bluuebunny/crossref_metadata_2025_split huggingface dataset:
A Cost Analysis of Mohs and Total Surgical Excision
Authors: Liu Sophia , Mathew Prakash , Al Bayati Mahmood , Remer Hallie , Verling Samantha , Spector Seth , Thaller Seth 
Published: July 2023

Purpose
Skin cancer risk is elevated in veterans, Whites, and males older than 50 years, who comprise the majority of patients at the Miami VA healthcare system.
Treatments include total surgical excision (TSE) with frozen section or permanent pathology, and Mohs surgery. Our protocol consists of Mohs procedures performed offsite followed by reconstruction at the VA. This retrospective study examines the cost difference between TSE and Mohs surgery.

Methods
A retrospective chart review was performed of VA patients who underwent TSE or Mohs surgery between 2017 and 2019. Patients younger than 18 or those without malignancy on final pathology were excluded. Patients were subdivided into TSE versus Mohs. Cost per operating room minute was determined using published data for similar institutions. Pathology costs were estimated using institution specific Medicare data. T test was performed using SPSS.

Results
Of 130 patients identified, 82 underwent TSE and 48 underwent Mohs with reconstruction. Cost per operating room minute for inpatient government-owned facilities was $37.94. A flat fee of $1400 for the Mohs surgery was the contracted rate with the offsite institution. Average cost of Mohs surgery with reconstruction was $3534.12. Average cost of TSE with pathology was $2643.85. Total surgical excision was significantly more cost efficient than Mohs with reconstruction (P < 0.01).

Conclusions
At our institution, TSE seems more cost effective than Mohs with subsequent reconstruction. While these are generalized costs, and data specific to our institution, cost efficiency is an important consideration in improving the value of care for VA patients.
Treatment of Pseudoangiomatous Stromal Hyperplasia of the Breast
Authors: Yturralde Kylee J. , Friedman Harold I. 
Published: July 2023

Abstract
Pseudoangiomatous stromal hyperplasia is an uncommon benign condition of mesenchymal proliferation. Fewer than 1500 cases have been reported in previous literature. It is observed most commonly in postmenopausal and perimenopausal women and is extremely rare to present in children. Recommended treatment in severe cases is often mastectomy due to high incidence of recurrence. However, a careful review of the literature suggests that treatment of this benign disease should be tailored to the mode in which it presents. This case report describes a 16-year-old girl with a severe case of bilateral pseudoangiomatous stromal hyperplasia that was managed with reduction mammoplasty, along with a 10-year case follow-up. Based on a literature review of more than 2800 cases and the current case report, a conservative management strategy is suggested, depending on disease presentation.
Autologous Reconstruction After Failed Implant-Based Breast Reconstruction
Authors: von Glinski Maxi , Holler Nikla , Kümmel Sherko , Reinisch Mattea , Wallner Christoph , Wagner Johannes Maximilian , Dadras Mehran , Sogorski Alexander , Lehnhardt Marcus , Behr Björn 
Published: July 2023

Introduction
Failure of an implant-based breast reconstruction often requires a change to an autologous procedure (salvage autologous breast reconstruction [Salv-ABR]). The aim of this study was to compare surgical and patient-reported outcomes of Salv-ABR to immediate or delayed-immediate ABR (I/DI-ABR), which has hardly been addressed in the existing literature.

Methods
All patients undergoing Salv- or I/DI-ABR between January 2014 and December 2020 were asked to participate in this study. Complication rates, the aesthetic outcome (5-point Likert scale), and quality of life (EORTC QLQ-C30 and -BR23, Breast-Q, Center for Epidemiology Studies Depression Scale) were compared between both procedures.

Results
Seventy patients participated in the study (Salv-ABR: n = 23; mean ± SD age, 53.5 ± 9.1 years; follow-up, 28.6 ± 18.5 month; I/DI-ABR: n = 45, mean ± SD age: 50.2 ± 7.3 years; follow-up, 32.8 ± 18.5 month). Main indication for Salv-ABR was a major capsular contracture (n = 14 [60.1%]). Early unplanned reoperation rates were significantly increased in the Salv-ABR (56.5% vs 14.9%; P < 0.01). Patients with I/DI-ABR showed a significantly improved overall aesthetic outcome (2.7 ± 0.9 vs 3.3 ± 0.7; P < 0.01) and scored significantly higher in several subscales of EORTC QLQ-C30/BR23 (Global Health Status, Role Functioning, Body Image; P < 0.05) and the Breast-Q (Psychosocial Well-being, Satisfaction with Breast; P < 0.05) compared with patients with Salv-ABR.

