119 patients, females comprised the minority of patients (n=16,056, 13.6%). Compared with males, female patients were older (74.8 vs. 71.9 y, P<0.01), more often white (89.5% vs. 86.7%, P<0.01), and had a higher prevalence of nearly all measured comorbidities. In the multivariable Cox proportional hazards model, we found that female patients had a significantly lower risk of operative recurrence at 5-year follow-up compared with males (aHR 0.70, 95% CI 0.60–0.82). The estimated cumulative incidence of recurrence was lower among females at all time points: 1 year [0.68% (0.67–0.68) vs. 0.88% (0.88–0.89)], 3 years [1.91% (1.89–1.92) vs. 2.49% (2.47–2.5)], and 5 years [2.85% (2.82–2.88) vs. 3.7% (3.68–3.75)]. We found no significant difference in the 30-day risk of complications.

Conclusions:

We found that female patients experienced a lower risk of operative hernia recurrence following elective groin hernia repair, which is contrary to what is often reported in the literature. However, the risk of operative recurrence was low overall, indicating excellent surgical outcomes among older adults for this common surgical condition.
Waiting to Operate
Authors: Boerner Thomas , Harrington Caitlin , Tan Kay See , Adusumilli Prasad S. , Bains Manjit S. , Bott Matthew J. , Downey Robert J. , Huang James , Ilson David H. , Isbell James M. , Janjigian Yelena Y. , Park Bernard J. , Rocco Gaetano , Rusch Valerie W. , Sihag Smita , Wu Abraham J. , Jones David R. , Molena Daniela
Published: February 2023

Objective:

To assess postoperative morbidity, disease-free survival (DFS), and overall survival (OS) in patients treated with salvage esophagectomy (SE).

Background Data:

A shift toward a “surgery as needed” approach for esophageal cancer has emerged, potentially resulting in delayed esophagectomy.

Methods:

We identified patients with clinical stage I-III esophageal adenocarcinoma or squamous cell carcinoma who underwent chemoradiation followed by esophagectomy from 2001 to 2019. SE was defined as esophagectomy performed >90 days after chemoradiation (“for time”) and esophagectomy performed for recurrence after curative-intent chemoradiation (“for recurrence”). The odds of postoperative serious complications were assessed by multivariable logistic regression. The relationship between SE and OS and DFS were quantified using Cox regression models.

Results:

Of 1137 patients identified, 173 (15%) underwent SE. Of those, 61 (35%) underwent SE for recurrence, and 112 (65%) underwent SE for time. The odds of experiencing any serious complication [odds ratio, 2.10 (95% CI, 1.37–3.20); P=0.001] or serious pulmonary complication [odds ratio, 2.11 (95% CI, 1.31–3.42); P=0.002] were 2-fold higher for SE patients; SE patients had a 1.5-fold higher hazard of death [hazard ratio, 1.56 (95% CI, 1.25–1.94); P<0.0001] and postoperative recurrence [hazard ratio, 1.43 (95% CI, 1.16–1.77); P=0.001]. Five-year OS for nonsalvage esophagectomy was 45% [(95% CI, 41.6%-48.6%) versus 26.5% (95% CI, 20.2%–34.8%) for SE (log-rank P<0.001)]. Five-year OS for SE for time was 27.1% [(95% CI, 19.5%–37.5%) versus 25.2% (95% CI, 15.3%–41.5%) for SE for recurrence (P=0.611)].

Conclusions:

SE is associated with a higher risk of serious postoperative complications and shorter DFS and OS.
Long-term Outcomes of Ultrasound-guided Thermal Ablation for the Treatment of Solitary Low-risk Papillary Thyroid Microcarcinoma
Authors: Yan Lin , Liu Ying , Li WenHui , Zhu YaLin , Wang Jinling , Zhang Mingbo , Tang Jie , Che Ying , Wang Hui , Wang Shurong , Luo Yukun
Published: February 2023

Objective:

To report more than 5-year outcomes of ultrasound-guided thermal ablation (TA) for patients with solitary low-risk papillary thyroid microcarcinoma (PTMC) in a large multicenter cohort.

Background:

TA, including radiofrequency ablation (RFA) and microwave ablation (MWA) have been used in patients with low-risk PTMC who refuse surgery or active surveillance. However, its clinical value remains controversial.

Materials and Methods:

This retrospective multicenter study included 474 patients with solitary low-risk PTMC treated with TA (357 for RFA; 117 for MWA) from 4 centers and followed up for at least 5 years. Disease progression including lymph node metastasis and recurrent tumors, volume reduction rate (VRR), tumor disappearance rate, complications, and delayed surgery were assessed. RFA and MWA outcomes were compared using propensity score matching.

