bluuebunny/crossref_metadata_2025_split huggingface dataset:
Posterior Inferior Cerebellar Artery/Vertebral Artery Subarachnoid Hemorrhage: A Comparison of Saccular vs Dissecting Aneurysms
Authors: Foster Mitchell T , Herwadkar Amit , Patel Hiren C 
Published: March 2017

Abstract

BACKGROUND
Two distinct categories of aneurysms are described in relation to the posterior inferior cerebellar artery (PICA) and vertebral artery (VA): saccular (SA) and dissecting (DA) types. This distinction is often unrecognized because abnormalities here are uncommon and most studies are small.

OBJECTIVE
To determine if there are any differences in the clinical presentation, in-hospital course, or outcomes in patients with DA vs SA of the PICA or VA.

METHODS
Thirty-eight patients with a VA or PICA aneurysm were identified from a departmental subarachnoid hemorrhage database and categorized into DA or SA types. Prospectively collected demographic and outcome data (length of stay, discharge Glasgow Outcome Score) were supplemented by abstracting records for procedural data (extraventricular drain [EVD], ventriculoperitoneal [VP] shunt, tracheostomy, and nasogastric feeding). Univariate, binary logistic regression, and Cox regression analysis was used to compare patients with SA vs DA.

RESULTS
Three aneurysms related to arteriovenous malformation were excluded. Five patients were conservatively managed. Of the 30 treated cases, more patients with a DA presented in poor grade (6/13 vs 2/17 SA; P = .035). More DA patients required an EVD (85% vs 29%; P = .003), VP shunt (54% vs 6%; P = .003), tracheostomy (46% vs 6%; P < .01), and nasogastric feeding (85% vs 35%; P = .007). The median length of stay (41 vs 17 d, P < .001) was longer, and the age and injury severity adjusted odds of discharge home were significantly lower in the DA group (P = .008). Thirty-day mortality was not significantly different (23% of DA vs 24% of SA; P = .2).

CONCLUSION
The presentation, clinical course, and outcomes differ in patients with DA vs SA of the PICA and VA.
Re-operation After Long-Segment Fusions for Adult Spinal Deformity: The Impact of Extending the Construct Below the Lumbar Spine
Authors: Witiw Christopher D , Fessler Richard G , Nguyen Stacie , Mummaneni Praveen , Anand Neel , Blaskiewicz Donald , Uribe Juan , Wang Michael Y , Kanter Adam S , Okonkwo David , Park Paul , Deviren Vedat , Akbarnia Behrooz A , Eastlack Robert K , Shaffrey Christopher , Mundis Gregory M ,   on behalf of the International Spine Study Group
Published: March 2017

Abstract

BACKGROUND
Deciding where to end a long-segment fusion for adult spinal deformity (ASD) may be a challenge, particularly in the absence of an abnormality at L5/S1. Some suggest prophylactic extension of the construct to the sacrum and/or ilium (S/I) to protect against distal junctional failure, while others support terminating in the lower lumbar spine to preserve motion.

OBJECTIVE
To compare the risk of re-operation after long-segment fusions for ASD that ends at L4 or L5 (L4/5) vs S/I.

METHODS
A multicenter database of patients treated for ASD by circumferential minimally invasive surgery or hybrid surgical technique was screened for individuals with long fusions (≥4 vertebral levels) ending at L4 or below and with at least 2 yr of follow-up. Multivariate regression modeling was used to compare surgical morbidity between the L4/5 and S/I groups, and Cox proportional hazard modeling was used to compare risk of re-operation.

RESULTS
There were 45 subjects with fusion to L4/5 and 71 to S/I. Over a 32-mo median follow-up, 41 re-operations were performed; 6 were for distal junctional failure. In those with normal or mild degeneration at L5/S1, fusion to S/I afforded no significant change in re-operative risk (hazard ratio = 1.18 [95% confidence interval: 0.53-2.62], P = .682). In those undergoing circumferential minimally invasive surgery correction, fusion to S/I was associated with significantly greater blood loss (499.6 cc, P < .001) and surgical time (97.5 min, P = .04).

