Publications by authors named "Charles Miller"

560 Publications

Outcomes of TEVAR in Patients with Concomitant Blunt Thoracic Aortic Injury and Traumatic Brain Injury from The Aortic Trauma Foundation Global Registry.

J Vasc Surg 2021 Oct 1. Epub 2021 Oct 1.

Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address:

Introduction: Traumatic brain injury (TBI) and blunt thoracic aortic injury (BTAI) are the top two leading causes of death after blunt force trauma. Patients presenting with concomitant BTAI and TBI pose a specific challenge with respect to management strategy, as optimal hemodynamic parameters are conflicting between the two pathologies. Early TEVAR is often performed, even in minimal aortic injuries, to allow for the higher blood pressure parameters required in TBI management. However, the optimal timing of TEVAR for the treatment of BTAI in patients with concomitant TBI remains an active matter of controversy.

Methods: The Aortic Trauma Foundation (ATF) international prospective multicenter registry was utilized to identify all patients who underwent TEVAR for BTAI in the setting of TBI from 2015 to 2020. Primary outcomes included delayed ischemic or hemorrhagic stroke, in-hospital mortality and aortic-related mortality. Outcomes were examined among patients who underwent TEVAR at emergent (< 6 vs. ≥ 6 hours) and urgent (< 24 vs. ≥ 24 hours) intervals.

Results: A total of 100 patients (median age 43, 79% male, median ISS 41) with BTAI (SVS BTAI grade 1, 3%; grade 2, 10%; grade 3, 78%; grade 4, 9%) and concomitant TBI who underwent TEVAR were identified. Emergent repair was performed for 51 patients (51%). Comparing emergent repair (< 6 hrs) to repairs conducted at ≥ 6 hrs, there was no difference in delayed cerebral ischemic events (2.0% vs. 4.1%, p = 0.614), in-hospital mortality (15.7% vs. 22.4%, p = 0.389) or aortic-related mortality (2.0% vs. 2.0%, p = 0.996) and no patients had delayed hemorrhagic stroke. Likewise, repairs conducted in an urgent (< 24 hours) fashion had no difference compared to those completed ≥ 24 hours, with regards to delayed ischemic stroke (2.6% vs. 4.3%, p = 0.548), in-hospital mortality (18.2% vs. 21.7%, p = 0.764) or aortic-related mortality (1.3% vs. 4.3%, p = 0.654), with no patients having delayed hemorrhagic stroke.

Conclusions: In contrast to prior retrospective efforts, Results from the ATF international prospective multicenter registry demonstrate that neither emergent or urgent TEVAR for patients with concomitant BTAI and TBI is associated with delayed stroke, in-hospital or aortic-related mortality. In these patients, the timing of TEVAR did not have an impact on outcomes. Therefore, the decision to intervene should be guided by individual patient factors rather than timing.
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http://dx.doi.org/10.1016/j.jvs.2021.09.028DOI Listing
October 2021

Ketone Ester D-β-Hydroxybutyrate-(R)-1,3 Butanediol Prevents Decline in Cardiac Function in Type 2 Diabetic Mice.

J Am Heart Assoc 2021 Oct 29;10(19):e020729. Epub 2021 Sep 29.

Department of Pharmacology University of California Davis CA.

Background Heart failure is responsible for approximately 65% of deaths in patients with type 2 diabetes mellitus. However, existing therapeutics for type 2 diabetes mellitus have limited success on the prevention of diabetic cardiomyopathy. The aim of this study was to determine whether moderate elevation in D-β-hydroxybutyrate improves cardiac function in animals with type 2 diabetes mellitus. Methods and Results Type 2 diabetic (db/db) and their corresponding wild-type mice were fed a control diet or a diet where carbohydrates were equicalorically replaced by D-β-hydroxybutyrate-(R)-1,3 butanediol monoester (ketone ester [KE]). After 4 weeks, echocardiography demonstrated that a KE diet improved systolic and diastolic function in db/db mice. A KE diet increased expression of mitochondrial succinyl-CoA:3-oxoacid-CoA transferase and restored decreased expression of mitochondrial β-hydroxybutyrate dehydrogenase, key enzymes in cardiac ketone metabolism. A KE diet significantly enhanced both basal and ADP-mediated oxygen consumption in cardiac mitochondria from both wild-type and db/db animals; however, it did not result in the increased mitochondrial respiratory control ratio. Additionally, db/db mice on a KE diet had increased resistance to oxidative and redox stress, with evidence of restoration of decreased expression of thioredoxin and glutathione peroxidase 4 and less permeability transition pore activity in mitochondria. Mitochondrial biogenesis, quality control, and elimination of dysfunctional mitochondria via mitophagy were significantly increased in cardiomyocytes from db/db mice on a KE diet. The increase in mitophagy was correlated with restoration of mitofusin 2 expression, which contributed to improved coupling between cytosolic E3 ubiquitin ligase translocation into mitochondria and microtubule-associated protein 1 light chain 3-mediated autophagosome formation. Conclusions Moderate elevation in circulating D-β-hydroxybutyrate levels via KE supplementation enhances mitochondrial biogenesis, quality control, and oxygen consumption and increases resistance to oxidative/redox stress and mPTP opening, thus resulting in improvement of cardiac function in animals with type 2 diabetes mellitus.
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http://dx.doi.org/10.1161/JAHA.120.020729DOI Listing
October 2021

AAGL 2021 Endometriosis Classification: An Anatomy-based Surgical Complexity Score.

J Minim Invasive Gynecol 2021 Sep 25. Epub 2021 Sep 25.

Gynecologic Division, BP-A Beneficência Portuguesa de São Paulo (Drs. Abrao, Andres, and Neto); Department of Obstetrics and Gynecology, Division of Gynecology, Faculty of Medicine, University of São Paulo (Drs. Abrao and Andres), São Paulo, São Paulo, Brazil; Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago (Dr. Miller); Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge (Dr. Miller), Illinois; Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Bronx, New York (Dr. Gingold); Department of Gynecology, Institute Clinic of Gynecology, Obstetrics, and Neonatology, Hospital Clínic de Barcelona (Drs. Rius and Carmona); Department of Gynecology, August Pi i Sunyer Biomedical Research Institute (Dr. Carmona), Barcelona, Spain.

