Background Obstructive jaundice is a common presenting symptom among patients with pancreatic cancer. While benefits of preoperative biliary drainage have been suggested by previous studies, recent ...evidence has shown no significant improvements of preoperative biliary drainage on the postoperative outcome but rather an increase of complications. There is no clear consensus on whether to treat malignant obstructive jaundice with preoperative biliary drainage prior to operative intervention or to proceed directly to resection. Thus, our aim was to elucidate the impact of preoperative biliary drainage of obstructive jaundice due to malignant pancreatic head tumors on postoperative morbidity and mortality. Methods We conducted a meta-analysis in accordance with the PRISMA guidelines and carried out a systematic search of medical databases. The results were analyzed according to predefined criteria. We pooled the incidence of overall complications, wound infection, pancreatic fistula, intra-abdominal abscess, and death within the perioperative time period. Results We initially identified 1,816 studies, and 25 of these (22 retrospective studies, 3 randomized controlled trials) were finally included in the analysis with a total number of 6,214 patients. Analysis revealed an increased incidence of overall complications (odds ratio: 1.40; 95% confidence interval: 1.14–1.72; P = .002) and wound infections (odds ratio: 1.94; 95% confidence interval: 1.48–2.53; P < .00001) in patients receiving preoperative biliary drainage compared to operative intervention first. Mortality, incidence of pancreatic fistula, or intra-abdominal abscess formation were not affected by preoperative biliary drainage. Conclusion Preoperative biliary drainage does not have a beneficial effect on postoperative outcome. The increase of postoperative overall complications and wound infections urges for precise indications for preoperative biliary drainage and against routine preoperative biliary decompression.
Background Landing zone 0, defined as a proximal landing zone in the ascending aorta, remains the last frontier to be taken. Midterm results of total arch rerouting and thoracic endovascular aortic ...repair (TEVAR) extending into landing zone 0 remain to be determined. Methods From 2003 to 2011, 66 patients (mean age, 70 years; 68% men) presenting with pathologic conditions affecting the aortic arch (atherosclerotic aneurysms n = 48, penetrating ulcers n = 6, type B dissections n = 6, type B after type A dissections n = 5, and anastomotic aneurysm n = 1) were treated in 5 participating centers. Of these 66 patients, only 12% would have been deemed suitable for any kind of conventional surgical repair because of multisegmental aortic disease or comorbidities. Results In-hospital mortality was 9%. Retrograde type A dissection was observed in 3% of patients. The assisted type I and type III endoleak rate was 0%. Stroke was seen in 5% of patients. Permanent paraplegia was observed in 3% of those studied. Median follow-up was 25 months (8–41 months). There was 1 late type Ib endoleak, which was followed by watchful waiting. Five-year survival was 72%. Five-year aorta-related survival was 96%. No aorta-related reintervention had to be performed in the segments treated. Conclusions Midterm results of total arch rerouting and TEVAR extending into landing zone 0 are excellent in regard to aorta-related survival and freedom from aorta-related reintervention. Retrograde type A dissection, potentially related to compliance mismatch between the ascending aorta and the stent-graft, warrants further attention. Extended application of this strategy augments therapeutic options in a group of patients who are not suitable candidates for conventional therapy.
Summary
The paper focuses on the identification of atypical fractures (AFFs). This paper examines the concordance between objective classification and expert subjective review. We believe the paper ...adds critical information about how to apply the American Society of Bone and Mineral Research (ASBMR) criteria to diagnose AFFs and is of high interest to the field.
Introduction
Assess American Society of Bone and Mineral Research (ASBMR) criteria for identifying atypical femoral fractures (AFFs).
Methods
Two orthopedic surgeons independently evaluated radiographs of 372 fractures, applying ASBMR criteria. We assessed ease of applying ASBMR criteria and whether criteria-based assessment matched qualitative expert assessment.
Results
There was up to 27% uncertainty about how to classify specific features. 84% of films were classified similarly for the presence of AFF according to ASBMR criteria; agreement increased to 94% after consensus meeting. Of 37 fractures categorized as AFFs based on ASBMR criteria, 23 (62.2%) were considered AFFs according to expert assessment (not relying on criteria). Only one (0.5%) femoral shaft fracture that did not meet ASBMR criteria was considered an AFF per expert assessment. The number of major ASBMR features present (four vs five) and whether there was periosteal or endosteal thickening (“beaking” or “flaring”) played major roles in the discrepancies between ASBMR criteria-based and expert-based determinations.