CONCLUSION
In the setting of a normal or mildly degenerated L5/S1 disc space, fusion to the sacrum/ilium did not significantly change the risk of requiring a re-operation after a long-segment fusion for ASD.
Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High-risk Cardiac Surgery Patients
Authors: Zarbock Alexander , Kellum John A. , Van Aken Hugo , Schmidt Christoph , Küllmar Mira , Rosenberger Peter , Martens Sven , Görlich Dennis , Meersch Melanie 
Published: March 2017

Abstract

Background
In a multicenter, randomized trial, the authors enrolled patients at high-risk for acute kidney injury as identified by a Cleveland Clinic Foundation score of 6 or more. The authors enrolled 240 patients at four hospitals and randomized them to remote ischemic preconditioning or control. The authors found that remote ischemic preconditioning reduced acute kidney injury in high-risk patients undergoing cardiac surgery. The authors now report on the effects of remote ischemic preconditioning on 90-day outcomes.

Methods
In this follow-up study of the RenalRIP trial, the authors examined the effect of remote ischemic preconditioning on the composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction at 90 days. Secondary outcomes were persistent renal dysfunction and dialysis dependence in patients with acute kidney injury.

Results
Remote ischemic preconditioning significantly reduced the occurrence of major adverse kidney events at 90 days (17 of 120 [14.2%]) versus control (30 of 120 [25.0%]; absolute risk reduction, 10.8%; 95% CI, 0.9 to 20.8%; P = 0.034). In those patients who developed acute kidney injury after cardiac surgery, 2 of 38 subjects in the remote ischemic preconditioning group (5.3%) and 13 of 56 subjects in the control group (23.2%) failed to recover renal function at 90 days (absolute risk reduction, 17.9%; 95% CI, 4.8 to 31.1%; P = 0.020). Acute kidney injury biomarkers were also increased in patients reaching the major adverse kidney event endpoint compared to patients who did not.

Conclusions
Remote ischemic preconditioning significantly reduced the 3-month incidence of a composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction in high-risk patients undergoing cardiac surgery. Furthermore, remote ischemic preconditioning enhanced renal recovery in patients with acute kidney injury.
Evidence-based Pediatric Orthopaedics: How Safe is “Safe”?
Authors: Augustithis G. Alexander , Ensor Hannah Margaret , Huntley James S. 
Published: March 2017

Background:
The aim of minimizing the risks of complications and adverse events is at the center of surgical practice.
This study aimed to assess the evidence on which pediatric orthopaedic surgical procedures are described as “safe.” In particular, the objective was to ascertain the proportion of studies describing a procedure as “safe,” which achieved a 95% upper limit confidence interval of risk of 5% or less for major adverse events.

Method:
A primary search of Journal of Paediatric Orthopaedics 2009 to 2014 for the single term “safe” returned 71 papers appropriate for analysis. Of these, 60 positively identified at least 1 intervention as “safe.” These papers were analyzed and the number of interventions and the number of complications recorded. Data sets (n=67) were created and the 95% upper confidence interval calculated for the probability of a complication.

Results:
Only 16 data sets (ex 67) provided evidence that the probability of a major complication was under 5%.

Conclusions:
This work suggests there is widespread failure of understanding of how low sample sizes or can lead to an unjustifiable claim that procedures are “safe.”

Level of Evidence:
Unclassifiable.
Delirium and Mortality in Critically Ill Children: Epidemiology and Outcomes of Pediatric Delirium*
Authors: Traube Chani , Silver Gabrielle , Gerber Linda M. , Kaur Savneet , Mauer Elizabeth A. , Kerson Abigail , Joyce Christine , Greenwald Bruce M. 
Published: March 2017

Objectives:
Delirium occurs frequently in adults and is an independent predictor of mortality. However, the epidemiology and outcomes of pediatric delirium are not well-characterized. The primary objectives of this study were to describe the frequency of delirium in critically ill children, its duration, associated risk factors, and effect on in-hospital outcomes, including mortality. Secondary objectives included determination of delirium subtype, and effect of delirium on duration of mechanical ventilation, and length of hospital stay.

Design:
Prospective, longitudinal cohort study.

Setting:
Urban academic tertiary care PICU.

Patients:
All consecutive admissions from September 2014 through August 2015.

Interventions:
Children were screened for delirium twice daily throughout their ICU stay.

Measurements and Main Results:
Of 1,547 consecutive patients, delirium was diagnosed in 267 (17%) and lasted a median of 2 days (interquartile range, 1–5). Seventy-eight percent of children with delirium developed it within the first 3 PICU days. Most cases of delirium were of the hypoactive (46%) and mixed (45%) subtypes; only 8% of delirium episodes were characterized as hyperactive delirium. In multivariable analysis, independent predictors of delirium included age less than or equal to 2 years old, developmental delay, severity of illness, prior coma, mechanical ventilation, and receipt of benzodiazepines and anticholinergics. PICU length of stay was increased in children with delirium (adjusted relative length of stay, 2.3; CI = 2.1–2.5; p < 0.001), as was duration of mechanical ventilation (median, 4 vs 1 d; p < 0.001). Delirium was a strong and independent predictor of mortality (adjusted odds ratio, 4.39; CI = 1.96–9.99; p < 0.001).

