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1. International Core Outcome Set for Acute Simple Appendicitis in Children

Author

Max Knaapen, Ernst W E Van Heurn, Martin Offringa, Shireen Anne Nah, Dayang Anita Abdul Aziz, Ramon R. Gorter, Nigel J. Hall, Roel Bakx, Sherif Emil, Johanna H. van der Lee, Erik D. Skarsgard, Shawn D. St. Peter, Jan F. Svensson, Janne S. Suominen, Darcy Moulin, Augusto Zani, Peter C. Minneci, Susan Adams, Nancy J. Butcher, Rambha Rai, Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Pediatric surgery, Amsterdam Reproduction & Development (AR&D), Other Research, Paediatric Surgery, AGEM - Amsterdam Gastroenterology Endocrinology Metabolism, ARD - Amsterdam Reproduction and Development, General Paediatrics, APH - Methodology, and APH - Quality of Care

Subjects
medicine.medical_specialty, appendicitis, appendicitis research, Consensus, Adolescent, Delphi Technique, MEDLINE, Delphi method, core outcome set, 03 medical and health sciences, 0302 clinical medicine, nonoperative treatment, Outcome Assessment, Health Care, medicine, Humans, simple appendicitis, Child, Adverse effect, business.industry, medicine.disease, Focus group, Appendicitis, Bowel obstruction, Clinical trial, Treatment Outcome, Systematic review, Research Design, 030220 oncology & carcinogenesis, Family medicine, Acute Disease, 030211 gastroenterology & hepatology, Surgery, business
Abstract

Objective: : To develop an international Core Outcome Set (COS), a minimal collection of outcomes that should be measured and reported in all future clinical trials evaluating treatments of acute simple appendicitis in children.Summary Background Data: A previous systematic review identified 115 outcomes in 60 trials and systematic reviews evaluating treatments for children with appendicitis, suggesting the need for a COS.Methods: The development process consisted of four phases: (1) an updated systematic review identifying all previously reported outcomes, (2) a two-stage international Delphi study in which parents with their children and surgeons rated these outcomes for inclusion in the COS, (3) focus groups with young people to identify missing outcomes, and (4) international expert meetings to ratify the final COS.Results: The systematic review identified 129 outcomes which were mapped to 43 unique outcome terms for the Delphi survey. The first-round included 137 parents (eight countries) and 245 surgeons (10 countries), the second-round response rates were 61% and 85% respectively, with ten outcomes emerging with consensus. After two young peoples’ focus groups, two additional outcomes were added to the final COS (12): mortality, bowel obstruction, intra-abdominal abscess, recurrent appendicitis, complicated appendicitis, return to baseline health, readmission, reoperation, unplanned appendectomy, adverse events related to treatment, major and minor complications.Conclusion: An evidence-informed COS based on international consensus, including patients and parents has been developed. This COS is recommended for all future studies evaluating treatment of simple appendicitis in children, to reduce heterogeneity between studies and facilitate data synthesis and evidence-based decision-making.

Published
2022

2. Umbilical access in laparoscopic surgery in infants less than 3 months: A single institution retrospective review

Author

Pablo Aguayo, Rebecca M. Rentea, Kayla B. Briggs, Wendy Jo Svetanoff, David Juang, Shawn D. St. Peter, Tolulope A. Oyetunji, Richard J. Hendrickson, Charles L. Snyder, Jason D. Fraser, and James A. Fraser

Subjects
Insufflation, Laparoscopic surgery, medicine.medical_specialty, medicine.medical_treatment, Population, Hernia, Inguinal, Postoperative Complications, medicine, Operative report, Humans, Child, education, Herniorrhaphy, Retrospective Studies, education.field_of_study, business.industry, Infant, Newborn, Infant, General Medicine, Carbon Dioxide, medicine.disease, Surgery, Umbilical hernia, Inguinal hernia, Embolism, Pediatrics, Perinatology and Child Health, Laparoscopy, Complication, business, Hernia, Umbilical
Abstract

Introduction : Umbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO2) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years. Methods : A retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016-2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO2 embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death. Results : Of 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO2 embolism. Conclusion : In this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO2 embolism exists, these complications are not exclusively associated with umbilical access technique.