Conclusions
Salvage ABR is associated with a higher complication rate, compromised aesthetic outcome, and quality of life compared with I/DI-ABR. This should be considered and discussed with the patient when planning any kind of reconstructive breast surgery.
Skin Popping for the Hand Surgeon
Authors: Shih Sabrina , Francoisse Caitlin A. , Xu Kyle Y. , Tadisina Kashyap Komarraju 
Published: July 2023

IntroductionSubcutaneous injection of illicit drugs, colloquially known as skin popping, is associated with skin and soft tissue infections of the upper extremity. Sequelae of these infections often present to hand surgeons in the late stages of disease, are associated with challenging clinical scenarios, and are a significant burden to both patients and providers. The authors present an illustrative case and review the literature regarding this growing phenomenon in upper extremity surgery.MethodsA case report detailing the surgical reconstruction of a large forearm wound in the setting of intravenous heroin use and skin popping is presented. Search terms related to upper extremity subcutaneous drug injection were used to find relevant articles in PubMed and EMBASE. A total of 488 articles were found, with 22 studies meeting the inclusion criteria.ResultsIn this case report, the patient had a long history of skin popping to the forearm and presented with a chronic wound with exposed bone. The patient was treated with serial debridement, bony fixation, intravenous antibiotics, and soft tissue coverage using an arteriovenous loop and a muscle-only latissimus flap. Literature review yielded 22 studies comprising 38 patients with 55% (11/20) women and age range of 23 to 58 years. Heroin was the most commonly used drug (50.0%). The most common presentation was soft tissue infection (6/20 patients), manifestations of noninfected wounds (5/20), and wound botulism (4/20 of patients). Seventy percent of patients presented with multiple injection sites. Surgical management was described in 18% of cases, with all but one case describing drainage and debridement techniques. Only one case of formal reconstruction using a dermal template was described.ConclusionsSkin popping infections have unique pathogenesis, presentation, and management patterns that hand surgeons must be aware of when treating these patients. A literature review revealed a relative paucity of reports regarding risk factors and surgical management of “skin popping” sequelae. If patients are reconstructive candidates, complex reconstruction requiring free tissue transfer may be warranted.
How Does Reduction Mammaplasty Surgical Technique Impact Clinical, Aesthetic, and Patient-Reported Outcomes?
Authors: Cunning Jessica R. , Mookerjee Vikram G. , Alper David P. , Rios-Diaz Arturo J. , Bauder Andrew R. , Kimia Rotem , Broach Robyn B. , Barrette Louis-Xavier , Fischer John P. , Butler Paris D. 
Published: July 2023

Background
A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes.

Methods
Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed.

Results
Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03).

Conclusions
The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.
Implant-Based Breast Reconstruction in the Elderly
Authors: Danko Dora , Ash Makenna E. , Brown Owen H. , Losken Albert , Thompson Peter W. 
Published: July 2023

Background
Advanced age is considered by many to be a relative contraindication to breast reconstruction. However, despite increased medical comorbidities and a perception that elderly patients are less concerned with body image, more women older than 70 years are choosing to undergo breast reconstruction. There is a paucity of data to guide reconstructive decision-making and counseling in this population.

Objectives
The aim of this study was to evaluate patient satisfaction, complication rates, and long-term outcomes in women older than 70 years undergoing implant-based breast reconstruction.

Methods
A total of 400 patients were identified at the authors' institution and divided into 2 groups: ≥70 and <70 years old. Medical comorbidities, surgical outcomes, and patient-reported outcomes as defined by the BREAST-Q were compared using the χ
2 tests for categorical variables and t tests for continuous variables.