Study Objective: To develop a new endometriosis classification system for scoring intraoperative surgical complexity and to examine its correlation with patient-reported pain and infertility.

Design: Multicenter study of patients treated at 3 recognized endometriosis centers.

Setting: Three specialized endometriosis surgical centers in São Paulo, Brazil and Barcelona, Spain.

Patients: Patients aged 15 to 45 years with histologically proven endometriosis and no history of pelvic malignancy underwent laparoscopic treatment of endometriosis.

Interventions: Demographic data and clinical history, including dysmenorrhea, noncyclic pelvic pain, dyspareunia, dysuria and dyschezia, were prospectively recorded. All patients were staged surgically according to the new 2021 American Association of Gynecologic Laparoscopists (AAGL) and revised American Society of Reproductive Medicine (ASRM) classification systems. The staging for each system was compared against a 4-level surgical complexity scale defined by the most complex procedure performed.

Measurements And Main Results: A total of 1224 patients undergoing surgery met inclusion criteria. The AAGL score discriminated between 4 stages of surgical complexity with high reproducibility (κ = 0.621), whereas the ASRM score discriminated between the complexity stages with poor reproducibility (κ = 0.317). The AAGL staging system correlated with dysmenorrhea, dyspareunia, dyschezia, total pain score, and infertility comparably with the ASRM staging system.

Conclusion: The AAGL 2021 Endometriosis Classification allows for identifying objective intraoperative findings that reliably discriminate surgical complexity levels better than the ASRM staging system. The AAGL severity stage correlates comparably with pain and infertility symptoms with the ASRM stage.
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http://dx.doi.org/10.1016/j.jmig.2021.09.709DOI Listing
September 2021

Outcomes and Practice Patterns of Medical Management of Blunt Thoracic Aortic Injury from the Aortic Trauma Foundation Global Registry.

J Vasc Surg 2021 Sep 21. Epub 2021 Sep 21.

Division of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address:

Objectives: Blunt Thoracic Aortic Injury (BTAI) is the second leading cause of death from blunt trauma. This study aims to determine the outcomes of medical management for BTAI. We hypothesized based on several previously published articles, that patients with minimal aortic injury (BTAI Grades 1 & 2) could safely be treated with definitive medical management (MM) alone.

Methods: The Aortic Trauma Foundation (ATF) international prospective multicenter registry was utilized to examine demographics, injury characteristics, management and outcomes of patients with BTAI. We analyzed a subset of patients in whom MM was initiated as definitive therapy.

Results: From November 2016 to April 2020, a total of 432 patients (median age 41, 76% male, median ISS 34) with BTAI (SVS Grade 1, 23.6%; Grade 2, 14.4%; Grade 3, 51.2%; Grade 4, 10.9%) were evaluated, of which 245 (57%) were treated with MM in the initial period and 114 patients (26.4%) were treated with MM as planned definitive therapy (Grade 1, 59.6%; Grade 2, 23.7%; Grade 3, 15.8%; Grade 4, 0.9%). The most common mechanism of BTAI was motor vehicle collision (60.4%). Hypotension was present on arrival in 74 patients (17.2%). Continuous titratable infusion of antihypertensive medication was utilized in 49.1%, followed by intermittent bolus administration (29.8%), with beta-blockers (74.6%) being the most common agent used. Treatments were targeted to a goal systolic blood pressure (SBP) in 83.3%, most commonly to target goal SBP < 120 mm Hg (66.3%). MM goals based on BP control were attained in 64.0% (73/114). Twelve (10.5%) patients (Grade 1, 1; Grade 2, 0; Grade 3, 10; Grade 4, 1) required subsequent intervention after MM, eleven (9.6%) of whom underwent thoracic endovascular aortic repair (TEVAR), while one (0.9%) required open repair for a Grade 4 injury. Overall in-hospital mortality for patients selected for definitive MM was 7.9%. There were no aortic-related deaths in patients undergoing definitive MM.

Conclusions: Approximately 1 in 4 patients with BTAI undergo MM as definitive therapy. There is considerable variation in pharmacological therapies utilized. Medical management for patients with minimal aortic injury (MAI; BTAI Grades 1 and 2) is safe and effective, with a low overall intervention rate and no aortic-related deaths. These findings support definitive MM for Grade 2 BTAI.
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http://dx.doi.org/10.1016/j.jvs.2021.08.084DOI Listing
September 2021

Reappraisal of the role of motor and somatosensory evoked potentials during open distal aortic repair.

J Thorac Cardiovasc Surg 2021 Aug 20. Epub 2021 Aug 20.

Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth, Houston, Tex. Electronic address:

Objective: Intraoperative motor and somatosensory evoked potentials have been applied to monitor spinal cord ischemia during repair. However, their predictive values remain controversial. The purpose of this study was to evaluate the impact of motor evoked potentials and somatosensory evoked potentials on spinal cord ischemia during open distal aortic repair.

Methods: Our group began routine use of both somatosensory evoked potentials and motor evoked potentials at the end of 2004. This study used a historical cohort design, using risk factor and outcome data from our department's prospective registry. Univariate and multivariable statistics for risk-adjusted effects of motor evoked potentials and somatosensory evoked potentials on neurologic outcome and model discrimination were assessed with receiver operating characteristic curves.

