bluuebunny/crossref_metadata_2025_split huggingface dataset:
Extracorporeal Membrane Oxygenation to Support Life-Threatening Drug-Refractory Electrical Storm
Authors: Baudry Guillaume , Sonneville Romain , Waintraub Xavier , Lebreton Guillaume , Deguillard Camille , Mertens Emilie , Bouadma Lila , Demondion Pierre , Bréchot Nicolas , Luyt Charles-Edouard , Extramiana Fabrice , Hékimian Guillaume , Dupuis Claire , Para Marylou , Pisani Angelo , Braham Wael , Gandjbakhch Estelle , Leenhardt Antoine , Timsit Jean-François , Leprince Pascal , Combes Alain , Schmidt Matthieu 
Published: August 2020

Objectives:
Despite rapid implementation of anti-arrhythmic treatment and sedation and controlling the triggering event, rare patients develop treatment-refractory electrical storm and their hemodynamic instability prevents emergency catheter ablation. In that context, venoarterial extracorporeal membrane oxygenation could rapidly restore hemodynamics and tissue perfusion and reduce myocardial oxygen consumption, until adequate anti-arrhythmic drug levels are reached to safely perform catheter ablation.

Design:
Retrospective, multicenter study over an 8-year period.

Setting:
Two French tertiary care centers.

Patients:
Eighty-three consecutive adults with venoarterial extracorporeal membrane oxygenation-supported treatment-refractory electrical storm (median [interquartile range] age, 55 yr [48–63 yr]).

Measurements and Main Results:
Fifty-nine percent of these patients had acute ischemic cardiomyopathy and 66% underwent cardiopulmonary resuscitation prior to venoarterial extracorporeal membrane oxygenation initiation, with 18% cannulated during it. Fifty patients (60%) had ventricular tachycardia and/or ventricular fibrillation alternating with short periods of sinus rhythm and 33 (40%) had refractory ventricular tachycardia and/or ventricular fibrillation. Twelve patients (15%) underwent safe catheter ablation under venoarterial extracorporeal membrane oxygenation. After a median of 3 days (1–13 d) on extracorporeal membrane oxygenation support, 37 patients (45%) were successfully weaned off and 42% were alive 6 months post-ICU admission. Multivariable analysis retained ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm (odds ratio, 0.18; 95% CI, 0.06–0.52; p = 0.002) and age less than 50 years (odds ratio, 0.32; 95% CI, 0.18–0.89; p = 0.002) as being independent protective factors with 6-month survival, regardless of the underlying electrical storm cause.

Conclusions:
Among venoarterial extracorporeal membrane oxygenation-supported drug-refractory electrical storm patients, 42% survived 6 months post-ICU admission. Ventricular tachycardia and/or ventricular fibrillation episodes alternating with short periods of sinus rhythm and age less than 50 years were independently associated with better survival.
The Development and Validation of a Machine Learning Model to Predict Bacteremia and Fungemia in Hospitalized Patients Using Electronic Health Record Data
Authors: Bhavani Sivasubramanium V. , Lonjers Zachary , Carey Kyle A. , Afshar Majid , Gilbert Emily R. , Shah Nirav S. , Huang Elbert S. , Churpek Matthew M. 
Published: August 2020

Objectives:
Bacteremia and fungemia can cause life-threatening illness with high mortality rates, which increase with delays in antimicrobial therapy. The objective of this study is to develop machine learning models to predict blood culture results at the time of the blood culture order using routine data in the electronic health record.

Design:
Retrospective analysis of a large, multicenter inpatient data.

Setting:
Two academic tertiary medical centers between the years 2007 and 2018.

Subjects:
All hospitalized patients who received a blood culture during hospitalization.

Interventions:
The dataset was partitioned temporally into development and validation cohorts: the logistic regression and gradient boosting machine models were trained on the earliest 80% of hospital admissions and validated on the most recent 20%.

Measurements and Main Results:
There were 252,569 blood culture days—defined as nonoverlapping 24-hour periods in which one or more blood cultures were ordered. In the validation cohort, there were 50,514 blood culture days, with 3,762 cases of bacteremia (7.5%) and 370 cases of fungemia (0.7%). The gradient boosting machine model for bacteremia had significantly higher area under the receiver operating characteristic curve (0.78 [95% CI 0.77–0.78]) than the logistic regression model (0.73 [0.72–0.74]) (p < 0.001). The model identified a high-risk group with over 30 times the occurrence rate of bacteremia in the low-risk group (27.4% vs 0.9%; p < 0.001). Using the low-risk cut-off, the model identifies bacteremia with 98.7% sensitivity. The gradient boosting machine model for fungemia had high discrimination (area under the receiver operating characteristic curve 0.88 [95% CI 0.86–0.90]). The high-risk fungemia group had 252 fungemic cultures compared with one fungemic culture in the low-risk group (5.0% vs 0.02%; p < 0.001). Further, the high-risk group had a mortality rate 60 times higher than the low-risk group (28.2% vs 0.4%; p < 0.001).

