bluuebunny/crossref_metadata_2025_split huggingface dataset:
Surgical Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation Cannulation
Authors: Dao Duy T. , Burgos Carmen M. , Harting Matthew T. , Lally Kevin P. , Lally Pamela A. , Nguyen Hong-An T. , Wilson Jay M. , Buchmiller Terry L. 
Published: August 2019

Objective:
To determine the optimal timing of congenital diaphragmatic hernia (CDH) repair after extracorporeal membrane oxygenation (ECMO) cannulation

Summary Background Data:
The timing of CDH repair after ECMO cannulation remains a controversial topic due to studies with low power or strong selection bias.

Methods:
This is a 2-aim retrospective cohort study based on the CDH Study Group registry for the period of 2007–2017. Aim 1—Compare On versus After ECMO repair. Aim 2—Compare Early versus Late repair on ECMO. In order to minimize selection bias and account for non-repairs, subjects in each aim were stratified into study groups based on their treatment center's characteristics. In each aim, the study groups were matched based on propensity score (PS). The main outcomes included mortality rate and incidence of non-repair.

Results:
In aim 1, 136 patients remained in each group after PS matching. Compared to the After ECMO group, patients in the On ECMO group demonstrated a lower mortality rate, hazard ratio (HR) 0.54 (0.38, 0.77) (P < 0.001), and lower incidence of non-repair, 5.9% versus 33.8% (P < 0.001). In aim 2, 77 patients remained in each group after PS matching. Compared to the Late group, Early repair of CDH on ECMO was associated with a lower mortality rate, HR 0.51 (0.33, 0.77) (P = 0.002), and lower incidence of non-repair, 9.1% versus 44.2% (P < 0.001).

Conclusions:
The approach of early repair after ECMO cannulation is associated with improved survival compared to delayed surgical correction.
Intraoperative 3D Hologram Support With Mixed Reality Techniques in Liver Surgery
Authors: Saito Yu , Sugimoto Maki , Imura Satoru , Morine Yuji , Ikemoto Tetsuya , Iwahashi Shuichi , Yamada Shinichiro , Shimada Mitsuo 
Published: August 2019

Objective:
The aim of this study was to investigate the potential of an intraoperative 3D hologram, which was a computer graphics model liver, with mixed reality techniques in liver surgery.

Summary Background Data:
The merits for the application of a hologram for surgical support are: 1) no sterilized display monitor; 2) better spatial awareness; and 3) 3D images shared by all the surgeons.

Methods:
3D polygon data using preoperative computed tomography data was installed into head mount displays, HoloLens (Microsoft Corporation, Redmond, WA).

Results:
In a Wi-Fi-enabled operative room, several surgeons wearing HoloLens succeeded in sharing the same hologram and moving that hologram from respective operators’ angles by means of easy gesture-handling without any monitors. The intraoperative hologram contributed to better imagination of tumor locations, and for determining the parenchymal dissection line in the hepatectomy for the patients with more than 20 multiple colo-rectal liver metastases. In another case, the hologram enabled a safe Gliisonean pedicle approach for hepato-cellular carcinoma with a hilar anatomical anomaly. Surgeons could easily compare the real patient's anatomy and that of the hologram just before the hepatic hilar procedure.

Conclusions:
This initial experience suggested that an intraoperative hologram with mixed reality techniques contributed to “last-minute simulation,” not for “navigation.” The intraoperative hologram might be a new next-generation operation-supportive tool in terms of spatial awareness, sharing, and simplicity.
Do the 2018 Leapfrog Group Minimal Hospital and Surgeon Volume Thresholds for Esophagectomy Favor Specific Patient Demographics?
Authors: Clark James M. , Cooke David T. , Hashimi Habiba , Chin David , Utter Garth H. , Brown Lisa M. , Nuño Miriam 
Published: August 2019

Objective:
We examine how esophagectomy volume thresholds reflect outcomes relative to patient characteristics.

Summary Background Data:
Esophagectomy outcomes are associated with surgeon and hospital operative volumes, leading the Leapfrog Group to recommend minimum annual volume thresholds of 7 and 20 respectively.

Methods:
Patients undergoing esophagectomy for cancer were identified from the 2007–2013 New York and Florida Healthcare Cost and Utilization Project's State Inpatient Databases. Logit models adjusted for patient characteristics evaluated in-hospital mortality, complications, and prolonged length of stay (PLOS). Median surgeon and hospital volumes were compared between young-healthy (age 18–57, Elixhauser Comorbidity Index [ECI] <2) and older-sick patients (age ≥71, ECI >4).