Results
The cohort of patients older than 70 years was made up of 25 women, with a mean age of 73 years, and the cohort of patients younger than 70 years was made up of 375 women, with a mean age of 50 years. There was no significant difference in body mass index (P = 0.373), smoking status (P = 0.360), or history of prior ipsilateral radiation (P = 0.508) between the 2 cohorts; however, the elderly cohort was significantly more likely to have diabetes (P = 0.026). Although elderly patients were less likely to undergo bilateral mastectomy (P < 0.001), there was no significant difference in the type of mastectomy, pathological diagnosis, or method of reconstruction. There was no significant difference in complication rates when looking at minor infection (P = 0.553) or major infection (P = 0.553). The 2 groups were equally likely to undergo secondary procedures (P = 0.192). Overall satisfaction rates were high in all BREAST-Q categories in the elderly group and not significantly different when compared with the group of patients younger than 70 years. Matched-pair analysis showed a significant difference with the group of patients older than 70 years having higher levels physical well-being (P < 0.001).

Conclusions
Immediate breast reconstruction can be performed safely and with similar high satisfaction rates in the elderly population as their younger counterparts. Age alone should not be used as a reason for excluding women from these life-changing operations.
Discordance in TME Specimen Grading in a Prospective Phase II Multicenter Rectal Cancer Trial
Authors: Sylla Patricia , Berho Mariana , Sands Dana , Ricardo Alison , Bonaccorso Antoinette , Moshier Erin , Hain Elisabeth , Letchinger Riva , Marks John , Whiteford Mark , Mclemore Elisabeth , Maykel Justin , Alavi Karim , Zaghiyan Karen , Chadi Sami , Shawki Sherief F. , Steele Scott , Pigazzi Alessio , Albert Matthew , DeBeche-Adams Teresa , Polydorides Alexandros , Wexner Steven 
Published: July 2023

Objectives:
To report the results of a rigorous quality control (QC) process in the grading of total mesorectal excision (TME) specimens during a multicenter prospective phase II trial of transanal TME.

Summary Background Data:
Grading of TME specimens is based on macroscopic assessment of the mesorectum and standardized through synoptic pathology reporting. TME grade is a strong predictor of outcomes with incomplete (IC) TME associated with increased rates of local recurrence relative to complete or near complete (C/NC) TME. Although TME grade serves as an endpoint in most rectal cancer trials, in protocols incorporating centralized review of TME specimens for quality assurance, discordance in grading and the management thereof has not been previously described.

Methods:
A phase II prospective taTME trial was conducted from 2017-2022 across 11 North American centers with TME quality as primary study endpoint. QC measures included training of site pathologists in TME protocols, (2) blinded grading of de-identified TME specimen photographs by central pathologists, and (3) reconciliation of major discordance prior to trial reporting. Cohen’s Kappa statistic was used to assess agreement in grading.

Results:
Overall agreement in grading of 100 TME specimens between site and central reviewer was rated as fair, (κ=0.35 (95% CI, 0.10-0.61, P<0.0001). Concordance was noted in 54%, with minor and major discordance in 32% and 14% of cases respectively. Upon reconciliation, 13/14 (93%) major discordances were resolved. Pre- versus post-reconciliation rates of C/NC and IC TME are 77%/16% and 7% versus 69%/21% and 10%. Reconciliation resulted in a major upgrade (IC to NC, N=1) or major downgrade (NC/C to IC, N=4) in 5 cases overall (5%).

Conclusions:
A 14% rate of major discordance was observed in TME grading between site and central reviewers. Resolution resulted in a major change in final TME grade in 5% of cases, which suggests that reported rates or TME completeness are likely overestimated in trials. QC through central review of TME photographs and reconciliation of major discordances is strongly recommended.
Long-Term Outcome of Immediate Versus Postponed Intervention in Patients With Infected Necrotizing Pancreatitis (POINTER)
Authors: Van Veldhuisen Charlotte L. , Sissingh Noor J. , Boxhoorn Lotte , van Dijk Sven M. , van Grinsven Janneke , Verdonk Robert C. , Boermeester Marja A. , Bouwense Stefan A.W. , Bruno Marco J. , Cappendijk Vincent C. , van Duijvendijk Peter , van Eijck Casper H J. , Fockens Paul , van Goor Harry , Hadithi M , Haveman JW , Jacobs MAJM , Jansen JM , Kop MPM , Manusama ER , Mieog JSD , Molenaar IQ , Nieuwenhuijs VB , Poen AC , Poley JW , Quispel R , Römkens TEH , Schwartz MP , Seerden TC , Dijkgraaf MGW , Stommel MWJ , Straathof JWA , Venneman NG , Voermans RP , van Hooft JE , van Santvoort HC , Besselink M.G. ,   for the Dutch Pancreatitis Study Group
Published: July 2023

Objective:
To compare the long-term outcomes of immediate drainage versus the postponed drainage approach in patients with infected necrotizing pancreatitis.