Conclusions:
Delirium occurs frequently in critically ill children and is independently associated with mortality. Some in-hospital risk factors for delirium development are modifiable. Interventional studies are needed to determine best practices to limit delirium exposure in at-risk children.
Cumulative Probability and Time to Reintubation in U.S. ICUs
Authors: Miltiades Andrea N. , Gershengorn Hayley B. , Hua May , Kramer Andrew A. , Li Guohua , Wunsch Hannah 
Published: March 2017

Objective:
Reintubation after liberation from mechanical ventilation is viewed as an adverse event in ICUs. We sought to describe the frequency of reintubations across U.S. ICUs and to propose a standard, appropriate time cutoff for reporting of reintubation events.

Design and Setting:
We conducted a cohort study using data from the Project IMPACT database of 185 diverse ICUs in the United States.

Patients:
We included patients who received mechanical ventilation and excluded patients who received a tracheostomy, had a do-not-resuscitate order placed, or died prior to first extubation.

Measurements and Main Results:
We assessed the percentage of patients extubated who were reintubated; the cumulative probability of reintubation, with death and do-not-resuscitate orders after extubation modeled as competing risks, and time to reintubation. Among 98,367 patients who received mechanical ventilation without death or tracheostomy prior to extubation, 9,907 (10.1%) were reintubated, with a cumulative probability of 10.0%. Median time to reintubation was 15 hours (interquartile range, 2–45 hr). Of patients who required reintubation in the ICU, 90% did so within the first 96 hours after initial extubation; this was consistent across various patient subtypes (89.3% for electives surgical patients up to 94.8% for trauma patients) and ICU subtypes (88.6% for cardiothoracic ICUs to 93.5% for medical ICUs).

Conclusions:
The reintubation rate for ICU patients liberated from mechanical ventilation in U.S. ICUs is approximately 10%. We propose a time cutoff of 96 hours for reintubation definitions and benchmarking efforts, as it captures 90% of ICU reintubation events. Reintubation rates can be reported as simple percentages, without regard for deaths or changes in goals of care that might occur.
Estrogen and DPP-4 inhibitor share similar efficacy in reducing brain pathology caused by cardiac ischemia-reperfusion injury in both lean and obese estrogen-deprived rats
Authors: Pratchayasakul Wasana , Sivasinprasasn Sivaporn , Sa-Nguanmoo Piangkwan , Proctor Cicely , Kerdphoo Sasiwan , Chattipakorn Nipon , Chattipakorn Siriporn C. 
Published: March 2017

Abstract

Objective:
Cardiac ischemia-reperfusion injury (I/R) caused an oxidative burst, increased beta-amyloid production, and decreased dendritic spine density in the brain. However, the effect of cardiac I/R in the brain of estrogen-deprived rats who were or were not obese have not been investigated. Moreover, the benefits of estrogen or dipeptidyl peptidase-4 (DDP-4) inhibitor therapies in those conditions have never been determined. We hypothesized that cardiac I/R aggravates brain pathology in estrogen-deprived obese rats, to a greater extent when compared with estrogen-deprived lean rats, and treatment with either estrogen or a DPP-4 inhibitor attenuates those adverse effects.

Methods:
In protocol 1, rats were divided into sham operation (n = 12) or ovariectomy (n = 24). Sham-operated rats were fed with normal diet (ND) and ovariectomized rats were fed with either ND or high-fat diet (HF) for 12 weeks. Then, rats were subdivided to sham operation or cardiac I/R injury. In protocol 2, ovariectomized rats were given either ND (n = 18) or HF (n = 18). At week 13, ovariectomized rats were subdivided to receive vehicle, estradiol, or DPP-4 inhibitor for 4 weeks. Then, all rats were subjected to cardiac I/R.

Results:
Cardiac I/R injury aggravated brain oxidative stress, beta-amyloid production, and decreased dendritic spine density in either sham-operated or ovariectomized ND-fed rats, but not in ovariectomized HF-fed rats. Either estrogen or DPP-4 inhibitor therapies reduced those conditions in all rats with cardiac I/R.