Published
2022

3. Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease

Author

Shawn D. St. Peter, Rebecca M. Rentea, Jason D. Fraser, James A. Fraser, Joseph Lopez, Wendy Jo Svetanoff, Tolulope A. Oyetunji, Pablo Aguayo, Kayla B. Briggs, David Juang, Richard J. Hendrickson, and Charles L. Snyder

Subjects
Male, medicine.medical_specialty, Hirschsprung associated enterocolitis, Anal Canal, Disease, Internal anal sphincter, Internal medicine, Outpatients, medicine, Humans, In patient, Hirschsprung Disease, Botulinum injections, Child, Retrospective Studies, Enterocolitis, business.industry, Infant, medicine.disease, Botulinum toxin, cardiovascular system, Surgery, medicine.symptom, Trisomy, business, medicine.drug
Abstract

Introduction Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. Methods A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 – July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. Results Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P Conclusion Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Published
2022

4. Thoracoscopic versus open lobectomy in infants with congenital lung malformations: A multi-institutional propensity score analysis

Author

Michael A. Helmrath, Shaun M. Kunisaki, Cartland R Burns, Katherine J. Deans, Grace Z. Mak, Tiffany Wright, Shawn D. St. Peter, Charles M. Leys, Samir K. Gadepalli, Rashmi Kabre, Jason D. Fraser, Dave R. Lal, Jennine H Weller, Mary E. Fallat, Matthew P. Landman, Ronald B. Hirschl, Jacqueline M. Saito, and Peter C. Minneci

Subjects
medicine.medical_specialty, Lung Neoplasms, Congenital lobar emphysema, Asymptomatic, 03 medical and health sciences, 0302 clinical medicine, 030225 pediatrics, medicine, Thoracoscopy, Humans, Child, Pneumonectomy, Propensity Score, Lung, Retrospective Studies, Intention-to-treat analysis, medicine.diagnostic_test, business.industry, Infant, Congenital pulmonary airway malformation, Retrospective cohort study, General Medicine, Perioperative, Length of Stay, medicine.disease, Surgery, Treatment Outcome, 030220 oncology & carcinogenesis, Pediatrics, Perinatology and Child Health, Propensity score matching, medicine.symptom, business
Abstract

The impact of thoracoscopic surgery on outcomes in children with congenital lung malformations (CLM) remains controversial. The purpose of this study was to determine the effect of operative approach on perioperative outcomes in infants undergoing lobectomy for an asymptomatic CLM.After IRB approval, a retrospective cohort study was conducted on 506 children with a CLM resected at one of eleven children's hospitals over a seven-year period. Infants undergoing elective lobectomy were identified, and covariates were balanced based on operative approach using propensity scores with full matching. Outcomes were analyzed based on intention to treat with weighted conditional regression.One hundred seventy-five infants met inclusion criteria. There were 67 (38.3%) open, 89 (50.9%) thoracoscopic, and 19 (10.9%) thoracoscopic-converted-to-open lobectomies. Thoracoscopic lobectomy was associated with significantly longer operative times (26 min, 95% CI 6-47 min, p = 0.012) but used less epidural anesthesia (OR 0.02, 95% CI 0.004-0.11, p0.001) when compared to open lobectomy. There were no significant differences in intraoperative blood loss, postoperative complications, chest tube duration, or length of stay.Thoracoscopy has become the most common operative approach for elective lobectomy in infants with asymptomatic CLMs. The non-inferiority of thoracoscopic lobectomy in postoperative outcomes supports its continued use as an alternative to open lobectomy.Treatment study, Level III.

Published
2021

5. Techniques of Laparoscopic Appendectomy for Pediatric Appendicitis: How I Do It

Author

Shawn D. St. Peter and Daniel J. Ostlie

Subjects
medicine.medical_specialty, Abdominal pain, Databases, Factual, Disease, law.invention, Randomized controlled trial, law, medicine, Appendectomy, Humans, Pediatric appendicitis, Longitudinal Studies, Child, Intensive care medicine, Laparoscopy, medicine.diagnostic_test, business.industry, Appendicitis, medicine.disease, Surgery, Current management, Observational study, medicine.symptom, business
Abstract

Background: Appendicitis is the most common operative emergency in children. As a result of accumulating evidence from randomized trials, observational studies, database work, and meta-analyses, the management of appendicitis in children has been shifting the past 15 years with many new debates emerging. In this article, we review our current management schemes. Methods: We reviewed the current and critical literature relevant to the rationale for our current management. Results: Clinical pathways appear to reduce variation and cost while improving the ability to diagnose and treat the disease. Minimally invasive approaches can be used to treat all forms of appendicitis. Conclusions: The future role of non-operative management deserves ongoing exploration. Refining diagnostic treatment algorithms and enhancing antibiotic stewardship are important moving forward.