Conclusions
ASBMR AFF criteria were useful for reviewers but several features were difficult to interpret. Expert assessments did not agree with the ASBMR classification in almost one-third of cases, but rarely identified an AFF when a femoral shaft fracture did not meet ASBMR AFF criteria. Experts identified lateral cortical transverse fracture line and associated new-bone formation along with no or minimal comminution as crucial features necessary for the definition of atypical femoral fractures.
Background Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated ...with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers. Methods 251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity. Results The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values ( p = 0.001 and p < 0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality ( p = 0.001 and p < 0.0005; and p = 0.002 and p < 0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP ( p = 0.01) and after longer operations ( p < 0.0005). Empyema ( p < 0.0005) and acute respiratory distress syndrome ( p = 0.02) were associated with longer duration of operation. Conclusions EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.
Abstract Backround The Translational Genome Research Network in Pancreatic Cancer performed a meta-analysis of publicly available various high-throughput gene analysis panels to identify drugable ...targets. There, the most differentially expressed gene between normal and cancerous pancreas was Kif20a. The aim of the study was to verify this expression pattern and further characterize Kif20a in pancreatic cancer. Materials and methods Detailed expression analyses were carried out in pancreatic tissues and in a wide panel of pancreatic cells including ductal adenocarcinoma (PDAC) and neuroendocrine-cancer cell lines as well as immortalized human pancreatic ductal epithelial and primary stellate cells using quantitative real-time polymerase chain reaction, immunohistochemistry, immunofluorescence, and immunoblot analyses. Effects on proliferation, apoptosis, and cell cycle were assessed by MTT assays, caspase-cleavage assays, and fluorescence-activated cell sorting analysis after Kif20a silencing. Cell motility was assessed by migration and invasion assays as well as time-lapse microscopy. Results Mean Kif20a messenger RNA expression was 18.4-fold upregulated in PDAC tissues compared with that in the normal pancreas. In line, neuroendocrine-cancer cell lines display a 1.6-fold increase and ductal adenocarcinoma cell lines a 11-fold increase of Kif20a messenger RNA ( P = 0.009) in comparison with primary stellate cells. A 7.3-fold overexpression was also found in immortalized pancreatic ductal epithelial cells. Kif20a silencing with small interfering RNA molecules resulted in an inhibition of proliferation, motility, and invasion of pancreatic cancer cell lines. Conclusions Targeting Kif20a reduces proliferation, migration, and invasion of pancreatic cancer cells. Together with its significant overexpression in PDAC, this makes it a potential target for diagnostic and interventional purposes.
Since the beginning of the coronavirus disease 2019 pandemic, hundreds of thousands of patients have been treated in ICUs across the globe. The severe acute respiratory syndrome-associated ...coronavirus 2 virus enters cells via the angiotensin-converting enzyme 2 receptor and activates several distinct inflammatory pathways, resulting in hematologic abnormalities and dysfunction in respiratory, cardiac, gastrointestinal renal, endocrine, dermatologic, and neurologic systems. This review summarizes the current state of research in coronavirus disease 2019 pathophysiology within the context of potential organ-based disease mechanisms and opportunities for translational research.
Investigators from the Research Section of the Society of Critical Care Medicine were selected based on expertise in specific organ systems and research focus. Data were obtained from searches conducted in Medline via the PubMed portal, Directory of Open Access Journals, Excerpta Medica database, Latin American and Caribbean Health Sciences Literature, and Web of Science from an initial search from December 2019 to October 15, 2020, with a revised search to February 3, 2021. The medRxiv, Research Square, and clinical trial registries preprint servers also were searched to limit publication bias.
Content experts selected studies that included mechanism-based relevance to the severe acute respiratory syndrome-associated coronavirus 2 virus or coronavirus disease 2019 disease.
Not applicable.
Not applicable.
Efforts to improve the care of critically ill coronavirus disease 2019 patients should be centered on understanding how severe acute respiratory syndrome-associated coronavirus 2 infection affects organ function. This review articulates specific targets for further research.
American Board of Orthopaedic Surgery/American Council on GraduateMedical Education Residency Review Committee training requirements have necessitated the need for the adoption of simulation ...education into existing programmatic requirements. Current guidelines focus only on interns at a potentially significant cost to programs; both in total dollar amount and time.
The authors aim to provide a model that can maximize utility for all resident levels, manage cost by maximizing the use of cadaveric material, and allow integration of varied industry support.