Conclusions:
Cardiac I/R aggravates brain toxicity in estrogen-deprived lean rats, but not in the estrogen-deprived obese rats. Estrogen and DPP-4 inhibitor treatments attenuate those effects in all groups.
Racial Differences and Disparities in Osteoporosis-related Bone Health
Authors: Cram Peter , Saag Kenneth G. , Lou Yiyue , Edmonds Stephanie W. , Hall Sylvie F. , Roblin Douglas W. , Wright Nicole C. , Jones Michael P. , Wolinsky Fredric D. 
Published: March 2017

Background:
Determining whether observed differences in health care can be called disparities requires persistence of differences after adjustment for relevant patient, provider, and health system factors. We examined whether providing dual-energy x-ray absorptiometry (DXA) test results directly to patients might reduce or eliminate racial differences in osteoporosis-related health care.

Design, Subjects, and Measures:
We analyzed data from 3484 white and 1041 black women who underwent DXA testing at 2 health systems participating in the Patient Activation after DXA Result Notification (PAADRN) pragmatic clinical trial (ClinicalTrials.gov NCT-01507662) between February 2012 and August 2014. We examined 7 outcomes related to bone health at 12 weeks and 52 weeks post-DXA: (1) whether the patient correctly identified their DXA baseline results; (2) whether the patient was on guideline-concordant osteoporosis pharmacotherapy; (3) osteoporosis-related satisfaction; (4) osteoporosis knowledge; (5 and 6) osteoporosis self-efficacy for exercise and for diet; and (7) patient activation. We examined whether unadjusted differences in outcomes between whites and blacks persisted after adjusting for patient, provider, and health system factors.

Results:
Mean age was 66.5 years and 29% were black. At baseline black women had less education, poorer health status, and were less likely to report a history of osteoporosis (P<0.001 for all). In unadjusted analyses black women were less likely to correctly identify their actual DXA results, more likely to be on guideline-concordant therapy, and had similar patient activation. After adjustment for patient demographics, baseline health status and other factors, black women were still less likely to know their actual DXA result and less likely to be on guideline-concordant therapy, but black women had greater patient activation.

Conclusions:
Adjustment for patient and provider level factors can change how racial differences are viewed, unmasking new disparities, and providing explanations for others.
Impact of Donor Age on Recipient Survival in Adult-to-Adult Living-donor Liver Transplantation
Authors: Kubota Toyonari , Hata Koichiro , Sozu Takashi , Ueda Yoshihide , Hirao Hirofumi , Okamura Yusuke , Tamaki Ichiro , Yoshikawa Junichi , Kusakabe Jiro , Tanaka Hirokazu , Kageyama Shoichi , Anazawa Takayuki , Yoshizawa Atsushi , Yagi Shintaro , Yamashiki Noriyo , Okajima Hideaki , Kaido Toshimi , Uemoto Shinji 
Published: March 2017

Objective:
To investigate the influence of donor age on recipient outcome after living-donor partial liver transplantation (LDLT).

Background:
Donor age is a well-known prognostic factor in deceased donor liver transplantation; however, its role in LDLT remains unclear.

Methods:
We retrospectively analyzed 315 consecutive cases of primary adult-to-adult LDLT in our center between April 2006 and March 2014. Recipients were divided into 5 groups according to the donor age: D-20s (n = 60); D-30s (n = 72); D-40s (n = 57); D-50s (n = 94); and D-60s (n = 32). The recipient survival and the association with various clinical factors were investigated.

Results:
Recipient survival proportions were significantly higher in D-20s compared with all the other groups (P = 0.008, < 0.001, < 0.001, and = 0.006, vs D-30s, -40s, -50s, and -60s, respectively), whereas there was no association between recipient survival and their own age. There are 3 typical relationships between donors and recipients in adult-to-adult LDLT: from child-to-parent, between spouses/siblings, and from parent-to-child. The overall survival in child-to-parent was significantly higher than in spouses/siblings (P = 0.002) and in parent-to-child (P = 0.005), despite significantly higher recipient age in child-to-parent [59 (42–69) years, P < 0.001]. Contrastingly, parent-to-child exhibited the lowest survival, despite the youngest recipient age [26 (20–43) years, P < 0.001]. In addition, younger donor age exhibited significantly better recipient survival both in hepatitis C virus-related and in non-hepatitis C virus diseases. Univariate and multivariate analyses both demonstrated that donor age and graft-type (right-sided livers) are independent prognostic factors for recipient survival.