Results:
Of 4330 esophagectomy patients, 3515 (81%) were male, median age was 64 (interquartile range 58–71), and mortality was 4.0%. Patients treated by both low-volume surgeons and hospitals had the greatest mortality risk (5.0%), except in the case of older-sick patients mortality was highest at high-volume hospitals with high-volume surgeons (12%). For mortality <1%, annual hospital and surgeon volumes needed were 23 and 8, respectively; mortality rose to 4.2% when volumes dropped to the Leapfrog thresholds of 20 and 7, respectively. Complication rose from 53% to 63% when hospital and surgeon volumes decreased from 28 and 10 to 19 and 7, respectively. PLOS rose from 19% to 27% when annual hospital and surgeon volumes decreased from 27 and 8 to 20 and 7, respectively.

Conclusions:
Current Leapfrog Group esophagectomy volume guidelines may not predict optimal outcomes for all patients, especially at extremes of age and comorbidities.
Nationwide Study of Ruptured Abdominal Aortic Aneurysms During Twenty Years (1994–2013)
Authors: Gunnarsson Kim , Wanhainen Anders , Björck Martin , Djavani-Gidlund Khatereh , Mani Kevin 
Published: August 2019

Objective:
To analyze the epidemiology of ruptured abdominal aortic aneurysms (RAAA) in Sweden over 20 years, and assess the effect of endovascular repair (EVAR) on surgical treatment rate and outcome.

Methods:
All Swedish citizens >50 years with RAAA 1994 to 2013 were extracted from 3 national (Cause of Death, Patient, and Vascular Surgical) registries. Incidence, proportion repaired, surgical techniques, and 90-day mortality were assessed based on sex and age groups, with regression analysis.

Results:
18,726 individuals with RAAA were identified, 74.0% men. The incidence of RAAA decreased from 33.1/100,000: 1994 to 21.3/100,000: 2013 (relative change −35.6%, P < 0.001). The proportion of men with RAAA undergoing repair was 44.5%: 1994–1998, 49.7%: 2009–2013 (+11.7%, P < 0.001). In women, 22.3% were repaired in 1994–1998, versus 28.2%: 2009–2013 (+26.4%, P < 0.001). The proportion undergoing repair increased in octogenarians (men: +44.3%, P < 0.001; women +49.3%, P = 0.001). EVAR increased from 0% initially to 42.3% in men and 41.2% in women 2013. Overall, mortality rate among all individuals with RAAA decreased, men 75.8%: 1994–1998, 64.8%: 2009–2013 (−14.5%, P < 0.001); women 88.5%: 1994–1998, 82.2%: 2009–2013 (−7.1%, P < 0.001). Among those who underwent repair, mortality was 47.0% in men: 1994–1998, 31.8%: 2009–2013 (−32.3%, P < 0.001); women 51.8%: 1994–1998, 41.4%: 2009–2013 (−20.1%, P = 0.010).

Conclusion:
RAAA mortality among men decreased, mainly attributed to falling incidence of RAAA. The mortality was further reduced by more patients being offered repair, increasingly often with EVAR, and improved survival after repair. Incidence of rupture remained unchanged among women, who had higher RAAA mortality. Focused efforts to reduce RAAA mortality among women are warranted.
Significance of Examined Lymph Node Number in Accurate Staging and Long-term Survival in Resected Stage I–II Pancreatic Cancer—More is Better? A Large International Population-based Cohort Study
Authors: Huang Lei , Jansen Lina , Balavarca Yesilda , van der Geest Lydia , Lemmens Valery , Koerkamp Bas Groot , van Santvoort Hjalmar C. , Grützmann Robert , Besselink Marc G. , Schrotz-King Petra , Brenner Hermann 
Published: August 2019

Objective:
This large international cohort study aimed to investigate the associations of examined lymph node (ELN) number with accurate staging and long-term survival in pancreatic adenocarcinoma (PaC) and to robustly determine the minimal and optimal ELN thresholds.

Summary Background Data:
ELN number is an important quality metric in cancer care. The recommended minimal ELN number in PaC to accurately stage cancer varies greatly across guidelines, and the optimal number especially to adequately stratify patient survival has not yet been established.

Methods:
Population-based data on patients with stage I to II PaC resected in 2003 to 2015 from the US Surveillance, Epidemiology, and End Results (SEER)-18 Program and Netherlands National Cancer Registry (NCR) were analyzed. Associations of ELN number with stage migration and survival were evaluated using multivariable-adjusted logistic and Cox regression models, respectively. The series of odds ratios (ORs) for negative-to-positive node stage migration and hazard ratios (HRs) for survival with more ELNs were fitted using a LOWESS smoother, and structural breakpoints were determined by Chow test.