Conclusions:
Our novel models identified patients at low and high-risk for bacteremia and fungemia using routinely collected electronic health record data. Further research is needed to evaluate the cost-effectiveness and impact of model implementation in clinical practice.
Nationwide Incidence and Outcomes of Patients With Coronavirus Disease 2019 Requiring Intensive Care in Iceland
Authors: Kristinsson Bjarki , Kristinsdottir Linda B. , Blondal Asbjorn T. , Thormar Katrin M. , Kristjansson Mar , Karason Sigurbergur , Sigvaldason Kristinn , Sigurdsson Martin I. 
Published: August 2020

Objectives:
To determine the nationwide demographics and hospital mortality of patients with severe acute respiratory syndrome coronavirus 2 infection requiring admission to the ICU for coronavirus disease 2019 in Iceland.

Design:
Prospective observational study.

Setting:
All ICUs in Iceland (Landspitali University Hospital and Akureyri Regional Hospital).

Patients:
All patients admitted to the ICU for management of coronavirus disease 2019 between March 14, 2020, and April 13, 2020, with follow-up through May 5, 2020.

Interventions:
None.

Measurements and Main Results:
A total of 27 patients were admitted to the ICU for coronavirus disease 2019 out of 1,788 severe acute respiratory syndrome coronavirus 2 positive cases, rendering an overall admission ratio of 1.5% (95% CI, 1.0–2.2%). The population rate of ICU admission for coronavirus disease 2019 was 7.4 (95% CI, 4.9–10.8) admissions per 100,000 individuals. The hospital mortality of patients admitted to the ICU was 15% (95% CI, 4–34%), and the mortality of patients receiving mechanical ventilation was 19% (95% CI, 4–46%).

Conclusions:
We report a lower overall ratio of ICU admissions for coronavirus disease 2019 among severe acute respiratory syndrome coronavirus 2 positive patients and a lower hospital mortality for patients treated in the ICU for coronavirus disease 2019 compared with initial reports from Italy and China. Our results could be explained by the early adoption of widespread testing and a successful national response to the pandemic.
Transpelvic Oblique Rectus Abdominis Myocutaneous Flap With Preservation of the Rectus Sheath
Authors: Canessa César E. , Cal Fernando Bonilla , Viglione Noelia Brito , Jalda Ricardo Misa 
Published: August 2020

BACKGROUND:
Perineal reconstructive surgery is an effective procedure to decrease the morbidity associated with extensive abdominoperineal resection in the treatment of advanced low rectal and anal malignancies. Rectus abdominis myocutaneous flaps are often utilized in perineal reconstruction with excellent results. However, the main disadvantages are donor-site morbidity and the need for an open procedure after laparoscopic resection, requiring larger incisions with a resultant increase in postoperative pain. Herein, we describe a modified oblique rectus abdominis myocutaneous flap technique that allows sparing of the rectus sheath and the linea alba.

TECHNIQUE:
We followed the 3 stages regularly described for the procedure: 1) abdominoperineal resection with simultaneous abdominal and perineal team approach, and removal of the specimen through the perineal wound; 2) right oblique rectus abdominis myocutaneous flap with inferior epigastric pedicle, and release of the rectus muscle from its aponeurotic sheath through the skin paddle incision and transposition of the oblique rectus abdominis myocutaneous flap through an incision in the transversalis fascia; and 3) perineal reconstruction by sutures of the skin paddle to the perineal wound skin edges.

RESULTS:
Release of the rectus muscle within its sheath through the incision in the skin paddle turned out to be a simple surgical procedure, without the need of specialized surgical instruments or additional incisions. There were no complications during the postoperative recovery. Our patient was pain-free 1 month after the surgery, with a well-healed flap and abdominal scar.