Conclusions:
Donor age is an independent, strong prognostic factor in adult-to-adult LDLT.
How Has Virtual Hepatectomy Changed the Practice of Liver Surgery?
Authors: Mise Yoshihiro , Hasegawa Kiyoshi , Satou Shouichi , Shindoh Junichi , Miki Kenji , Akamatsu Nobuhisa , Arita Junichi , Kaneko Junichi , Sakamoto Yoshihiro , Kokudo Norihiro 
Published: March 2017

Objective:
To assess how virtual hepatectomy (VH), conducted using surgical planning software, influences the outcomes of liver surgery.

Background:
Imaging technology visualizes the territories of the liver vessels, which were previously impossible. However, the clinical impact of VH has not been evaluated.

Methods:
From 2004 to 2013, we performed 1194 VHs preoperatively. Outcomes of living donor liver transplantation (LDLT) and hepatectomy for hepatocellular carcinoma (HCC)/colorectal liver metastases (CRLM) were compared between patients in whom VH was performed (VH) and those without VH evaluation (non-VH).

Results:
In LDLT, the rate of right liver graft use was higher in the VH (62.1%) than in the non-VH (46.5%) (P < 0.01), which did not increase morbidity of donor surgery. Duration of recipient surgery in the VH in which middle hepatic vein branch reconstruction was skipped was shorter than that in the VH with venous reconstruction. Among HCC patients with impaired liver function, portal territory-oriented resection was conducted more often in the VH than in the non-VH. The 5-year disease-free survival rate for localized HCC was higher in the VH than in the non-VH (37.2% vs 23.9%; P = 0.04). In CRLM, long-term outcomes were similar in the VH and non-VH despite the larger tumor load in the VH.

Conclusions:
VH in LDLT allows double equipoise for the recipient and donor by optimizing decision-making on graft selection and venous reconstruction. VH offers a chance for radical hepatectomy even in HCC patients with impaired liver function and CRLM patients with advanced tumors, without compromising survival.
Clearance of BK Virus Nephropathy by Combination Antiviral Therapy With Intravenous Immunoglobulin
Authors: Kable Kathy , Davies Carmen D. , O'connell Philip J. , Chapman Jeremy R. , Nankivell Brian John 
Published: March 2017

Background
Reactivation of BK polyoma virus causes a destructive virus allograft nephropathy (BKVAN) with graft loss in 46%. Treatment options are limited to reduced immunosuppression and largely ineffective antiviral agents. Some studies suggest benefit from intravenous immunoglobulin (IVIG).

Methods
We evaluated effectiveness of adjuvant IVIG to eliminate virus from blood and tissue, in a retrospective, single-center cohort study, against standard-of-care controls. Both groups underwent reduced immunosuppression; conversion of tacrolimus to cyclosporine; and mycophenolate to leflunomide, oral ciprofloxacin, and intravenous cidofovir.

Results
Biopsy-proven BKVAN occurred in 50 kidneys at 7 (median interquartile range, 3-12) months after transplantation, predominantly as histological stage B (92%), diagnosed following by dysfunction in 46%, screening viremia in 20%, and protocol biopsy in 34%. After treatment, mean viral loads fell from 1581 ± 4220 × 103 copies at diagnosis to 1434 ± 70 639 midtreatment, and 0.138 ± 0.331 after 3 months (P < 0.001). IVIG at 1.01 ± 0.18 g/kg was given to 22 (44%) patients. The IVIG group more effectively cleared viremia (hazard ratio, 3.68; 95% confidence interval, 1.56-8.68; P = 0.003) and BK immunohistochemistry from repeated tissue sampling (hazard ratio, 2.24; 95% confidence interval, 1.09-4.58; P = 0.028), and resulted in faster (11.3 ± 10.4 months vs 29.1 ± 31.8 months, P = 0.015) and more complete resolution of viremia (33.3% vs 77.3%, P = 0.044). Numerically, fewer graft losses occurred with IVIG (27.3% vs 53.6% for control, P = 0.06), although graft and patient survivals were not statistically different. Acute renal dysfunction requiring pulse corticosteroid was common (59.1% vs 78.6%, P = 0.09), respectively, after immunosuppression reduction.

Conclusions
Combination treatment incorporating adjuvant IVIG was more effective eliminating virus from BKVAN, compared with conventional therapy. Validation by multicenter randomized trial is needed.