Results: Both somatosensory evoked potentials and motor evoked potentials were measured in 822 patients undergoing open distal aortic repair between December 2004 and December 2019. Both motor evoked potentials and somatosensory evoked potentials were intact for the duration of surgery in 348 patients (42%). Isolated motor evoked potential loss was observed in 283 patients (34%), isolated somatosensory evoked potential loss was observed in 18 patients (3%), and both motor evoked potential and somatosensory evoked potential loss were observed in 173 patients (21%). No spinal cord ischemia occurred in the 18 cases with isolated somatosensory evoked potential loss. When both signals were lost, signal loss happened in the order of motor evoked potentials and then somatosensory evoked potentials. Immediate spinal cord ischemia occurred in none of those without signal loss, 4 of 283 (1%) with isolated motor evoked potential loss, and 15 of 173 (9%) with motor evoked potential plus somatosensory evoked potential loss. Delayed spinal cord ischemia occurred in 12 of 348 patients (3%) with intact evoked potentials, 24 of 283 patients (8%) with isolated motor evoked potentials loss, and 27 of 173 patients (15%) with motor evoked potentials + somatosensory evoked potentials loss (P < .001). Motor evoked potentials and somatosensory evoked potentials loss were each independently associated with spinal cord ischemia. For immediate spinal cord ischemia, no return of motor evoked potential signals at the conclusion of the surgery had the highest odds ratio of 15.87, with a receiver operating characteristic area under the curve of 0.936, whereas motor evoked potential loss had the highest odds ratio of 3.72 with an area under the curve of 0.638 for delayed spinal cord ischemia.

Conclusions: Somatosensory evoked potentials and motor evoked potentials are both important monitoring measures to predict and prevent spinal cord ischemia during and after open distal aortic repairs. Intraoperative motor evoked potential loss is a risk for immediate and delayed spinal cord ischemia after open distal aortic repair, and somatosensory evoked potential loss further adds predictive value to the motor evoked potential.
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http://dx.doi.org/10.1016/j.jtcvs.2021.08.033DOI Listing
August 2021

Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel.

Neurointervention 2021 Sep 10. Epub 2021 Sep 10.

Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.

In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol's vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.
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http://dx.doi.org/10.5469/neuroint.2021.00290DOI Listing
September 2021

Liver Transplantation in the United Arab Emirates From Deceased and Living Donors: Initial 2-Year Experience.

Transplantation 2021 Sep;105(9):1881-1883

Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.

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http://dx.doi.org/10.1097/TP.0000000000003455DOI Listing
September 2021

Central Retinal Vein Occlusion in a 46-Year-Old Man with COVID-19: Case Report and Review of the Literature.

Case Rep Ophthalmol 2021 May-Aug;12(2):646-652. Epub 2021 Jul 19.

Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

A 46-year-old man with a history of well-controlled hypertension presented with a central retinal vein occlusion (CRVO) in his right eye, which was complicated by cystoid macular edema. When the patient noted new visual symptoms, he was also experiencing muscle aches and easy fatiguability. A standard hypercoagulability panel failed to identify an etiology for his CRVO. However, the patient underwent COVID-19 antibody testing, which returned positive. The patient received a series of aflibercept injections for his macular edema, and his vision improved. Further study is warranted to determine if there is any association between mild infection with COVID-19 and the development of CRVO.
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http://dx.doi.org/10.1159/000517417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8339514PMC
July 2021

Mortality in Congenital Diaphragmatic Hernia: A Multicenter Registry Study of Over 5000 Patients Over 25 Years.

Ann Surg 2021 Jul 29. Epub 2021 Jul 29.

Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA Department of Cardiovascular Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, TX, USA Department of Pediatric Surgery, University of Michigan School of Medicine, Ann Arbor, MI Department of Paediatric Surgery, Royal Hospital for Children, Glasgow, United Kingdom Arkansas Children's Hospital, Little Rock, AR, USA Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA Division of Neonatology, University of Utah, Salt Lake City, Utah, USA Department of Neonatal Medicine; The Royal Children's Hospital, Melbourne, Victoria, Australia.

Objective: To determine if risk-adjusted survival of patients with congenital diaphragmatic hernia (CDH) has improved over the last 25 years within centers that are long-term, consistent participants in the CDH Study Group (CDHSG).

Summary Background Data: The CDHSG is a multicenter collaboration focused on evaluation of infants with CDH. Despite advances in pediatric surgical and intensive care, CDH mortality has appeared to plateau. Herein, we studied CDH mortality rates amongst long-term contributors to the CDHSG.

Methods: We divided registry data into five-year intervals, with Era 1 (E1) beginning in 1995, and analyzed multiple variables (operative strategy, defect size, and mortality) to assess evolution of disease characteristics and severity over time. For mortality analyses, patients were risk stratified using a validated prediction score based on 5-minute Apgar (Apgar5) and birth weight. A risk-adjusted, observed to expected (O:E) mortality model was created using E1 as a reference.

Results: 5,203 patients from 23 centers with ≥22 years of participation were included. Birth weight, Apgar5, diaphragmatic agenesis, and repair rate were unchanged over time (all p > 0.05). In E5 compared to E1, minimally invasive and patch repair were more prevalent, and timing of diaphragmatic repair was later (all p < 0.01). Overall mortality decreased over time: E1 (30.7%), E2 (30.3%), E3 (28.7%), E4 (26.0%), E5 (25.8%) (p = 0.03). Risk-adjusted mortality showed a significant improvement in E5 compared to E1 (OR 0.78, 95% CI 0.62-0.98; p = 0.03). O:E mortality improved over time, with the greatest improvement in E5.

Conclusions: Risk-adjusted and observed-to-expected CDH mortality have improved over time.
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http://dx.doi.org/10.1097/SLA.0000000000005113DOI Listing
July 2021

Induction Therapy With Antithymocyte Globulin and Delayed Calcineurin Inhibitor Initiation for Renal Protection in Liver Transplantation: A Multicenter Randomized Controlled Phase II-B Trial.

Transplantation 2021 Jul 27. Epub 2021 Jul 27.

Digestive Disease and Surgery Institute, Transplant Center, Cleveland Clinic, Cleveland, OH. Division of Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH. Transplant Center, Cleveland Clinic Weston, Weston, FL. Division of Transplantation Surgery, Medical College of Wisconsin, Milwaukee, WI. Transplantation Institute, University of Chicago Medicine, Chicago, IL.

Background: Calcineurin inhibitor (CNI) based immunosuppression in liver transplantation (LTx) is associated with acute and chronic deterioration of kidney function. Delaying CNI initiation by using induction rabbit anti-thymocyte globulin (rATG) may provide kidneys with adequate time to recover from a perioperative insult reducing the risk of early post-LTx renal deterioration.

