bluuebunny/crossref_metadata_2025_split huggingface dataset:
Comparative Safety of Sleeve Gastrectomy and Gastric Bypass
Authors: Chhabra Karan R. , Telem Dana A. , Chao Grace F. , Arterburn David E. , Yang Jie , Thumma Jyothi R. , Ryan Andrew M. , Blumenthal Blanche , Dimick Justin B. 
Published: November 2020

Objective:
To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation.

Summary of Background Data:
Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies).

Methods:
Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable—exploiting variation in the timing of payers’ decisions to cover sleeve gastrectomy as a natural experiment.

Results:
Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009).

Conclusions and Relevance:
In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.
Clinical Trajectories of Acute Kidney Injury in Surgical Sepsis
Authors: Ozrazgat-Baslanti Tezcan , Loftus Tyler J. , Mohandas Rajesh , Wu Quran , Brakenridge Scott , Brumback Babette , Efron Philip A. , Anton Stephen , Moore Frederick A. , Moldawer Lyle L. , Segal Mark S. , Bihorac Azra 
Published: November 2020

Objective:
To characterize endothelial function, inflammation, and immunosuppression in surgical patients with distinct clinical trajectories of AKI and to determine the impact of persistent kidney injury and renal non-recovery on clinical outcomes, resource utilization, and long-term disability and survival.

Summary of Background Data:

AKI is associated with increased healthcare costs and mortality. Trajectories that account for duration and recovery of AKI have not been described for sepsis patients, who are uniquely vulnerable to renal dysfunction.

Methods:
This prospective observational study included 239 sepsis patients admitted and enrolled between January 2015 and July 2017. Kidney Disease: Improving Global Outcomes (KDIGO) and Acute Disease Quality Initiative (ADQI) criteria were used to classify subjects as having no AKI, rapidly reversed AKI, persistent AKI with renal recovery, or persistent AKI without renal recovery. Serial biomarker profiles, clinical outcomes, resource utilization, and long-term physical performance status and survival were compared among AKI trajectories.

Results:
Sixty-two percent of the study population developed AKI. Only one-third of AKI episodes rapidly reversed within 48 hours; the remaining had persistent AKI, among which 57% did not have renal recovery by discharge. One-year survival and proportion of subjects fully active 1 year after sepsis was lowest among patients with persistent AKI compared with other groups. Long-term mortality hazard rates were 5-fold higher for persistent AKI without renal recovery compared with no AKI.

Conclusions:
Among critically ill surgical sepsis patients, persistent AKI and the absence of renal recovery are associated with distinct early and sustained immunologic and endothelial biomarker signatures and decreased long-term physical function and survival.
Challenges and Opportunities for the Academic Mission Within Expanding Health Systems
Authors: Chhabra Karan R. , Diaz Adrian , Byrnes Mary E. , Rajkumar Abishek , Yang Phillip , Dimick Justin B. , Nathan Hari 
Published: November 2020

Objective:
To explore challenges and opportunities for surgery departments’ academic missions as they become increasingly affiliated with expanding health systems.

Summary Background Data:
Academic medicine is in the midst of unprecedented change. In addition to facing intense competition, narrower margins, and decreased federal funding, medical schools are becoming increasingly involved with large, expanding health systems. The impact of these health system affiliations on surgical departments’ academic missions is unknown.

Methods:
Semistructured interviews with 30 surgical leaders at teaching hospitals affiliated with health systems from August - December 2019. Interviews were transcribed verbatim and coded in an iterative process using MaxQDA software. The topic of challenges and opportunities for the academic mission was an emergent theme, analyzed using thematic analysis.

Results:
Academic health systems typically expanded to support their business goals, rather than their academic mission. Changes in governance sometimes disempowered departmental leadership, shifted traditional compensation models, redirected research programs, and led to cultural conflict. However, at many institutions, health system growth cross-subsidized surgical departments’ research and training missions, expanded their clinical footprint, enabled them to improve standards of care, and enhanced opportunities for researchers and trainees.