CONCLUSION:
Performance of an oblique rectus abdominis myocutaneous flap that is specifically fitted for the perineal defect after abdominoperineal resection, with muscle dissection performed through the skin paddle incision and transposition into the pelvis through the transversalis fascia, offers good functional outcome while minimizing damage to the abdominal wall.
Robotic Harvest of a Rectus Abdominis Muscle Flap After Abdominoperineal Resection
Authors: Hammond Jacob B. , Howarth Ashley L. , Haverland Rachael A. , Rebecca Alanna M. , Yi Johnny , Bryant Lyndsey A. , Polveroni Thomas M. , Mishra Nitin 
Published: August 2020

INTRODUCTION:
As multidisciplinary treatment modalities for rectal cancer continue to evolve, neoadjuvant chemoradiation then surgical resection is a common approach. Robotic-assisted abdominoperineal resection is becoming more prevalent in part because of better visualization and instrument mobility within the pelvis. After abdominoperineal resection, postoperative perineal wound complications remain a significant risk. Pelvic reconstruction lowers this risk, and a pedicled rectus abdominis muscle flap is frequently used to achieve this. Traditional flap harvest requires laparotomy, resulting in violation of both rectus sheaths and a large midline scar. Robotic harvest of the rectus abdominis muscle for pelvic reconstruction after abdominoperineal resection is a novel approach with foreseeable benefits.

TECHNIQUE:
After completion of abdominoperineal resection, 2 additional trocars are inserted in the lateral abdomen, and the robot is reoriented toward the posterior abdominal wall. The peritoneum and posterior rectus sheath are incised, and dissection is carried superiorly and inferiorly in a sagittal plane to reveal the rectus abdominis muscle. The muscle body is separated from the anterior rectus sheath. Once the inferior epigastric artery is identified, the superior pole of the muscle is transected. Continued lateral dissection ensures flap mobility for placement within the pelvis. After obtaining proper reach, the robot is undocked, and the flap is sutured in place through the perineal defect.

RESULTS:
After trocar placement and robot repositioning, both the colorectal and plastic surgeons trade places at the console. Robotic flap harvest precludes the need for laparotomy. The anterior rectus sheath remains unviolated and the patient avoids an additional midline scar. The aforementioned benefits of robot-assisted abdominoperineal resection, namely increased visualization and maneuverability, were also found applicable when robotically harvesting this flap.

CONCLUSIONS:
This technique exemplifies an additional minimally invasive technique for patients pursuing abdominoperineal resection. With knowledge of this novel approach, surgeons can better tailor their operations to benefit the patient.
Organ Preservation in the Treatment of Stage II and III Rectal Cancer
Authors: Hagen Edward R. , Cleary Robert K. 
Published: August 2020

CASE SUMMARY:
A 65-year-old man underwent colonoscopy to evaluate rectal bleeding and was found to have a low rectal mass. Biopsy revealed moderately differentiated microsatellite stable adenocarcinoma. The tumor was palpable at the fingertip in the anterior rectum with the inferior border 5 cm from the anal verge by rigid proctoscopy. CEA was 0.8 ng/mL. CT imaging of the chest, abdomen, and pelvis showed no evidence of distant metastases. MRI confirmed a 5-cm mass with one 8-mm mesorectal lymph node metastasis and no extramural venous invasion. The tumor penetrated the mesorectal fat to a depth of 4 mm, and the circumferential margin was estimated to be 1 mm from the tumor (Fig. 1). He was presented at the multidisciplinary tumor board conference and interviewed and examined at the multidisciplinary clinic. He was dismayed at the prospect of his surgical options, a low anterior resection versus abdominoperineal resection, and wished to keep the options for organ preservation available. Standard long-course chemoradiation was initiated, with resolution of his bleeding after 2 weeks. He then completed 6 cycles of folinic acid, fluorouracil, and oxaliplatin (FOLFOX) chemotherapy (consolidation total neoadjuvant therapy (TNT)). The tumor was no longer palpable on office examination. A complete clinical response (cCR) was confirmed by flexible sigmoidoscopy (Fig. 2) and MRI (Fig. 3). He was entered into the nonoperative management program with intense surveillance scheduling and has no evidence of recurrent disease almost 2 years after completion of TNT.
Complications After Mohs Micrographic Surgery in Patients Aged 85 and Older
Authors: Nemer Kathleen M. , Ko James J. , Hurst Eva A. 
Published: August 2020

BACKGROUND
As the US population ages, safe surgical procedures are necessary for treatment of cutaneous neoplasms in very elderly patients.

OBJECTIVE
To determine the incidence of complications associated with Mohs micrographic surgery (MMS) in patients aged 85 and older, and the risk factors that predispose to complications.

METHODS
A 9-year retrospective chart review of patients aged 85 and older who underwent MMS at our institution between 07/2007 and 11/2016 was performed. Six types of complications associated with scalpel-based cutaneous surgery were recorded, as well as patient, tumor, and repair characteristics.