Methods: This was an open-label, multicenter, randomized controlled clinical trial comparing use of induction rATG with delayed CNI initiation (day-10) against upfront CNI commencement (SOC; standard of care) in those patients deemed at standard risk of postoperative renal dysfunction following LTx. The primary end point was change in (delta) creatinine from baseline to month-12.

Results: Fifty-five patients were enrolled in each study arm. Mean Tacrolimus levels remained comparable in both groups from day-10 throughout the study period. A significant difference in delta creatinine was observed between rATG and SOC groups at 9-months (p=0.03) but not at month-12 (p=0.05). eGFR levels remained comparable between cohorts at all time points. Rates of biopsy-proven acute rejection at 1-year were similar between groups (16.3 vs 12.7%, p= 0.58). rATG showed no significant adverse effects. Survival at 12-months was comparable between groups (p= 0.48).

Conclusions: Although the use of induction rATG and concurrent CNI deferral in this study did not demonstrate a significant difference in delta creatinine at 1 year, these results indicate a potential role for rATG in preserving early kidney function, especially when considered with CNI deferral beyond 10 days and/or lower target Tacrolimus levels, with acceptable safety and treatment efficacy.
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http://dx.doi.org/10.1097/TP.0000000000003904DOI Listing
July 2021

The Proteome of Preretinal Tissue in Proliferative Vitreoretinopathy.

Ophthalmic Surg Lasers Imaging Retina 2021 Jul 1;52(S1):S5-S12. Epub 2021 Jul 1.

Background And Objective: Proliferative vitreoretinopathy (PVR) is the leading cause of retinal detachment repair failure. However, the molecular pathogenesis remains incompletely understood. Determining the proteome of PVR will help to identify novel therapeutic targets.

Materials And Methods: Preretinal tissue samples, delaminated during surgery from six PVR cases and one idiopathic epiretinal membrane (ERM) were analyzed by mass spectrometry. Tandem mass spectra were extracted using the UniProt database, generating a list of 896 proteins, which were subjected to pathway set and fold-change (ERM vs PVR) analyses.

Results: Two pathways were enriched in PVR: extracellular matrix (ECM) organization and extracellular structure organization. A fold-change analysis comparing mean total spectral counts from PVR to an ERM control identified fibronectin, the ECM glycoprotein, as the protein most significantly elevated in PVR compared to ERM.

Conclusion: These data identify pathwayskey to PVR progression, including thoseinvolved in cell-mediated ECM assembly and thus tractional force generation at the cellular level. .
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http://dx.doi.org/10.3928/23258160-20210518-02DOI Listing
July 2021

The Concept of Functional Graft Size: an Eternal Theme of Maximizing Donor Safety and Recipient Survival in Living Donor Liver Transplantation.

Transplantation 2021 Jul 13. Epub 2021 Jul 13.

Department of General Surgery, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1097/TP.0000000000003891DOI Listing
July 2021

The Impact of COVID-19 on CO Emissions in the Los Angeles and Washington DC/Baltimore Metropolitan Areas.

Geophys Res Lett 2021 Jun 7;48(11):e2021GL092744. Epub 2021 Jun 7.

National Institute of Standards and Technology Gaithersburg MD USA.

Responses to COVID-19 have resulted in unintended reductions of city-scale carbon dioxide (CO) emissions. Here, we detect and estimate decreases in CO emissions in Los Angeles and Washington DC/Baltimore during March and April 2020. We present three lines of evidence using methods that have increasing model dependency, including an inverse model to estimate relative emissions changes in 2020 compared to 2018 and 2019. The March decrease (25%) in Washington DC/Baltimore is largely supported by a drop in natural gas consumption associated with a warm spring whereas the decrease in April (33%) correlates with changes in gasoline fuel sales. In contrast, only a fraction of the March (17%) and April (34%) reduction in Los Angeles is explained by traffic declines. Methods and measurements used herein highlight the advantages of atmospheric CO observations for providing timely insights into rapidly changing emissions patterns that can empower cities to course-correct CO reduction activities efficiently.
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http://dx.doi.org/10.1029/2021GL092744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8206775PMC
June 2021

The Prognostic Utility of Intraoperative Allograft Vascular Inflow Measurements in Donation After Circulatory Death Liver Transplantation.

Liver Transpl 2021 Jun 16. Epub 2021 Jun 16.

Transplantation Center, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

Donation after circulatory death (DCD) liver transplantation improves deceased donor liver use and decreases waitlist burden, albeit at an increased risk of biliary complications and inferior graft survival. Employing liver vascular inflow measurements intraoperatively permits allograft prognostication. However, its use in DCD liver transplantation is hitherto largely unknown and further explored here. DCD liver transplantation patient records at a single center from 2005 to 2018 were retrospectively scrutinized. Intraoperative flow data and relevant donor parameters were analyzed against endpoints of biliary events and graft survival. A total of 138 cases were chosen. The incidence of cumulative biliary complications was 38%, the majority of which were anastomotic strictures and managed successfully by endoscopic means. The ischemic cholangiopathy rate was 6%. At median thresholds of a portal vein (PV) flow rate of <92 mL/minute/100 g and buffer capacity (BC) of >0.04, both variables were independently associated with risk of biliary events (P = 0.01 and 0.04, respectively). Graft survival was 90% at 12 months and 75% at 5 years. Cox regression analysis revealed a PV flow rate of <50 mL/minute/100 g as predictive of poorer graft survival (P = 0.01). Furthermore, 126 of these DCD livers were analyzed against a propensity-matched group of 378 contemporaneous donation after brain death liver allografts (1:3), revealing significantly higher rates (P < 0.001) of both early allograft dysfunction (70% versus 30%) and biliary complications (37% versus 20%) in the former group. Although flow data were comparable between both sets, PV flow and BC were predictive of biliary events only in the DCD cohort. Intraoperative inflow measurements therefore provide valuable prognostication on biliary/graft outcomes in DCD liver transplantation, can help inform graft surveillance, and its routine use is recommended.
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http://dx.doi.org/10.1002/lt.26212DOI Listing
June 2021

Direct Vertebral Artery Access for Coil Embolization of a Partially Thrombosed Mid-Basilar Trunk Aneurysm: Technical Limitations.