Conclusions:
Although health system expansion generally intended to advance business goals, the accompanying academic and clinical opportunities were not always fully captured. Alignment between medical school and health system goals enabled some surgical department leaders to take advantage of their health systems’ reach and resources to support their academic missions.
Multicenter International Cohort Validation of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-sedation Scale
Authors: Rakhit Shayan , Wang Li , Lindsell Christopher J. , Hosay Morgan A. , Stewart James W. , Owen Gary D. , Frutos-Vivar Fernando , Pen~uelas Oscar , Esteban Andre´s , Anzueto Antonio R. , Raymondos Konstantinos , Rios Fernando , Thille Arnaud W. , Gonza´lez Marco , Du Bin , Maggiore Salvatore M. , Matamis Dimitrios , Abroug Fekri , Amin Pravin , Zeggwagh Amine A. , Ely E. Wesley , Vasilevskis Eduard E. , Patel Mayur B. 
Published: November 2020

Objective:
In a multicenter, international cohort, we aimed to validate a modified Sequential Organ Failure Assessment (mSOFA) using the Richmond Agitation-Sedation Scale, hypothesized as comparable to the Glasgow Coma Scale (GCS)-based Sequential Organ Failure Assessment (SOFA).

Summary Background Data:
The SOFA score, whose neurologic component is based on the GCS, can predict intensive care unit (ICU) mortality. But, GCS is often missing in lieu of other assessments, such as the also reliable and validated Richmond Agitation Sedation Scale (RASS). Single-center data suggested an RASS-based SOFA (mSOFA) predicted ICU mortality.

Methods:
Our nested cohort within the prospective 2016 Fourth International Study of Mechanical Ventilation contains 4120 ventilated patients with daily RASS and GCS assessments (20,023 patient-days, 32 countries). We estimated GCS from RASS via a proportional odds model without adjustment. ICU mortality logistic regression models and c-statistics were constructed using SOFA (measured GCS) and mSOFA (measured RASS-estimated GCS), adjusted for age, sex, body-mass index, region (Europe, USA-Canada, Latin America, Africa, Asia, Australia-New Zealand), and postoperative status (medical/surgical).

Results:
Cohort-wide, the mean SOFA=9.4+/−2.8 and mean mSOFA = 10.0+/−2.3, with ICU mortality = 31%. Mean SOFA and mSOFA similarly predicted ICU mortality (SOFA: AUC = 0.784, 95% CI = 0.769–0.799; mSOFA: AUC = 0.778, 95% CI = 0.763–0.793, P = 0.139). Across models, other predictors of mortality included higher age, female sex, medical patient, and African region (all P < 0.001).

Conclusions:
We present the first SOFA modification with RASS in a “real-world” international cohort. Estimating GCS from RASS preserves predictive validity of SOFA to predict ICU mortality. Alternative neurologic measurements like RASS can be viably integrated into severity of illness scoring systems like SOFA.
Two-year Outcomes of Prehabilitation Among Obese Patients With Ventral Hernias
Authors: Bernardi Karla , Olavarria Oscar A. , Dhanani Naila H. , Lyons Nicole , Holihan Julie L. , Cherla Deepa V. , Berger David H. , Ko Tien C. , Kao Lillian S. , Liang Mike K. 
Published: November 2020

Objective:
To determine if preoperative nutritional counseling and exercise (prehabilitation) improve outcomes in obese patients seeking ventral hernia repair (VHR)?

Summary Background Data:
Obesity and poor fitness are associated with complications following VHR. It is unknown if preoperative prehabilitation improves outcomes of obese patients seeking VHR.

Methods:
This is the 2-year follow-up of a blinded randomized controlled trial from 2015 to 2017 at a safety-net academic institution. Obese patients (BMI 30–40) seeking VHR were randomized to prehabilitation versus standard counseling. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years. Complications included recurrence, reoperation, and mesh complications. Primary outcome was compared using chi-square. We hypothesize that prehabilitation in obese patients with VHR results in more hernia- and complication-free patients at 2-years.

Results:
Of the 118 randomized patients, 108 (91.5%) completed a median (range) follow-up of 27.3 (6.2–37.4) months. Baseline BMI (mean±SD) was similar between groups (36.8 ± 2.6 vs 37.0 ± 2.6). More patients in the prehabilitation group underwent emergency surgery (5 vs 1) or dropped out of the program (3 vs 1) compared to standard counseling (13.6% vs 3.4%, P = 0.094). Among patients who underwent surgery, there was no difference in major complications (10.2% vs 9.1%, P = 0.438). At 2-years, there was no difference in percentage of hernia-free and complication-free patients (72.9% vs 66.1%, P = 0.424, 1.14, 0.88–1.47).