Results:

During the median follow-up period of 77.2 months, disease progression incidence, lymph node metastasis, and recurrent tumors rates were 3.6%, 1.1%, and 2.5%, respectively. Age below 40 years old, male sex, Hashimoto thyroiditis, and tumor size were not independent factors associated with disease progression by Cox analysis. The median VRR was 100% and 471 tumors disappeared radiographically. Eight patients experienced transient voice change (1.7%) which recovered within 3 months. None of the patients underwent delayed surgery because of anxiety. After 1:1 matching, no significant differences were found in the disease progression, VRR, tumor disappearance rate, or complications between RFA and MWA subgroups.

Conclusion:

This multicenter study revealed that TA was an effective and safe treatment for patients with solitary low-risk PTMC, which could be offered as a treatment option for the management for low-risk PTMC.
Variation in Anesthesiology Provider–Volume for Complex Gastrointestinal Cancer Surgery
Authors: Hallet Julie , Sutradhar Rinku , Eskander Antoine , Carrier François M. , McIsaac Daniel , Turgeon Alexis F. , d’Empaire Pablo Perez , Idestrup Chris , Flexman Alana , Lorello Gianni , Darling Gail , Kidane Biniam , Chan Wing C , Kaliwal Yosuf , Barabash Victoria , Coburn Natalie , Jerath Angela
Published: February 2023

Objective:

Examine between-hospital and between-anesthesiologist variation in anesthesiology provider–volume (PV) and delivery of high-volume anesthesiology care.

Background:

Better outcomes for anesthesiologists with higher PV of complex gastrointestinal cancer surgery have been reported. The factors linking anesthesiology practice and organization to volume are unknown.

Methods:

We identified patients undergoing elective esophagectomy, hepatectomy, and pancreatectomy using linked administrative health data sets (2007–2018). Anesthesiology PV was the annual number of procedures done by the primary anesthesiologist in the 2 years before the index surgery. High-volume anesthesiology was PV>6 procedures/year. Funnel plots to described variation in anesthesiology PV and delivery of high-volume care. Hierarchical regression models examined between-anesthesiologist and between-hospital variation in delivery of high-volume care use with variance partition coefficients (VPCs) and median odds ratios (MORs).

Results:

Among 7893 patients cared for at 17 hospitals, funnel plots showed variation in anesthesiology PV (median ranging from 1.5, interquartile range: 1–2 to 11.5, interquartile range: 8–16) and delivery of HV care (ranging from 0% to 87%) across hospitals. After adjustment, 32% (VPC 0.32) and 16% (VPC: 0.16) of the variation were attributable to between-anesthesiologist and between-hospital differences, respectively. This translated to an anesthesiologist MOR of 4.81 (95% CI, 3.27–10.3) and hospital MOR of 3.04 (95% CI, 2.14–7.77).

Conclusions:

Substantial variation in anesthesiology PV and delivery of high-volume anesthesiology care existed across hospitals. The anesthesiologist and the hospital were key determinants of the variation in high-volume anesthesiology care delivery. This suggests that targeting anesthesiology structures of care could reduce variation and improve delivery of high-volume anesthesiology care.
Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy—Experience of 3726 Cases From a Tertiary Care Teaching Institute
Authors: Bansal Virinder K. , Asuri Krishna , Jain Mayank , Prakash Om , Bhattacharjee Hemanga K. , Isukapati Samrajya , Dey Souvik , Baksi Aditya , Khan Washim Firoz , Subramaniam Rajeshwari , Ramachandran Rashmi , Garg Pramod , Kumar Subodh , Mishra Mahesh C.
Published: February 2023

Introduction:

Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications.

Materials and Methods:

All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted.

Results:

Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%.

Conclusion:

This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.
Is Cystogastrostomy a Definitive Operation for Pancreatitis Associated Pancreatic Fluid Collections?
Authors: Darwish Muhammad Bassel , Logarajah Shankar , McLaren Patrick James , Campilan Beatrice , Benzie Annie Laurie , Cho Edward , Osman Houssam , Jeyarajah D. Rohan
Published: February 2023

Background:

Pancreatic-enteric drainage procedures have become standard therapy for symptomatic pancreatic pseudocysts and walled-off pancreatic necrosis. The need for pancreatic resection after cyst-enteric drainage procedure in the event of recurrence is not well studied. This study aimed to quantify the percentage of patients requiring resection due to recurrence after surgical cystogastrostomy and identify predictors of drainage failure.