Summary Background Data:
In the randomized POINTER trial, patients assigned to the postponed-drainage approach using antibiotic treatment required fewer interventions, as compared to immediate drainage, and over a third were treated without any intervention.

Methods:
Clinical data of those patients alive after the initial 6-month follow-up were re-evaluated. Primary outcome was a composite of death and major complications.

Results:
Out of 104 patients, 88 were re-evaluated with a median follow-up of 51 months. After the initial 6-month follow-up, the primary outcome occurred in 7 of 47 patients (15%) in the immediate-drainage group and 7 of 41 patients (17%) in the postponed-drainage group (RR 0.87, 95% CI 0.33-2.28; P=0.78). Additional drainage procedures were performed in 7 patients (15%) versus 3 patients (7%) (RR 2.03; 95% CI 0.56-7.37; P=0.34). The median number of additional interventions was 0 (IQR 0-0) in both groups (P=0.028). In the total follow-up, the median number of interventions was higher in the immediate-drainage group than in the postponed-drainage group (4 vs. 1, P=0.001). Eventually, 14 of 15 patients (93%) in the postponed-drainage group who were successfully treated in the initial 6-month follow-up with antibiotics and without any intervention, remained without intervention. At the end of follow-up, pancreatic function and quality of life were similar.

Conclusions:
Also during long-term follow-up, a postponed drainage approach using antibiotics in patients with infected necrotizing pancreatitis results in fewer interventions as compared to immediate drainage, and should therefore be the preferred approach.

Trial registration:
ISRCTN33682933
See One, Do One, Improve One’s Wellness
Authors: Abahuje Egide , Smith Kathryn S. , Amortegui Daniela , Eng Joshua S. , Philbin Sarah E , Verma Rhea , Dastoor Jehannaz Dinyar , Schlick Cary , Ma Meixi , Mackiewicz Natalia I. , Choi Jennifer Nicole , Greenberg Jacob , Johnson Julie , Bilimoria Karl Y. , Hu Yue-Yung 
Published: July 2023

Objective:
We sought to examine the factors associated with resident perceptions of autonomy and to characterize the relationship between resident autonomy and wellness.

Summary Background Data:
Concerns exist that resident autonomy is decreasing, impacting competence.

Methods:
Quantitative data were collected through a cross-sectional survey administered following the 2020 ABSITE. Qualitative data were collected via interviews and focus groups with residents and faculty at 15 programs.

Results:
7233 residents (85.5% response rate) from 324 programs completed the survey. Of 5139 residents with complete data, 4424 (82.2%) reported appropriate autonomy, and these residents were less likely to experience burnout (OR 0.69; 95% CI 0.58-0.83), suicidality (OR 0.69; 95% CI 0.54-0.89), and thoughts of leaving their programs (OR 0.45; 95% CI 0.37-0.54). Women were less likely to report appropriate autonomy (OR 0.81; 95% CI 0.68-0.97). Residents were more likely to report appropriate autonomy if they also reported satisfaction with their workload (OR 1.65; 95% CI 1.28-2.11), work-life balance (OR 2.01; 95% CI 1.57-2.58), faculty engagement (OR 3.55; 95% CI 2.86-4.35), resident camaraderie (OR 2.23; 95% CI, 1.78-2.79), and efficiency and resources (OR 2.37; 95% CI 1.95-2.88). Qualitative data revealed that (1) autonomy gives meaning to the clinical experience of residency, (2) multiple factors create barriers to autonomy, and (3) autonomy is not inherent to the training paradigm, requiring residents to learn behaviors to “earn” it.