Conclusion:
There is no difference in 2-year outcomes of obese patients seeking VHR who undergo prehabilitation versus standard care. Prehabilitation may not be warranted in obese patients undergoing elective VHR.
Clinical Trial Registration: This trial was registered with clinicaltrials.gov (NCT02365194).
The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy
Authors: Trudeau Maxwell T. , Casciani Fabio , Maggino Laura , Seykora Thomas F. , Asbun Horacio J. , Ball Chad G. , Bassi Claudio , Behrman Stephen W. , Berger Adam C. , Bloomston Mark P. , Callery Mark P. , Castillo Carlos Fernandez-del , Christein John D. , Dillhoff Mary E. , Dickson Euan J. , Dixon Elijah , Fisher William E. , House Michael G. , Hughes Steven J. , Kent Tara S. , Malleo Giuseppe , Salem Ronald R. , Wolfgang Christopher L. , Zureikat Amer H. , Vollmer Charles M. ,   on behalf of the Pancreas Fistula Study Group
Published: November 2020

Objective:
To investigate the role of intraoperative estimated blood loss (EBL) on development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD).

Background:
Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development.

Methods:
This study consists of 5534 PDs from a 17-institution collaborative (2003–2018). EBL was progressively categorized (≤150mL; 151–400mL; 401–1,000 mL; > 1,000 mL). Impact of additive EBL was assessed using 20 3– factor fistula risk score (FRS) scenarios reflective of endogenous CR-POPF risk.

Results:
CR-POPF developed in 13.6% of patients (N = 753) and median EBL was 400 mL (interquartile range 250-600 mL). CR-POPF and Grade C POPF were associated with elevated EBL (median 350 vs 400 mL, P = 0.002; 372 vs 500 mL, P < 0.001, respectively). Progressive EBL cohorts displayed incremental CR-POPF rates (8.5%, 13.4%, 15.2%, 16.9%; P < 0.001). EBL >400mL was associated with increased CR-POPF occurrence in 13/20 endogenous risk scenarios. Moreover, 8 of 10 scenarios predicated on a soft gland demonstrated increased CR-POPF incidence. Hypothetical projections demonstrate significant reductions in CR-POPF can be obtained with 1–, 2–, and 3-point decreases in FRS points attributed to EBL risk (12.2%, 17.4%, and 20.0%; P < 0.001). This is especially pronounced in high-risk (FRS7–10) patients, who demonstrate up to a 31% reduction (P < 0.001). Surgeons in the lowest-quartile of median EBL demonstrated CR-POPF rates less than half those in the upper-quartile (7.9% vs 18.8%; P < 0.001).

Conclusion:
EBL independently contributes significant biological risk to CR-POPF. Substantial reductions in CR-POPF occurrence are projected and obtainable by minimizing EBL. Decreased individual surgeon EBL is associated with improvements in CR-POPF.
Intermittent Pneumatic Compression in Addition to Standard Prophylaxis of Postoperative Venous Thromboembolism in Extremely High-risk Patients (IPC SUPER): A Randomized Controlled Trial
Authors: Lobastov Kirill , Sautina Ekaterina , Alencheva Eleanora , Bargandzhiya Astanda , Schastlivtsev Ilya , Barinov Victor , Laberko Leonid , Rodoman Grigoriy , Boyarintsev Valeriy 
Published: November 2020

Objective:
To assess the efficacy of adjunctive IPC to standard prophylaxis of postoperative VTE in patients at extremely high-risk.

Summary of Background Data:
The standard prophylaxis for postoperative VTE is insufficient in extremely high-risk patients. It is unclear whether an adjunctive use of IPC would result in a lower incidence of postoperative venous thrombosis.

Methods:
We randomly assigned patients who underwent major surgery and had a Caprini score of ≥11 to receive either IPC in addition to standard prophylaxis with anti-embolic stockings (pressure of 18–21 mm Hg at the ankle) and low-molecular-weight heparin (IPC group) or standard prophylaxis alone (control group). The primary outcome was an asymptomatic venous thrombosis of the lower limbs, as detected by duplex ultrasound scan performed before inclusion and every 3–5 days after surgery.

Results:
A total of 407 patients underwent randomization, of which 204 were assigned to the IPC group and 203 to the control group. The primary outcome occurred in 1 (0.5%) patient in the IPC group and 34 (16.7%) patients in the control group [relative risk, 0.03, 95% confidential interval (CI): 0.01–0.21]. Pulmonary embolism occurred in none of the 204 patients in the IPC group and in 5 (2.5%) patients in the control group (relative risk, 0.09; 95% CI, 0.01–1.63), and postoperative death occurred in 6 (2.9%) patients in the IPC group and 10 (4.9%) in the control group (relative risk, 0.50; 95% CI, 0.50–1.60).