Oper Neurosurg (Hagerstown) 2021 Sep;21(4):E381-E385

Department of Neurosurgery, Medstar Washington Hospital Center, Washington, District of Columbia, USA.

Background And Importance: Partially thrombosed basilar aneurysms have a high morbidity from the rupture risk and mass effect prompting early treatment. Depending on the size and location, they pose a surgical challenge often requiring multiple endovascular treatment modalities. Here we present a partially thrombosed mid-basilar aneurysm successfully coil embolized with direct vertebral artery access and discuss the technical limitations of direct V1 access.

Clinical Presentation: A 70-yr-old woman presented with acute onset headache, nausea, and vomiting. A computed tomography (CT) head demonstrated a hyperdense prepontine mass which was further characterized as a partially thrombosed basilar aneurysm on CT angiography. After multiple failed attempts to access the vertebral artery via femoral and radial access the patient was taken to the operating room (OR) for surgical exposure of the right V1 segment and direct cannulation of the vertebral artery. The aneurysm was successfully coiled and the vertebral artery closed primarily. The patient was discharged home without any neurological deficits.

Conclusion: Partially thrombosed mid-basilar aneurysms are difficult to treat both surgically and endovascularly. We present a case where endovascular access to the aneurysm was very challenging requiring direct exposure and cannulation of the V1 segment to successfully embolize with coils and discuss the technical limitations of this approach.
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http://dx.doi.org/10.1093/ons/opab186DOI Listing
September 2021

Long term outcomes and complications of reno-portal anastomosis in liver transplantation: results from a propensity score-based outcome analysis.

Transpl Int 2021 Oct 31;34(10):1938-1947. Epub 2021 Aug 31.

Transplantation Center, Cleveland Clinic, Cleveland, OH, USA.

Diffuse splanchnic vein thrombosis (DSVT) remains a serious challenge in liver transplantation (LT). Reno-portal anastomosis (RPA) has previously been reported as a valid option for management of patients with DSVT during LT. The aim of this study was to evaluate post-transplant renal function and surgical outcomes of patients with DSVT who underwent RPA during LT. Between January 2005 and December 2017, 1270 patients underwent LT at our institution, including 16 with DSVT managed with RPA (RPA group). We compared renal function and surgical outcomes in these patients to outcomes in 48 propensity score (PS)-matched patients without thrombosis (control group), using a 1:3 matching model. The two groups had similar rates of postoperative portal vein thrombosis (PVT), renal dysfunction as measured by estimated glomerular filtration rate (eGFR), and overall postoperative complications (Clavien grade III), although the RPA group had a higher incidence of postoperative upper gastrointestinal (GI) bleeding (31.3% vs 4.2%; P = 0.009) that had no clinical consequence. There were no significant differences in five-year graft and patient survival rates between the groups (P = 0.133 and P = 0.166, respectively). RPA is an established technique in the management of patients with DSVT during LT, with comparable outcomes to patients without thrombosis. Our report is the first to demonstrate similar surgical outcomes, including long-term renal function, in LT recipients with or without RPA.
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http://dx.doi.org/10.1111/tri.13920DOI Listing
October 2021

Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas.

Neurosurg Rev 2021 Apr 24. Epub 2021 Apr 24.

Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.

Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.
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http://dx.doi.org/10.1007/s10143-021-01553-xDOI Listing
April 2021

Fusion for subaxial bow hunter's syndrome results in remote osseous remodeling of the hyperostotic growth responsible for vertebral artery compression.

Surg Neurol Int 2021 17;12:104. Epub 2021 Mar 17.

Department of Neurosurgery, Naval Medical Center San Diego, San Diego, California, United States.

Background: The authors present a previously unreported case of a patient with diffuse idiopathic skeletal hyperostosis (DISH) who developed bow hunter's syndrome (BHS) or positional vertebrobasilar insufficiency. In addition, the authors demonstrate angiographic evidence of remote osseous remodeling after segmental fusion without direct decompression of the offending bony growth. BHS is a rare, yet well established, cause of posterior circulation ischemia and ischemic stroke. Several etiologies such as segmental instability and spondylosis have been described as causes, however, DISH has not been associated with BHS before this publication.

Case Description: A 77-year-old man who presented with BHS was found to have cervical spine changes consistent with DISH, and angiography confirmed right vertebral artery (VA) stenosis at C4-5 from a large pathological elongation of the right C5 lateral mass. Head rotation resulted in occlusion of the VA. The patient underwent an anterior cervical discectomy and fusion and reported complete resolution of his symptoms. A delayed angiogram and CT of the cervical spine demonstrated complete resolution of the baseline stenosis, no dynamic compression, and remote osseous remodeling of the growth, respectively.

Conclusion: This case represents the first publication in the literature of DISH as a causative etiology of BHS and of angiographic data demonstrating resolution of a compressive osseous pathology without direct decompression in BHS.
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http://dx.doi.org/10.25259/SNI_762_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053469PMC
March 2021

In-hospital outcomes and long-term survival of women of childbearing age with aortic dissection.

J Vasc Surg 2021 Oct 20;74(4):1135-1142.e1. Epub 2021 Apr 20.

Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Tex. Electronic address:

Objective: In the present study, we defined the outcomes and effects of pregnancy in a cohort of women of childbearing age with acute aortic dissection (AAD).

Methods: We reviewed our database of AAD to identify all eligible female patients. Women aged <45 years were included. Data on pregnancy timing with respect to the occurrence of dissection, the demographic data, dissection extent, dissection treatment, dissection-related outcomes, overall maternal and fetal mortality, and genetic testing results were analyzed.

Results: A total of 62 women aged <45 years had presented to us with AAD from 1999 to 2017. Of the 62 women, 37 (60%) had had a history of pregnancy at AAD. Of these 37 patients, 10 (27%) had had a peripartum aortic dissection, defined as dissection during pregnancy or within 12 months postpartum. Of the 10 AADs, 5 were type A and 5 were type B. Three patients had presented with AAD during pregnancy (one in the second and two in the third trimester). Five patients (50%) had developed AAD in the immediate postpartum period (within 3 months) and two (20%) in the late postpartum period. For the immediate postpartum AADs (<3 months), four of the five patients delivered via cesarean section. Of these 10 peripartum AADs, 3 (30%) had occurred in patients with known Marfan syndrome. In-hospital mortality for those with peripartum AAD was 10% (1 of 10). Fetal mortality was 20% (2 of 10).