The Oregon Health & Science University Orthopaedic education program has developed a high-fidelity training curriculum that (1) is applicable to both junior and senior residents (2) has minimized the cost per resident with the reuse of cadaveric specimens and (3) has nurtured partnerships with industry stakeholders to reduce bias in training by collaborating with most major industry representatives.
The simulation curriculum outlined in this manuscript may serve as a reference for other programs and institutions to develop their own residency educational curriculum models.
Abstract We reviewed 46 patients who underwent salvage hip arthroplasty (SHA) for revision of failed cannulated screws (CS), sliding hip screws (SHS), or intramedullary nails (IMN). The primary ...objective was to determine differences in operative difficulty. SHA after failed femoral neck fixation was associated with lower intra-operative demands than after failed peri-trochanteric fractures. Similarly, analysis by the index implant found that conversion arthroplasty after failed CSs was associated with lower intra-operative morbidity than failed SHSs or IMNs; differences between SHS and IMN were not as clear. Importantly, intra-operative data in cases of failed SHSs were similar regardless of the original fracture type, showing the device played a larger role than the fracture pattern. Complications and revision surgery rates were similar regardless of fracture type or fixation device. Our results suggest that operative demands and subsequent patient morbidity are more dependent on the index device than the fracture pattern during SHA.
Background Serum C-reactive protein (CRP) is an established discriminating factor for necrotizing pancreatitis. In this study, the CRP response with respect to inflammatory postoperative ...complications was examined in a large, homogeneous series of pancreatic resections in order to define a relevant clinical parameter for early detection of inflammatory postoperative complications. Methods 688 consecutive pancreatic resections with jejunal anastomosis were screened for inflammatory postoperative complications based on a prospective database. Ninety-one patients had at least one inflammatory postoperative complication and were compared to a subgroup of 60 consecutive patients with uneventful postoperative courses. Results In the postoperative setting after pancreatic resection, CRP peaked on postoperative day (POD) 3 with a median serum CRP of 132 mg/L, and gradually decreased thereafter in patients with an uncomplicated postoperative course. In complicated cases (with the exception of cholangitis), increase in CRP was significantly greater, peaked on POD 3 (median CRP 173 mg/L), and persisted thereafter, whereas white blood cell count and body temperature did not differ significantly from uneventful courses until POD 6. The median day of diagnosis of inflammatory postoperative complications was POD 9. A cutoff CRP value of 140 mg/dL on POD 4 yielded a positive predictive value of 89.1% (adjusted to the prevalence of inflammatory postoperative complications: 48.7%) with a specificity of 87.1% and a sensitivity of 69.5% for inflammatory postoperative complications. Conclusion Persistence of CRP elevation above 140 mg/dL on POD 4 is predictive of inflammatory postoperative complications and should prompt an intense clinical search for major septic processes (e.g. pancreatic fistula or abscess) if pneumonia and wound infection are unlikely or excluded.
Many investigations have evaluated local and systemic consequences of intramedullary (IM) reaming and suggest that reaming may cause, or exacerbate, injury to the soft tissues adjacent to fractures. ...To date, no study has examined the effect on local muscular physiology as measured by intramuscular pH (IpH). Here, we observe in vivo IpH during IM reaming for tibia fractures.
Adults with acute tibia shaft fractures (level 1, academic, 2019-2021) were offered enrollment in an observational cohort. During IM nailing, a sterile, validated IpH probe was placed into the anterior tibialis (<5 cm from fracture, continuous sampling, independent research team). IpH before, during, and after reaming was averaged and compared through repeated measures ANOVA. As the appropriate period to analyze IpH during reaming is unknown, the analysis was repeated over periods of 0.5, 1, 2, 5, 10, and 15 minutes prereaming and postreaming time intervals.
Sixteen subjects with tibia shaft fractures were observed during nailing. Average time from injury to surgery was 35.0 hours (SD, 31.8). Starting and ending perioperative IpH was acidic, averaging 6.64 (SD, 0.21) and 6.74 (SD, 0.17), respectively. Average reaming time lasted 15 minutes. Average IpH during reaming was 6.73 (SD, 0.15). There was no difference in IpH between prereaming, intrareaming, and postreaming periods. IpH did not differ regardless of analysis over short or long time domains compared with the duration of reaming.
Reaming does not affect IpH. Both granular and broad time domains were tested, revealing no observable local impact.
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