Results:
Overall 16,241 patients were analyzed. With increasing ELN number, both cohorts exhibited significant proportional increases from nodenegative to node-positive disease [OR
SEER-18 = 1.05, 95% confidence interval (CI) = 1.04–1.05; ORNCR = 1.10, 95% CI = 1.08–1.12] and serial improvements in survival (HR
SEER-18 = 0.98, 95% CI = 0.98–0.99; HRNCR = 0.98, 95% CI = 0.97–0.99) per additional ELN after controlling for confounders. Associations for stage migration and survival remained significant in most stratifications by patient, tumor, and treatment factors. Cut-point analyses suggested a minimal threshold ELN number of 11 and an optimal number of 19, which were validated both internally in the derivative US cohort and externally in the Dutch cohort with the ability to well discriminate different probabilities of both survival and stage migration.

Conclusions:
In stage I to II PaC, more ELNs are associated with more precise nodal staging, which might largely explain the survival association. Our observational study does not suggest causality, and does not encourage more extended lymphadenectomy before further randomized evidence is obtained. Our results robustly conclude 11 ELNs as the minimal and suggest 19 ELNs as the optimal cut-points, for evaluating quality of lymph node examination and possibly for stratifying postoperative prognosis.
Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial
Authors: Neogi Probal , Kumar Pankaj , Kumar Shritosh 
Published: August 2019

Background/Purpose:
To compare the changes in hepatic enzymes and comfort level of the surgeon in low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPPLC, 7 mm Hg) with that of normal pressure pneumoperitoneum laparoscopic cholecystectomy (NPPLC, 14 mm Hg).

Methods:
Eighty-two patients were randomly divided into 2 groups (LPPLC and NPPLC). Serum levels of bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and lactate dehydrogenase were measured before the operation, at the time of reversal from anesthesia, 24 hours after the operation, and on day 7. Serious adverse events, intra-operative complications, surgeon’s comfort level of dissection, operative time, conversion rates to an open procedure, or normal pressure pneumoperitoneum were recorded.

Results:
Of the 41 patients randomized for LPPLC, 8 patients were converted to NPPLC due to difficulty in dissection and 1 converted to open in each group. There was statistically significant fall in mean serum bilirubin level in both the groups in the immediate postoperative period (P<0.05). Statistically significant increase in its level was observed after 24 hours in the NPPLC group only (P<0.05). Levels of mean serum serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and lactate dehydrogenase increased significantly (P<0.05) in immediate postoperative period and a further increase was observed after 24 hours (P<0.05) in the NPPLC group only. The comfort level of surgeon was found to be significantly better in the NPPLC group.

Conclusions:
LPPLC is a safe procedure, especially in the hands of an experienced surgeon with clinically insignificant systemic effects. But the comfort level of surgeon is better in normal pressure when compared with low pressure. In patients with deranged hepatic functions undergoing advanced laparoscopic procedures, it is advisable to start the surgery with low-pressure pneumoperitoneum. Pressure may be escalated further as per the surgeon’s comfort.
Selective nonoperative management of renal gunshot wounds
Authors: Schellenberg Morgan , Benjamin Elizabeth , Piccinini Alice , Inaba Kenji , Demetriades Demetrios 
Published: August 2019

BACKGROUND
Selective nonoperative management (SNOM) of blunt kidney injuries has been the standard of care for decades. However, the role of SNOM after renal gunshot wounds (GSWs) remains unclear. The purpose of this study was to assess the safety and outcomes of SNOM of renal GSWs at a national level.

METHODS
The National Trauma Data Bank was queried for patients who sustained a GSW to the kidney (January 2007 to December 2014). Patients with emergency department death, transfer, nonsurvivable (Abbreviated Injury Scale score = 6) injuries, absent vitals on arrival, associated hollow viscus or major abdominal vascular injury, or missing procedure/discharge data were excluded. Study groups were defined according to management strategy, with operative management (OM) defined as laparotomy 4 hours or less from admission and SNOM defined by the lack of laparotomy 4 hours or less from admission. Demographics, injury data, and outcomes (mortality, complications, need for nephrectomy, failure of SNOM [defined as laparotomy 5–72 hours after admission], and hospital length of stay [LOS]) were collected. Logistic regression compared outcomes between SNOM and OM.