Conclusions: The frequency of aortic dissection in women of childbearing age at our institution was low. However, pregnancy might increase the risk of those young women genetically predisposed to dissection events. From these data, this risk appears to be greatest in the immediate postpartum period, even for those who undergo cesarean section. Close clinical and radiographic surveillance is required for all women with suspected aortopathy, especially in the third trimester and early postpartum period.
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http://dx.doi.org/10.1016/j.jvs.2021.03.028DOI Listing
October 2021

Fifty years of EPA science for air quality management and control.

Environ Manage 2021 06 9;67(6):1017-1028. Epub 2021 Apr 9.

U.S. Environmental Protection Agency, Office of Research and Development, Research Triangle Park, NC, 27711, USA.

Research and development has been a key part of the foundation for improvements in US air quality since the establishment of the Environmental Protection Agency (EPA) 50 years ago. Although the scientific accomplishments and advances over the course of EPA's history are often overshadowed by policy debates, much of the air pollution science and engineering we now consider to be routine did not exist when EPA was established. Many of the advances in air pollutant measurement, monitoring, modeling, and control were developed by EPA researchers or supported by EPA programs. The technical foundation built during EPA's early years has since given the Agency the scientific ability to respond quickly and effectively to unexpected and emerging issues. Equally important, EPA also developed approaches to conducting and presenting science in policy settings to ensure that the science was as objective and complete as possible and was communicated effectively. A look back at some of the accomplishments of EPA scientists and engineers provides a reminder that the cumulative effect of continual, incremental advances can result in large and lasting benefits to society.
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http://dx.doi.org/10.1007/s00267-021-01468-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106583PMC
June 2021

Effectiveness of Standard Local Anesthetic Bupivacaine and Liposomal Bupivacaine for Postoperative Pain Control in Patients Undergoing Truncal Incisions: A Randomized Clinical Trial.

JAMA Netw Open 2021 03 1;4(3):e210753. Epub 2021 Mar 1.

McGovern Medical School at the University of Texas Health Science Center at Houston.

Importance: Liposomal bupivacaine for pain relief is purported to last 3 days compared with 8 hours with standard bupivacaine. However, its effectiveness is unknown in truncal incisions for cardiothoracic or vascular operations.

Objective: To compare the effectiveness of single-administration standard bupivacaine vs liposomal bupivacaine in patients undergoing truncal incisions.

Design, Setting, And Participants: This randomized clinical trial enrolled patients undergoing sternotomy, thoracotomy, minithoracotomy, and laparotomy from a single cardiovascular surgery department in an academic medical center between November 2012 and June 2018. The study was powered to detect a Cohen effect size of 0.35 with a power of greater than 80%. Data analysis was performed from July to December 2018.

Intervention: Patients were randomized to standard bupivacaine or liposomal bupivacaine.

Main Outcomes And Measures: Pain was assessed over 3 postoperative days by the Numeric Rating Scale (NRS). Adjunctive opioids were converted to morphine equivalents units (MEU). NRS scores were compared using Wilcoxon rank-sum (3-day area under the curve) and 2-way nonparametric mixed models (daily scale score) to assess time-by-group interaction. Secondary outcomes included cumulative opioid consumption.

Results: A total of 280 patients were analyzed, with 140 in each group (single-administration standard bupivacaine vs liposomal bupivacaine). Mean (SD) age was 60.2 (14.4) years, and 101 of 280 patients (36%) were women. Irrespective of treatment assignment, pain decreased by a mean of approximately 1 point per day over 3 days (β = -0.87; SE = 0.11; mixed model regression P < .001). Incision type was associated with pain with patients undergoing thoracotomy (including minithoracotomy) reporting highest median (interquartile range [IQR]) pain scores on postoperative days 1 (liposomal vs standard bupivacaine, 6 [4-8] vs 5 [3-7]; P = .049, Wilcoxon rank-sum) and 2 (liposomal vs standard bupivacaine, 5 [4-7] vs 4 [2-6]; P = .003, Wilcoxon rank-sum) but not day 3 (liposomal vs standard bupivacaine, 3 [2-6] vs 3 [1-5]; P = .10, Wilcoxon rank-sum), irrespective of treatment group. Median (IQR) 3-day cumulative NRS was 12.0 (8.0-16.5) for bupivacaine and 13.5 (9.0-17.0) for liposomal bupivacaine (P = .15, Wilcoxon rank-sum) Furthermore, use of opioids was greater following liposomal bupivacaine compared with standard bupivacaine (median [IQR], 41.5 [21.3-73.8] MEU vs 33.0 [17.8-62.5] MEU; P = .03, Wilcoxon rank-sum). On multivariable analysis, no interaction by incision type was observed for mean pain scores or opioid use.

Conclusions And Relevance: In this randomized clinical trial involving truncal incisions for cardiovascular procedures, liposomal bupivacaine did not provide improved pain control and did not reduce adjunctive opioid use compared with conventional bupivacaine formulation over 3 postoperative days.

Trial Registration: ClinicalTrials.gov Identifier: NCT02111746.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.0753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967071PMC
March 2021

Seamless Introduction of a Purely Laparoscopic Full-Lobe Living Donor Hepatectomy Program in a North American Center.

Liver Transpl 2021 08 20;27(8):1203-1206. Epub 2021 Jul 20.

Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH.

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http://dx.doi.org/10.1002/lt.26030DOI Listing
August 2021

Endovascular treatment of complicated versus uncomplicated acute type B aortic dissection.

J Thorac Cardiovasc Surg 2021 Jan 21. Epub 2021 Jan 21.

Department of Clinical and Community Sciences, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.

Objective: The study objective was to analyze the outcomes of thoracic endovascular aortic repair performed for complicated and uncomplicated acute type B aortic dissections.

Methods: Patients from WL Gore's Global Registry for Endovascular Aortic Treatment who underwent thoracic endovascular aortic repair for acute type B aortic dissections were included, and data were retrospectively analyzed.