Methods:

A single-institution retrospective review was conducted to identify all patients undergoing surgical cystogastrostomy between 2012 and 2020. Demographic, disease, and treatment characteristics were identified. Failure of surgical drainage was defined as the need for subsequent pancreatic resection due to recurrence. Characteristics between failure and nonfailure groups were compared with identifying predictors of treatment failure.

Results:

Twenty-four cystogastrostomies were performed during the study period. Three patients (12.5%) required a subsequent distal pancreatectomy after surgical drainage. There was no difference in comorbidities between drainage alone and failure of drainage groups. Mean cyst size seemed to be larger in patients that underwent drainage alone versus those that needed subsequent resection (15.2 vs 10.3 cm, P=0.05). Estimated blood loss at initial operation was similar between groups (126 vs 166 mL, P=0.36).

Conclusion:

Surgical pancreatic drainage was successful in the initial management of pancreatic fluid collections. We did not identify any predictors of failure of initial drainage. There was a trend suggesting smaller cyst size may be associated with cystgastrostomy failure. Resection with distal pancreatectomy for walled-off pancreatic necrosis and pancreatic pseudocysts can be reserved for cases of failure of drainage.
Timing of Colonoscopy for Hemodynamically Stable Patients With Acute Lower Gastrointestinal Bleeding
Authors: Özkan Atakan
Published: February 2023

Introduction:

The detection rate of the etiology of the lower gastrointestinal system (GIS) hemorrhage has been low, although urgent colonoscopy has been performed. Even if the etiology has been specified, the possibility of rebleeding is uncertain. Furthermore, adequate bowel cleansing required for colonoscopy cannot be achieved in emergency situations, so the procedure may fail. The aim of this study is to compare the etiological diagnoses of patients with lower GIS bleeding after bowel preparation at their first hospitalization and after discharge.

Material and Method:

Patients who were hemodynamically stable after upper GIS bleeding were identified and divided into 2 groups. Colonoscopy was performed in the first group of patients at their first hospitalization. The second group of patients was called again for colonoscopy within 2 weeks after discharge. Patients were classified according to their age, gender, bleeding etiology, whether complete colonoscopy procedure was possible (The cecum was intubated, and the bowel cleansing was sufficient to evaluate the intestinal mucosa), and whether the colonoscopic intervention was performed.

Results:

The rate of patients who are hemodynamically stable and require emergency intervention at their first hospitalization is 5%. The colonoscopy repeat rate is 70% for the first hospitalization group, and the patients with no findings despite the second colonoscopy at a rate of 50% are re-evaluated electively.

Discussion:

Our study suggests that colonoscopy should be performed in elective conditions after a complete bowel cleansing in hemodynamically stable patients.
Diagnostic Accuracy of Imaging Modalities on Occult Groin Hernias According to Hernia type and a Surgeon-centered Individualized Groin Hernia Management Algorithm
Authors: Akgul Nedim , Turan Mehmet Ilker
Published: February 2023

Background:

The purpose of this study is to evaluate the diagnostic performance of imaging techniques for the identification of groin hernias based on the type of hernia and to demonstrate the efficacy of an algorithm based on the surgeon and surgical technique.

Materials and Methods:

Medical records of 561 patients who were operated on for groin hernia were retrospectively analyzed. A total of 102 patients who had both pelvic computed tomography (CT) and ultrasonography (USG) recordings preoperatively and underwent transabdominal preperitoneal repair were included in the study.

Results:

A contralateral asymptomatic occult groin hernia was detected in 25.5% of all patients. The overall sensitivity of USG and CT on contralateral asymptomatic occult hernia was 42.3% and 65.4%, respectively. The sensitivity of USG according to the contralateral occult hernia type was 66.7%, 35.7%, 33.3%, and 50% for direct, indirect, femoral, and pantaloon hernias, respectively. The sensitivity of CT according to the contralateral occult hernia type was 0%, 57.1%, 100%, and 100% for direct, indirect, femoral, and pantaloon hernias, respectively.

Conclusions:

The handicap created by the variability in the diagnostic sensitivity of imaging modalities can be overcome with the choice of transabdominal preperitoneal repair in the surgical technique.
Centering Group Treatment for Women With Interstitial Cystitis/Bladder Pain Syndrome: A Prospective, Parallel-Group Cohort Study
Authors: Meriwether Kate V. , Ravichandran Niharika , Darley Cassandra J. , Panter Virginia , Komesu Yuko M.
Published: February 2023

Importance

Women with interstitial cystitis/bladder pain syndrome (ICBPS) face isolation and treatment challenges. Group medical visits using Centering models have successfully treated other conditions but have not been explored in ICBPS.