RESULTS
This study included 949 patients totaling in 1683 MMS cases. There were 30 complications: infection (N = 11), wound dehiscence (N = 6), hematoma (N = 6), hemorrhage (N = 5), flap necrosis (N = 1), and graft necrosis (N = 1), resulting in an overall complication rate of 1.78%. Independent risk factors associated with a statistically higher incidence of complications were anticoagulant use (odds ratio [OR], 2.78; 95% confidence interval [CI], 1.26–6.13; p = .012), extremity location (OR, 2.80; 95% CI, 1.19–6.54; p = .018), greater than 2 MMS stages (OR, 2.43; 95% CI, 1.08–5.46; p = .032), and flap repair (OR, 2.27; 95% CI, 1.05–4.90; p = .036).

CONCLUSION
Mohs micrographic surgery is a safe procedure for treatment of cutaneous neoplasms in the very elderly.
Dermoscopic Findings in the Presurgical Evaluation of Basal Cell Carcinoma. A Prospective Study
Authors: Conforti Claudio , Giuffrida Roberta , Zalaudek Iris , Guarneri Fabrizio , Cannavò Serafinella Patrizia , Pizzichetta Maria Antonietta , Bonin Serena , Corneli Paola , Bussani Rossana , Bazzacco Giulia , Di Meo Nicola 
Published: August 2020

BACKGROUND
Surgery is the best treatment for basal cell carcinoma (BCC); however, incomplete excisions are possible.

OBJECTIVE
Assessment of the accurateness of dermoscopy and clinical evaluation in the detection of borders of BCC and description of dermoscopic findings in clinically healthy tissue surrounding BCC.

MATERIALS AND METHODS
Eighty-eight lesions with clinical dermoscopic diagnosis of BCC were examined clinically and dermoscopically, to delineate the correct site of surgical incision, demarcating the respective margins with colred dermographic pencils. Specific dermoscopic features were searched in the skin adjacent to the demarcated clinical margin.

RESULTS
In 29 of 88 lesions, clinical and dermoscopic margins of the tumor coincided. In the remaining 59 (67%), 10 (16.9%) presented, in the lesion area identified under dermoscopy, classical criteria for BCC and 57 (96.6%) nonclassical criteria. Differences between clinical and dermoscopic margins were significantly more frequent in superficial BCCs (p = .006). The frequency was not significantly different (p = .85) in relation to body sites.

CONCLUSION
Dermoscopy improves the identification of margins for surgical excision in BCC. The observation of nontraditional dermoscopic criteria of BCC, mainly pink–white areas and short telangiectasias in the area between clinically and dermoscopically detected margins, helps to define the actual tumoral margins and to achieve a really radical excision.
Trimethoprim-sulfamethoxazole-induced hyponatremia in an elderly lady with Achromobacter xylosoxidans pneumonia
Authors: Ghali Michael George Zaki , Kim Marc J. 
Published: August 2020

Abstract

Rationale:
Hyponatremia occurs frequently in the hospital setting and may be attributable to a host of etiologies. Drugs are frequently implicated. Trimethoprim-sulfamethoxazole (TMP/SMX) represents a well-recognized pharmacologic precipitant of drug-induced hyponatremia, with several reports extant in the retrievable literature. Nephrologists thus debate the mechanisms giving rise to TMP/SMX-induced hyponatremia and the precise mechanism by which treatment with TMP/SMX generates reductions of serum sodium concentration remain controversial. The agent has a well-known effect of antagonizing the effects of aldosterone upon the distal nephron. Renal salt wasting and the syndrome of inappropriate antidiuretic hormone secretion represent implicated mechanistic intermediaries in TMP/SMX-induced hyponatremia.

Patient concerns:
The patient endorsed no explicit concerns.

Diagnoses:
We describe the case of an 83-year-old female clinically diagnosed with pneumonia found to have an initial serum sodium in the range of 130 to 134 mEq/L consistent with mild hyponatremia upon admission. Sputum cultures grew Achromobacter xylosoxidans susceptible to TMP/SMX. The patient's serum sodium concentration precipitously decline following institution of treatment with TMP/SMX to 112 to 114 mEq/L during the course of 5 days.

Interventions:
Severe hyponatremia proved recalcitrant to initial therapy with supplemental salt tabs and standard doses of the vasopressin receptor antagonist tolvaptan.