Conclusion:
Autonomy is not considered an inherent part of the training paradigm such that residents can assume that they will achieve it. Resources to function autonomously should be allocated equitably to support all residents’ educational growth and wellness.
Decreased Risk of Esophageal Adenocarcinoma after Gastric Bypass Surgery in a Cohort Study from Three Nordic Countries
Authors: Hardvik Åkerström Johan , Santoni Giola , von Euler Chelpin My , Chidambaram Swathikan , R Markar Sheraz , Maret-Ouda John , Ness-Jensen Eivind , Kauppila Joonas H. , Holmberg Dag , Lagergren Jesper 
Published: July 2023

Objective:
To test the hypothesis that bariatric surgery decreases the risk of esophageal and cardia adenocarcinoma.

Background:
Obesity is strongly associated with esophageal adenocarcinoma and moderately with cardia adenocarcinoma, but whether weight loss prevents these tumors is unknown.

Methods:
This population-based cohort study included patients with an obesity diagnosis in Sweden, Finland, or Denmark. Participants were divided into a bariatric surgery group and a non-operated group. The incidence of ECA was first compared with the corresponding background population by calculating standard incidence ratios (SIR) with 95% confidence intervals (CI). Second, the bariatric surgery group and the non-operated group were compared using multivariable Cox regression, providing hazard ratios (HR) with 95% CI, adjusted for sex, age, comorbidity, calendar year, and country.

Results:
Among 748,932 participants with an obesity diagnosis, 91,731 underwent bariatric surgery, predominantly gastric bypass (n=70,176; 76.5%). The SIRs of ECA decreased over time following gastric bypass, from SIR=2.2 (95% CI 0.9-4.3) after 2-5 years to SIR=0.6 (95% CI <0.1-3.6) after 10-40 years. Gastric bypass patients were also at a decreased risk of ECA compared to non-operated patients with obesity (adjusted HR=0.6, 95% CI 0.4-1.0 [0.98]), with decreasing point estimates over time. Gastric bypass was followed by a strongly decreased adjusted risk of esophageal adenocarcinoma (HR=0.3, 95% CI 0.1-0.8), but not of cardia adenocarcinoma (HR=0.9, 95% CI 0.5-1.6), when analyzed separately. There were no consistent associations between other bariatric procedures (mainly gastroplasty, gastric banding, sleeve gastrectomy, and biliopancreatic diversion) and ECA.

Conclusion:
Gastric bypass surgery may counteract the development of esophageal adenocarcinoma in morbidly obese individuals.
Pudendal Nerve Block With Liposomal Bupivacaine for Sacrospinous Ligament Suspension
Authors: Ezzedine Dima , Dhariwal Laura , Wasenda Erika , Salamon Charbel , Caraballo Ricardo 
Published: July 2023

Importance
Pudendal nerve block has been frequently used as a pain management modality for vaginal prolapse surgery. However, studies investigating its efficacy and the type of anesthetic used have had conflicting results.

Objective
This study aimed to evaluate the effect of intraoperative pudendal nerve block with liposomal bupivacaine on postoperative pain after sacrospinous ligament suspension surgery.

Study Design
In this single-blinded randomized controlled trial, 83 women undergoing sacrospinous ligament suspension were randomized to receive either intraoperative pudendal nerve block with liposomal bupivacaine or no block. Participants recorded their pain level on postoperative days (PODs) 1–3 and 7, the number of pain medication pills consumed, and the quality of their recovery using a validated questionnaire.

Results
There were no significant differences in pain scores between the groups on POD 1 and POD 3: 5 (2–6.25) versus 5.5 (4–8; P = 0.058) and 4 (1–6) versus 5 (2–7; P = 0.146), respectively. On POD 2, the overall pain score was statistically different between the groups, with the block group having lower interquartile ranges. This difference, however, was not clinically significant: 5 (1.75–5) versus 5 (3.25–7.75; P = 0.023). In the subset of participants who underwent a concomitant midurethral sling procedure, POD 2 and POD3 pain scores were significantly lower in those who received the block: 3 (1–5) versus 6 (5–8; P = 0.006) for POD 2 and 3 (1–5) versus 5 (3.250–7; P = 0.042) for POD 3. There were no significant differences in pain medication consumption or the quality of recovery scores.

Conclusion
Pudendal nerve block with liposomal bupivacaine did not result in significant differences in postoperative pain after sacrospinous ligament suspension, except in those participants who underwent a concomitant midurethral sling procedure.