Objective

This study aimed to describe ICBPS pain and symptom control comparing standard treatment alone versus standard treatment augmented with Centering visits.

Study Design

This prospective cohort study recruited women with ICBPS receiving standard care (control) or standard care augmented with group Centering. We administered validated questionnaires at baseline and monthly for 12 months. The primary outcome was change in the pain numerical rating scale, with Patient-Reported Outcomes Measurement Information System Pain Interference Scale and Bladder Pain/Interstitial Cystitis Symptom Score change as secondary measures.

Results

We enrolled 45 women (20 Centering, 25 controls). Centering had significantly better numerical rating scale pain scores at 1 month (mean difference [diff], −3.45) and 2 months (mean diff, −3.58), better Patient-Reported Outcomes Measurement Information System Pain Interference Scale scores at 1 month (mean diff, −10.62) and 2 months (mean diff, −9.63), and better Bladder Pain/Interstitial Cystitis Symptom Score scores at 2 months (mean diff, −13.19), and 3 months (mean diff, −12.3) compared with controls. In modeling, treatment group (Centering or control) and educational levels were both associated with all the outcomes of interest. Beyond 6 months, there were too few participants for meaningful analyses.

Conclusions

Women with ICBPS participating in a Centering group have, in the short term, less pain, pain interference, and ICBPS-specific symptoms than patients with usual care alone. Larger studies with more follow-up are needed to determine if this treatment effect extends over time.
Supraphysiologic Vaginal Estrogen Therapy in Aged Mice Mitigates Age-Associated Bladder Inflammatory Response to Urinary Tract Infections
Authors: Fashemi Bisiayo E. , Wang Caihong , Chappidi Rayvanth R. , Morsy Haidy , Mysorekar Indira U.
Published: February 2023

Importance

Bladder diseases characterized by chronic inflammation are highly prevalent in older women, as are recurrent urinary tract infections (rUTIs). Recurrent urinary tract infections lead to chronic inflammation of the bladder mucosa and cause lower urinary tract symptoms that persist even after the infection is cleared. Vaginal estrogen therapy (VET) has long been used for the treatment of rUTIs; however, its mechanism of action remains unclear.

Objectives

The objective of this study was to examine the mechanism(s) by which VET affects bladder inflammation and response to rUTIs.

Study Design

Here, we induced surgical menopause in aged (18 months old) mice followed by VET. Mice were then infected with uropathogenic Escherichia coli, and course of infection was investigated. Inflammatory cytokine response was assessed before and during infection using enzyme-linked immunosorbent assay. RNA sequencing analysis was used to compare the inflammatory status of the young versus aged bladder and principal changes confirmed via quantitative reverse transcriptase–polymerase chain reaction to determine the effects of VET on bladder inflammation. Impact on age-associated bladder tertiary lymphoid tissue formation was evaluated histologically.

Results

In the ovariectomized aged model, VET not only mitigated uterine atrophy but was also associated with reduced rUTIs, number of bacterial reservoirs, dampened immune response, and promotion of terminal differentiation of urothelial cells. Bladder tertiary lymphoid tissue lesions were also reduced with VET, with an associated decrease in signals important for bladder tertiary lymphoid tissue formation. Finally, we determined that VET reverses age-associated upregulation of inflammatory genes and pathways.

Conclusions

Our data suggest that VET is effective by reducing age-associated hyperinflammatory conditions in bladder mucosa and in enhancing the host response to infection.
Despite Recommendations, Anticholinergics Account for the Majority of Prescriptions to Treat Overactive Bladder in the United States
Authors: Carr Danielle N. , Macharia Annliz , Hacker Michele R. , Winkelman William D.
Published: February 2023

Importance

There are significant associations between anticholinergic medication use and an increased risk of cognitive impairment and dementia. Many experts now advocate minimizing the use of anticholinergic medications to treat overactive bladder (OAB) in elderly women.

Objective

The aim of this study was to describe temporal and geographic trends in the pharmacologic treatment of OAB for patients 65 years or older across the United States.

Study Design

The U.S. Centers for Medicare & Medicaid Services publishes annual Medicare Provider Utilization and Payment Data. The data set includes the number of unique Part D beneficiaries 65 years or older with at least 1 claim for a drug and the number of 30-day fills dispensed. The database also includes the U.S. state and rural-urban commuting area designation of the prescriber.