Outcomes:
Escalating doses of tolvaptan increased the patient's sodium to 120 to 124 mEq/L. The patient was transferred to another hospital for further management. During her stay, the patient did not exhibit frank or obvious clinical features consistent with hyponatremia nor readily appreciable evidence of volume depletion.

Lessons:
TMP/SMX represents a frequent, though underreported cause of hyponatremia in the hospital setting several authors believe natriuresis may represent the most common mechanism underlying TMP/SMX-induced hyponatremia. Evidence implicating natriuresis to be mechanistic in TMP/SMX-induced hyponatremia include clinically appreciable hypovolemia and resolution of hyponatremia with oral or intravenous salt repletion. Salt repletion failed to monotherapeutically enhance our patient's hyponatremiadisfavoring renal salt wasting as originately mechanistic. Contemporaneous refractoriness of serum sodium to fluid restriction nor standard doses of tolvaptan confounded our initial attempts to mechanistically attribute the patient's hyponatremia to a specific cause. Clinical euvolemia and rapid response of hyponatremia to exceptionally high doses of tolvaptan strongly favors syndrome of inappropriate antidiuretic hormone to represent the chief mechanism by which TMP/SMX exacerbates hyponatremia.
Anterior cervical discectomy and fusion vs posterior laminoplasty for the treatment of myelopathy due to two-level localized ossification of the posterior longitudinal ligament
Authors: Noh Sung Hyun , Kim Kyung Hyun , Park Jeong Yoon , Kuh Sung Uk , Chin Dong Kyu , Kim Keun Su , Cho Yong Eun 
Published: August 2020

Abstract
We conducted a retrospective study to compare the clinical and radiological results of anterior cervical discectomy and fusion (ACDF) and posterior laminoplasty for two-level localized ossification of the posterior longitudinal ligament (OPLL).
ACDF and posterior laminoplasty are performed for localized OPLL at the disc and vertebral body levels, respectively.
Eighty six patients with two-level localized OPLL who underwent surgery from January 2011 to December 2016 were retrospectively investigated (41, ACDF group; 45, laminoplasty group). Clinical outcomes were reviewed, and radiologic results such as occupying ratio (OR), space available in the spinal cord, cranial and caudal OPLL-to-disc distance (ODD)/posterior body height (PBH) ratios, segmental angle, C2–C7 Cobb angle, T1 slope, C2–C7 sagittal vertical axis (SVA), and range of motion were investigated.
Patients were followed-up for an average of 42.7 ± 10.5 months. Clinical outcomes, postoperative OR, and space available in the spinal cord were significantly improved at the final follow-up in both groups. Preoperatively, the OR and cranial and caudal ODD/PBH ratios were not significantly different between the groups. Compared to pre-operative values, differences in the segmental and C2–C7 Cobb angles at the final follow-up were statistically significant for the ACDF group (P < .05). The mean operative time, bleeding volume, and the duration of hospitalization were significantly lower in the ACDF group than in the laminoplasty group (P < .05). Complications occurred in 1 ACDF case and in 5 laminoplasty cases.
Both ACDF and laminoplasty provided satisfactory clinical and radiologic outcomes for two-level localized OPLL. However, ACDF was associated with a lower operation time, bleeding loss, duration of hospitalization, and complications.
Nodes staging score to quantify lymph nodes for examination in gastric cancer
Authors: Sun Liping , Liu Qiaohong , Ren He , Li Ping , Liu Gang , Sun Lining 
Published: August 2020

Abstract
The lymph nodal invasion diagnosis is critical for therapeutic-decision and follows up in gastric cancer. However, the number of nodes to be examined for nodal invasion diagnosis is still under controversy, and the model for quantifying risk of missing positive node is currently not reported yet. We analyzed the nodal invasion status of 13,857 gastric cancer samples with records of primary tumor stage, the number of examined and positive lymph nodes in the surveillance, epidemiology, and end results (SEER) database, fitting a beta-binomial model. The nodes need to be examined with different primary tumor stage were determined based on the model. Overall, examining 11 lymph nodes reduces the probability of missing positive nodes to <10%, and the currently median nodes dissected is adequate (12 nodes). While the number of nodes demands to be dissected for T1, T2, T3, and T4 subgroups are 6, 19, 40, and 66, respectively. The currently implemented median value for these samples was 12, 12, 13, and 16, separately. It implies that the number of nodes to be examined is sufficient for early gastric cancer (T1), but it is inadequate for middle and advanced gastric cancer (T2–T3). The clinical significance of nodal staging score was validated with survival information. In summary, we first quantified the lymph nodes to be examined during surgery using a beta-binomial model, and validated with survival information.