Results: Of 5014 patients enrolled in the Global Registry for Endovascular Aortic Treatment, 172 underwent thoracic endovascular aortic repair for acute type B aortic dissections. Of these repairs, 102 were for complicated acute type B aortic dissections and 70 were for uncomplicated acute type B aortic dissections. There were 46 (45.1%) procedures related to aortic branch vessels versus 15 (21.4%) in complicated type B aortic dissections and uncomplicated type B aortic dissections (P = .002). The mean length of stay was 14.3 ± 10.6 days (median, 11; range, 2-75) versus 9.8 ± 7.9 days (median, 8; range, 0-42) in those with complicated type B aortic dissections versus those with uncomplicated acute type B aortic dissections (P < .001). Thirty-day mortality was not different between groups (complicated type B aortic dissections 2.9% vs uncomplicated acute type B aortic dissections 1.4%, P = .647), as well as aortic complications (8.8% vs 5.7%, P = .449). Aortic event-free survival was 62.9% ± 37.1% versus 70.6% ± 29.3% at 3 years (P = .696).

Conclusions: In the Global Registry for Endovascular Aortic Treatment, thoracic endovascular aortic repair results for complicated type B aortic dissections versus uncomplicated acute type B aortic dissections showed that 30-day mortality and perioperative complications were equally low for both. The midterm outcome was positive. These data confirm that thoracic endovascular aortic repair as the first-line strategy for treating complicated type B dissections is associated with a low risk of complications. Further studies with longer follow-up are necessary to define the role of thoracic endovascular aortic repair in uncomplicated acute type B dissections compared with medical therapy. However, in the absence of level A evidence from randomized trials, results of the uncomplicated acute type B aortic dissection patient cohort treated with thoracic endovascular aortic repair from registries are important to understand the related risk and benefit.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.027DOI Listing
January 2021

Conditional probability of graft survival in liver transplantation using donation after circulatory death grafts - a retrospective study.

Transpl Int 2021 Aug 13;34(8):1433-1443. Epub 2021 Jul 13.

Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH, USA.

The use of livers from donation after circulatory death (DCD) is historically characterized by increased rates of biliary complications and inferior short-term graft survival (GS) compared to donation after brain death (DBD) allografts. This study aimed to evaluate the dynamic prognostic impact of DCD livers to reveal whether they remain an adverse factor even after patients survive a certain period following liver transplant (LT). This study used 74 961 LT patients including 4065 DCD LT in the scientific registry of transplant recipients from 2002-2017. The actual, 1 and 3-year conditional hazard ratio (HR) of 1-year GS in DCD LT were calculated using a conditional version of Cox regression model. The actual 1-, 3-, and 5-year GS of DCD LT recipients were 83.3%, 73.3%, and 66.3%, which were significantly worse than those of DBD (all P < 0.01). Actual, 1-, and 3-year conditional HR of 1-year GS in DCD compared to DBD livers were 1.87, 1.49, and 1.39, respectively. Graft loss analyses showed that those lost to biliary related complications were significantly higher in the DCD group even 3 years after LT. National registry data demonstrate the protracted higher risks inherent to DCD liver grafts in comparison to their DBD counterparts, despite survival through the early period after LT. These findings underscore the importance of judicious DCD graft selection at individual center level to minimize the risk of long-term biliary complications.
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http://dx.doi.org/10.1111/tri.13846DOI Listing
August 2021

Neuroendocrine liver metastases: The role of liver transplantation.

Transplant Rev (Orlando) 2021 04 15;35(2):100595. Epub 2021 Jan 15.

Transplantation Center, Department of Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA. Electronic address:

Purpose Of Review: Neuroendocrine tumor (NET) metastasis localized to the liver is an accepted indication for liver transplantation as such tumors have a low biological aggressiveness in terms of malignancy and are slow growing.

Recent Findings: The long-term results are comparable with and in some cases even better than those of transplantations performed for primary liver cancer. However, compared with nonmalignant conditions, neuroendocrine liver metastasis (NELM) may result in an inferior outcome of transplantation. In the face of the scarcity of donated organs and recent improved results of non-surgical treatment for NELM, controversy over patient selection and timing for liver transplantation continues.

Summary: In this review, we provide an overview of the diagnostic work-up and selection criteria of patients with NELM being considered for liver transplantation. Thereafter, we provide a critical analysis of the reported outcomes of OLT.
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http://dx.doi.org/10.1016/j.trre.2021.100595DOI Listing
April 2021

Neural Correlates of Vocal Auditory Feedback Processing: Unique Insights from Electrocorticography Recordings in a Human Cochlear Implant User.

eNeuro 2021 Jan-Feb;8(1). Epub 2021 Jan 28.

Human Brain Research Laboratory, Department of Neurosurgery, The University of Iowa, Iowa City, 52242 IA

There is considerable interest in understanding cortical processing and the function of top-down and bottom-up human neural circuits that control speech production. Research efforts to investigate these circuits are aided by analysis of spectro-temporal response characteristics of neural activity recorded by electrocorticography (ECoG). Further, cortical processing may be altered in the case of hearing-impaired cochlear implant (CI) users, as electric excitation of the auditory nerve creates a markedly different neural code for speech compared with that of the functionally intact hearing system. Studies of cortical activity in CI users typically record scalp potentials and are hampered by stimulus artifact contamination and by spatiotemporal filtering imposed by the skull. We present a unique case of a CI user who required direct recordings from the cortical surface using subdural electrodes implanted for epilepsy assessment. Using experimental conditions where the subject vocalized in the presence (CIs ON) or absence (CIs OFF) of auditory feedback, or listened to playback of self-vocalizations without production, we observed ECoG activity primarily in γ (32-70 Hz) and high γ (70-150 Hz) bands at focal regions on the lateral surface of the superior temporal gyrus (STG). High γ band responses differed in their amplitudes across conditions and cortical sites, possibly reflecting different rates of stimulus presentation and differing levels of neural adaptation. STG γ responses to playback and vocalization with auditory feedback were not different from responses to vocalization without feedback, indicating this activity reflects not only auditory, but also attentional, efference-copy, and sensorimotor processing during speech production.
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http://dx.doi.org/10.1523/ENEURO.0181-20.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877459PMC
June 2021

Implementation of a Prescriptive Extracorporeal Circuit and Its Effect on Hemodilution and Blood Product Usage during Cardiac Surgery.