Results

From 2013 to 2019, Medicare Part D beneficiaries 65 years or older received 47.7 million 30-day fills for the treatment of OAB. In 2013, anticholinergics represented 98% of the total 30-day fills (5.6 million) for OAB. The use of β3 agonists was nearly 24 times greater in 2019 than in 2013. Geographic variation in prescribing practices was evident.

Conclusions

The number of anticholinergics dispensed for the treatment of OAB remained relatively stable, and there was a substantial increase in the use of β3 agonists. Percentages of anticholinergics dispensed varied among states. More patients are being treated for OAB; however, anticholinergics comprised the majority of prescriptions for treatment in 2019.
Impact of Sternal Fixation on Patient Outcomes: A Case Matched Review
Authors: Bauman Zachary M. , Todd Sydney J. , Raposo-Hadley Ashley , Binkley Jana , King Tylor , Cahoy Kevin , Kamien Andrew , Cemaj Samuel , Berning Bennett , Evans Charity H. , Cantrell Emily
Published: February 2023

Introduction

Sternal fractures are debilitating injuries often resulting in severe pain and respiratory compromise. Surgical fixation of sternal fractures is gaining popularity as a treatment modality for sternal fractures. Unfortunately, little literature exists on this topic. This study looks to further examine the benefits of sternal fixation, hypothesizing sternal fixation results in improved pain, improved respiratory function, and decreased opioid use.

Methods

Retrospective review was performed between patients with sternal fractures who underwent non-operative management (NOM) versus operative sternal fixation (SF). Case matching was used to construct an artificial control group matched on age and Injury Severity Score (ISS) using a 1:1 ratio of treatment to control. Exclusion criteria were age < 18 years. Outcomes of interest included mean pain score, total opioid requirements (in morphine milliequivalents (MME)) within 24 hours of discharge, ICU and hospital length of stay (LOS), and incentive spirometry (IS) percent predicted value at discharge. Dependent variables were analyzed utilizing t-test and ISS was analyzed utilizing the sign test. Statistical significance was set at p < 0.05.

Results

Fifty-eight patients from the SF cohort were matched with 58 patients from the NOM cohort. Average age was 59.8 for the SF group and 62.2 years for the NOM group. ISS was matched at 9 for both cohorts. Although pain scores were similar for both cohorts, the SF group required significantly less opioids at discharge (62.1 vs 92.2 MME; p = 0.007). Additionally, the SF cohort demonstrated significantly improved respiratory function per IS percent predicted value at discharge (75.5% vs 59.9%; p < 0.001). ICU/hospital LOS were similar between cohorts.

Conclusion

Despite similarities in pain scores, ICU, and hospital LOS SF was associated with decreased opioid requirements and improved respiratory function at discharge in this study.

Level of Evidence

IV
Cover with caution: Management of the Left Subclavian Artery in TEVAR for trauma
Authors: Romagnoli Anna Noel , Paterson Jeanette , Dua Anahita , Kauvar David , Saqib Naveed , Miller Charles , Starnes Benjamin , Azizzadeh Ali , DuBose Joseph
Published: February 2023

BACKGROUND

Elective Thoracic Endovascular Aortic Repair (TEVAR) with left subclavian artery coverage (LSA-C) without revascularization is associated with increased rates of ischemic stroke. In patients with blunt thoracic aortic injury (BTAI) requiring TEVAR, LSA-C is frequently required in over one-third of patients. This study aimed to evaluate outcomes of TEVAR in BTAI patients with and without LSA-C.

METHODS

The largest existing international multicenter prospective registry of BTAI, developed and implemented by the Aortic Trauma Foundation, was utilized to evaluate all BTAI patients undergoing TEVAR from March 2016 to January 2021. Patients with uncovered left subclavian artery (LSA-U) were compared with patients who had left subclavian artery coverage with (LSA-R) and without (LSA-NR) revascularization.

RESULTS

Of the 364 patients with BTAI who underwent TEVAR, 97 (26.6%) underwent LSA-C without revascularization, 10 (2.7%) underwent LSA-C with revascularization (LSA-R). Late and all ischemic strokes were more common in LSA-NR patients than LSA-U patients (p = 0.006, p = 0.0007). There was no difference in rate of early, late, or overall incidence of paralysis/paraplegia between LSA-NR and LSA-U. When compiled as composite central nervous system ischemic sequelae, there was an increased rate in early, late, and overall events in LSA-NR compared with LSA-U (p = 0.04, p = 0.01, p = 0.001).

CONCLUSION

While prior studies have suggested the relative safety of LSA-C in BTAI, preliminary multicenter prospective data suggests there is a significant increase in ischemic events when the left subclavian artery is covered and not revascularized. Additional prospective study and more highly powered analysis is necessary.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.