Conclusions:
Among patients with a Caprini score of ≥11 who received standard prophylaxis for VTE, adjunctive IPC resulted in a significantly lower incidence of asymptomatic venous thrombosis.
Artificial Intelligence for Intraoperative Guidance
Authors: Madani Amin , Namazi Babak , Altieri Maria S. , Hashimoto Daniel A. , Rivera Angela Maria , Pucher Philip H. , Navarrete-Welton Allison , Sankaranarayanan Ganesh , Brunt L. Michael , Okrainec Allan , Alseidi Adnan 
Published: November 2020

Objective:
The aim of this study was to develop and evaluate the performance of artificial intelligence (AI) models that can identify safe and dangerous zones of dissection, and anatomical landmarks during laparoscopic cholecystectomy (LC).

Summary Background Data:
Many adverse events during surgery occur due to errors in visual perception and judgment leading to misinterpretation of anatomy. Deep learning, a subfield of AI, can potentially be used to provide real-time guidance intraoperatively.

Methods:
Deep learning models were developed and trained to identify safe (Go) and dangerous (No-Go) zones of dissection, liver, gallbladder, and hepatocystic triangle during LC. Annotations were performed by 4 high-volume surgeons. AI predictions were evaluated using 10-fold cross-validation against annotations by expert surgeons. Primary outcomes were intersection- over-union (IOU) and F1 score (validated spatial correlation indices), and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, ± standard deviation.

Results:
AI models were trained on 2627 random frames from 290 LC videos, procured from 37 countries, 136 institutions, and 153 surgeons. Mean IOU, F1 score, accuracy, sensitivity, and specificity for the AI to identify Go zones were 0.53 (±0.24), 0.70 (±0.28), 0.94 (±0.05), 0.69 (±0.20). and 0.94 (±0.03), respectively. For No-Go zones, these metrics were 0.71 (±0.29), 0.83 (±0.31), 0.95 (±0.06), 0.80 (±0.21), and 0.98 (±0.05), respectively. Mean IOU for identification of the liver, gallbladder, and hepatocystic triangle were: 0.86 (±0.12), 0.72 (±0.19), and 0.65 (±0.22), respectively.

Conclusions:
AI can be used to identify anatomy within the surgical field. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.
Optimising patient fitness: strategies to reduce the effects of cancer cachexia in patients with advanced lung cancer
Authors: Phillips Iain , Kestenbaum Samantha 
Published: November 2020

Purpose of review
Outcomes for patients with advanced lung cancer have traditionally been very poor. This patient group are often comorbid, less fit and experience multiple symptoms. This review discusses strategies for minimizing the impact of cachexia on patients with advanced lung cancer. This is timely, as in recent years there has been a rapid increase in available systemic therapy options, with the potential of long-term survival for some patients.

Recent findings
The review discusses current strategies in combating cachexia, including: symptom control, systemic therapy for cancer and for cachexia, nutritional interventions and exercise interventions. It discusses current clinical trials, combining interventions and the paradigm of prehabilitation.

Summary
It is likely that the optimal way of minimizing the impact of cachexia in advanced lung cancer is through a combination of early interventions including symptom management.
The 2020 breakthroughs in early secondary prevention: dual antiplatelet therapy versus single antiplatelet therapy
Authors: Kargiotis Odysseas , Tsivgoulis Georgios 
Published: November 2020

Purpose of review
Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA.

Recent findings
Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed.

Summary
DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
Acute stroke treatment during coronavirus disease 2019 pandemic
Authors: Baracchini Claudio , Pieroni Alessio 
Published: November 2020

Purpose of review
The coronavirus disease 2019 (COVID-19) pandemic has caused a major impact on stroke care. This review synthesizes the available data and provides a framework for optimal management of stroke patients with confirmed or suspected COVID-19 infection and eligible to reperfusion treatments.

Recent findings
Reorganization of health services has led to the conversion of stroke units and relocation of stroke staff to COVID units. During the pandemic surge, there has been a general decline of stroke presentations, increased time delays, and reduced activity across all areas of stroke care, specifically the delivery of acute treatment. Moreover, COVID-19 patients seem to have a worse outcome despite prompt recanalization. Periprocedural monitoring studies are needed in these patients to target a more adequate therapy.

Summary
The COVID-19 pandemic has jeopardized the ability of stroke centers to provide timely assessment and acute therapies such as reperfusive treatments. Yet, as stroke remains a medical emergency, efforts to maintain stroke teams and safe provision of highly effective stroke treatments should be prioritized despite healthcare systems reorganization. This can be accomplished through the activation of telestroke networks, protected stroke pathways, 24/7 open-access high-quality stroke centers, and stroke awareness programs.