RESULTS
Over the study period, 1,329 patients met inclusion and exclusion criteria. Of these, 459 (34.5%) underwent SNOM (38.6% of American Association for the Surgery of Trauma kidney injury grades I–II, 39.4% of grade III, 24.0% of grade IV, and 5.2% of grade V). SNOM was associated with significantly shorter hospital LOS (6 days vs. 9 days, p < 0.001). Failure of SNOM occurred in 10.2%. Logistic regression showed no association between SNOM and mortality (odds ratio [OR], 0.614, p = 0.244). However, SNOM was independently associated with fewer complications (OR, 0.711; p = 0.008) and a reduction in need for nephrectomy (OR, 0.056; p < 0.001).

CONCLUSION
SNOM of GSWs to the kidney has become a common practice in the United States. It is safe and has a high success rate, even in severe kidney injuries. It decreases hospital LOS and is independently associated with fewer complications and reduced need for nephrectomy.

LEVEL OF EVIDENCE
Therapeutic/Care Management, level IV.
Delayed interhospital transfer of critically ill patients with surgical sepsis
Authors: Loftus Tyler J. , Wu Quran , Wang Zhongkai , Lysak Nicholas , Moore Frederick A. , Bihorac Azra , Efron Philip A. , Mohr Alicia M. , Brakenridge Scott C. 
Published: August 2019

BACKGROUND
Suboptimal triage of critically ill patients with surgical sepsis may contribute to adverse outcomes. Patients transferred to a tertiary care center after spending 24 hours or longer at an outside facility were compared with patients who had early triage to a tertiary care center with the null hypothesis that management parameters and outcomes would be similar between groups.

METHODS
This prospective observational cohort study included 308 patients treated for surgical sepsis in a surgical intensive care unit at a tertiary care center. Patients transferred after spending more than 24 hours at an outside facility (n = 69) were compared with patients who were directly admitted or transferred within 24 hours (n = 239). Patient characteristics, management parameters, and outcomes were compared between groups. This study was registered at ClinicalTrials.gov (NCT02276066).

RESULTS
Average outside facility length of stay in the delayed transfer group was 43 hours. Delayed transfer patients had higher sequential organ failure assessment (7 vs. 5, p = 0.003) and APACHE II scores (19 vs. 16, p = 0.007) on admission. The interval between admission and source control was significantly longer in the delayed transfer group (12.1 hours vs. 1.0 hours, p = 0.009). The incidence of nosocomial infection was significantly higher in the delayed transfer group (41% vs. 23%, p = 0.005). Delayed transfer was independently associated with a 10-day increase in hospital length of stay. Delayed transfer patients were less likely to be discharged home (22% vs. 59%, p < 0.001) and suffered twofold higher in-hospital mortality (14.5% vs. 7.1%, p = 0.056).

CONCLUSION
Patients with surgical sepsis who spent more than 24 hours at an outside facility prior to transfer had greater initial illness severity, longer intervals between admission and source control, and more nosocomial infections compared with patients who had early triage to a tertiary care center.

LEVEL OF EVIDENCE
Care management/therapeutic, Level IV; Epidemiologic/prognostic, Level III.
The Israel Defense Forces experience with freeze-dried plasma for the resuscitation of traumatized pediatric patients
Authors: Nadler Roy , Mozer-Glassberg Yael , Gaines Barbara , Glassberg Elon , Chen Jacob 
Published: August 2019

BACKGROUND
With the growing recognition of the disadvantages of crystalloid- and colloid-based resuscitation and the advantages of using blood products as the preferred resuscitation fluid, the Israel Defense Forces Medical Corps (IDF-MC) adopted plasma as the primary volume resuscitation regimen in 2013. While data are accumulating for prehospital plasma transfusion, little to no data exist regarding using plasma as a prehospital resuscitation fluid for traumatized pediatric patients.

METHODS
All patients treated by the IDF-MC personnel are recorded in the IDF Trauma Registry, a unique prehospital trauma registry. All patients treated by the IDF advanced life support providers with FDP at the point of injury between April 2013 and June 2018 who were younger than 18 years at the time of injury were included.

RESULTS
Six hundred seventy-nine children were treated by IDF medical providers, of whom 33 (5%) were identified in the IDF Trauma Registry as having received FDP at the point of injury. Most patients (80%) were treated for penetrating injuries. Most patients received one plasma unit. Fifty-four percent of the patients were also treated by Tranexamic Acid (TXA) and 48% were transfused with crystalloids. In 33% of patients, additional life-saving interventions were performed.

CONCLUSION
While the ideal resuscitation fluid for the pediatric population remains to be determined, it seems reasonable to pursue a similar approach to that of applied that for adults. In the IDF-MC, the resuscitation fluid of choice for trauma patients in hemorrhagic shock is freeze-dried plasma transfused at the point of injury. The current study demonstrates the feasibility of FDP administration in the prehospital scenario for injured children and further supports the growing confidence in the use of FDP for the treatment of pediatric trauma patients.