J Extra Corpor Technol 2020 Dec;52(4):295-302

McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas; Memorial Hermann Hospital, Texas Medical Center, Houston, Texas; and University of Nebraska Medical Center, Omaha, Nebraska.

The use of cardiopulmonary bypass (CPB) contributes significantly to intraoperative anemia. The use of a prescriptive circuit that is tailored to the patient size could significantly reduce priming volumes, resulting in less hemodilution. The purpose of this study was to determine whether a prescriptive circuit resulted in decreased hemodilution, reduced blood product usage, and improved outcomes. In total, 204 patients prospectively received the prescriptive protocol between March 2019 and November 2019. This protocol was composed of three circuit sizes: small [body surface area (BSA) ≤ 1.85 m], medium (BSA 1.86-2.30 m), and large (BSA ≥ 2.31 m). Data for CPB and post-bypass transfusions were collected, along with postoperative outcomes. These patients were then 1:2 propensity score matched to 401 patients who were retrospectively reviewed who had undergone cardiac surgery using a one-sized CPB circuit. The prescriptive protocol cohort had more patients with renal disease, whereas the conventional cohort had more history of hypertension. Intraoperative results show the prescriptive circuit had lower mean prime volume and total prime volume after reverse autologous prime (1,084 mL vs. 1,798 mL, < .0001; 725 mL vs. 1,181 mL, < .0001). Ultrafiltration was higher in the prescriptive group (872 vs. 645 mL, < .0001), which likely balanced the increased use of del Nido cardioplegia in the prescriptive group (1,295 vs. 377 mL, < .0001). The drop in hematocrit (HCT) from baseline was less in the prescriptive group (15.1 ± 4.91 vs. 16.2 ± 4.88, = .0149), whereas the postoperative HCT was higher (32.79 ± 4.88 vs. 31.68 ± 4.99, = .0069). Transfusion of packed red cells did not change between the two groups. Implementation of a prescriptive circuit did not reduce on-bypass or intraoperative blood product usage. However, there was a significant reduction in on-bypass hemodilution and increased postoperative HCT.
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http://dx.doi.org/10.1182/ject-2000037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728493PMC
December 2020

Management of Diabetic Retinopathy in the Anti-Vascular Endothelial Growth Factor Era.

Retina 2021 Mar;41(3):461-463

Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1097/IAE.0000000000003071DOI Listing
March 2021

Transpacific Aeromedical Evacuation for a Ruptured Brain Arteriovenous Malformation During the COVID-19 Pandemic.

Mil Med 2021 05;186(5-6):e632-e636

Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.

The COVID-19 pandemic has altered preexisting patient treatment algorithms and referral patterns, which has affected neurosurgical care worldwide. Brain arteriovenous malformations are complex vascular lesions that frequently present with intracerebral hemorrhage. Care for these patients is best performed at large medical centers by specialists with high volumes. The authors describe the care of a patient who presented in extremis to a resource-limited, community-sized military treatment facility (MTF) in Southeast Asia. In the MTF, the patient underwent emergent neurosurgical therapy. However, given newly implemented restrictions enacted to mitigate COVID-19 spread, local transfer for definitive care to a tertiary care facility was not possible. In order to attain definitive care for the patient, a transpacific aeromedical evacuation augmented with a critical care air transport team was utilized for transfer to a tertiary care, teaching hospital. This case demonstrates the safe treatment of a patient with hemorrhagic arteriovenous malformations and postoperative management under limited conditions in an MTF outside the CONUS. Given the unique circumstances and challenges the pandemic presented, the authors feel that this patient's outcome was only possible by leveraging all the capability military medicine has to offer.
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http://dx.doi.org/10.1093/milmed/usaa531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798835PMC
May 2021

The Endometrioma Treatment Paradigm when Fertility Is Desired: A Systematic Review.

Authors:
Charles E Miller

J Minim Invasive Gynecol 2021 03 26;28(3):575-586. Epub 2020 Nov 26.

Department of Clinical Sciences, Rosalind Franklin University of Medicine and Science, North Chicago; Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois.. Electronic address:

Objective: To establish an endometrioma treatment paradigm (decision tree) in the treatment of an ovarian endometrioma through the review of current literature.

Data Sources: A thorough literature search, including PubMed, Google Scholar, and the Cochrane Library, was performed from April 2020 to July 2020. The review was completed by using the following keywords: METHODS OF STUDY SELECTION: Articles published in English that addressed the endometrioma in regard to the following were included: (1) diagnosis, (2) treatment of pain on the basis of size and/or surgical intervention, (3) treatment of fertility on the basis of size and/or surgical intervention, (4) surgical technique, (5) in vitro fertilization success on the basis of size and/or surgical intervention, (6) risk of rupture at the time of egg retrieval, (7) impact on the antimüllerian hormone and antral follicle count postsurgery, and (8) impact on implantation.

Tabulation, Integration, And Results: Fifty-six articles were included in this systematic review. While conducting this literature review, several themes were noted. In general, the literature on the ovarian endometrioma seems to be homogeneous in regard to imaging the endometrioma, excision rather than desiccation for an endometrioma ≥3-cm causing pain and/or infertility, minimal use of bipolar energy at the time of ovarian surgery, and risk of severe infection secondary to inadvertent rupture of cysts during egg retrieval. Conversely, studies on the ovarian endometrioma are much more heterogeneous in terms of surgery and assisted reproductive technology, that is, whether surgery should be performed. Certainly, an endometrioma ≥5-cm should be excised before assisted reproductive technology. Moreover, it seems that the antral follicle count and implantation may be enhanced with surgery.

Conclusion: By completing an extensive literature review, an easy-to-use algorithm for the diagnosis, evaluation, and treatment of endometriomas was developed to help clinicians in their treatment of patients with endometriosis in the short and long terms.
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http://dx.doi.org/10.1016/j.jmig.2020.11.020DOI Listing
March 2021
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