LEVEL OF EVIDENCE
Retrospective descriptive study, level IV.
Ketamine infusion for pain control in elderly patients with multiple rib fractures: Results of a randomized controlled trial
Authors: Kugler Nathan W. , Carver Thomas W. , Juul Janelle , Peppard William J. , Boyle Kelly , Drescher Karin Madsen , Szabo Aniko , Rein Lisa , Somberg Lewis B. , Paul Jasmeet S. 
Published: August 2019

BACKGROUND
Rib fractures are associated with increased mortality, particularly in the elderly. While opiate-based pain regimens remain the cornerstone of rib fracture management, issues related to opioids have driven research into alternative analgesics. Adjunctive ketamine use in lieu of opioids continues to increase but little evidence exists to support its efficacy or safety within the elderly trauma population.

METHODS
A prospective, randomized, double-blind placebo-controlled trial of elderly patients (age, ≥65 years) with three or more rib fractures admitted to a Level I trauma center was conducted. Exclusion criteria included Glasgow Coma Scale score less than 14, and chronic opiate use. Groups were randomized to either low-dose ketamine (LDK) at 2 μg·kg−1·min−1 or an equivalent rate of 0.9% normal saline. The primary outcome was reduction in numeric pain scores (NPS). Secondary outcomes included oral morphine equivalent (OME) utilization, epidural rates, pulmonary complications, and adverse events.

RESULTS
Thirty (50.8%) of 59 were randomized to the experimental arm. Groups were similar in makeup. Low-dose ketamine failed to reduce 24-hour NPS or OME totals. Subgroup analysis of 24 patients with Injury Severity Score greater than 15 demonstrated that LDK was associated with a reduction in OME utilization the first 24-hours (25.6 mg vs. 42.6 mg, p = 0.04) but at no other time points. No difference in other secondary outcomes or adverse events was noted.

CONCLUSION
Low-dose ketamine failed to affect NPS or OME within the overall cohort, but a decrease in OME was observed in those with an Injury Severity Score greater than 15. Additional studies are necessary to confirm whether LDK benefits severely injured elderly patients.

LEVEL OF EVIDENCE
Therapeutic, level I.
The Sequential Clinical Assessment of Respiratory Function (SCARF) score: A dynamic pulmonary physiologic score that predicts adverse outcomes in critically ill rib fracture patients
Authors: Hardin Kimberly S. , Leasia Kiara N. , Haenel James , Moore Ernest E. , Burlew Clay Cothren , Pieracci Fredric M. 
Published: August 2019

BACKGROUND
Rib fracture scoring systems are limited by a lack of serial pulmonary physiologic variables. We created the Sequential Clinical Assessment of Respiratory Function (SCARF) score and hypothesized that admission, maximum, and rising scores predict adverse outcomes among critically ill rib fracture patients.

METHODS
Prospective cohort study of rib fracture patients admitted to the surgical intensive care unit (ICU) at a Level I trauma center from August 2017 to June 2018. The SCARF score was developed a priori and validated using the cohort. One point was assigned for: <50% predicted, respiratory rate >20, numeric pain score ≥5, and inadequate cough. Demographics, injury patterns, analgesics, and adverse pulmonary outcomes were abstracted. Performance characteristics of the score were assessed using the receiver operator curve area under the curve.

RESULTS
Three hundred forty scores were available from 100 patients. Median admission and maximum SCARF score was 2 (range 0-4). Likelihood of pneumonia (p = 0.04), high oxygen requirement (p < 0.01), and prolonged ICU length of stay (p < 0.01) were significantly associated with admission and maximum scores. The receiver operator curve area under the curve for the maximum SCARF score for these outcomes were 0.86, 0.76, and 0.79, respectively. In 10 patients, the SCARF score worsened from admission to day 2; these patients demonstrated increased likelihood of pneumonia (p = 0.04) and prolonged ICU length of stay (p = 0.07). Patients who developed complications maintained a SCARF score one point higher throughout ICU stay compared with patients who did not (p = 0.04). The SCARF score was significantly associated with both narcotic (p = 0.03) and locoregional anesthesia (p = 0.03) usage.

CONCLUSION
Admission, maximum, daily, and rising scores were associated with utilization of pain control therapies and development of adverse outcomes. The SCARF score may be used to guide therapies for critically ill rib fracture patients, with a proposed threshold greater than 2.

LEVEL OF EVIDENCE
Prognostic study, level II.