Published
2021

6. Management of Pediatric Breast Masses: A Multi-institutional Retrospective Cohort Study

Author

Cynthia D. Downard, Jason D. Fraser, Dave R. Lal, Jonathan E. Kohler, Naila Merchant, Tiffany Wright, Amy E. Lawrence, Mercedes Pilkington, Patricia Lu, Grace Z. Mak, Troy A. Markel, Mary E. Fallat, Elle L. Kalbfell, Amanda Onwuka, Shawn D. St. Peter, Charles M. Leys, Maria E. Knaus, Cathleen M. Courtney, Tina Nguyen, Rashmi Kabre, Samir K. Gadepalli, Peter C. Minneci, Katherine J. Deans, Yara K. Duran, Julia Grabowski, Elissa Port, Thomas T. Sato, Alexis N. Bowder, Matthew P. Landman, Jacqueline M. Saito, and Beth Rymeski

Subjects
medicine.medical_specialty, Adolescent, Breast imaging, medicine.medical_treatment, Clinical Decision-Making, Breast Neoplasms, BI-RADS, Mastectomy, Segmental, Diagnosis, Differential, Diagnostic Self Evaluation, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Phyllodes Tumor, medicine, Humans, Breast, Child, Watchful Waiting, Breast ultrasound, Retrospective Studies, medicine.diagnostic_test, business.industry, Lumpectomy, Ultrasound, Retrospective cohort study, Pediatric Surgeon, medicine.disease, Fibroadenoma, 030220 oncology & carcinogenesis, Practice Guidelines as Topic, Feasibility Studies, Female, 030211 gastroenterology & hepatology, Surgery, Biopsy, Large-Core Needle, Ultrasonography, Mammary, Radiology, business
Abstract

Background The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. Materials and methods A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. Results Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. Conclusions Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.

Published
2021

7. A single institution experience with Laparoscopic Hernia repair in 791 children

Author

Pablo Aguayo, David Juang, James A. Fraser, Wendy Jo Svetanoff, Shawn D. St. Peter, Jason D. Fraser, Tolulope A. Oyetunji, Rebecca M. Rentea, Jessica K. Staszak, Charlene Dekonenko, Richard J. Hendrickson, Charles L. Snyder, and Kayla B. Briggs

Subjects
Male, medicine.medical_specialty, Percutaneous, Adolescent, medicine.medical_treatment, Hernia, Inguinal, Suture (anatomy), Recurrence, medicine, Humans, Single institution, Child, Herniorrhaphy, Retrospective Studies, business.industry, Infant, General Medicine, Hernia repair, medicine.disease, Surgery, Inguinal hernia, Treatment Outcome, Pediatrics, Perinatology and Child Health, Cauterization, Operative time, Laparoscopy, business, Pediatric population
Abstract

Introduction There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique. Methods A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p Results 791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically. Conclusions The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.

Published
2021

8. Current Status of Training and Certification for Congenital Heart Surgery Around the World: Proceedings of the Meetings of the Global Council on Education for Congenital Heart Surgery of the World Society for Pediatric and Congenital Heart Surgery

Author

Morten Helvind, Bohdan Maruszewski, Emile A. Bacha, Kisaburo Sakamoto, Christo I. Tchervenkov, Susan Vosloo, Cheul Lee, James S. Tweddell, Christian Kreutzer, Attilio A. Lotto, Hani K. Najm, Giovanni Stellin, Nguyen Ly Thinh Truong, Piya Samankatiwat, Jeffrey P. Jacobs, Joseph A. Dearani, Drissi Boumzebra, Miguel Arboleda, Krishna S Iyer, Pedro Becker, Tae-Gook Jun, James D St Louis, Valdano Manuel, Claudia Herbst, Bistra Zheleva, George E. Sarris, Richard A. Jonas, Frank Edwin, Kirsten Finucane, Sivakumar Sivalingam, Hafil B Abdulgani, Hao Zhang, David M. Overman, Marcelo B. Jatene, Vladimiro L. Vida, David J. Barron, Zohair Al-Halees, José Fragata, Adel Elgamal, Budi Rahmat, Elizabeth H. Stephens, Jorge Cervantes, Nestor Sandoval, Darshan Reddy, James K. Kirklin, and Justin T. Tretter

Subjects
Heart Defects, Congenital, Nonprofit organization, medicine.medical_specialty, Certification, Heart disease, education, 030204 cardiovascular system & hematology, 03 medical and health sciences, 0302 clinical medicine, medicine, Humans, Cardiac Surgical Procedures, Quality of care, Child, Societies, Medical, business.industry, Thoracic Surgery, General Medicine, medicine.disease, Surgery, Cardiac surgery, 030228 respiratory system, Cardiothoracic surgery, Pediatrics, Perinatology and Child Health, Cardiology and Cardiovascular Medicine, business
Abstract

The optimal training of the highly specialized congenital heart surgeon is a long and complex process, which is a significant challenge in most parts of the world. The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) has established the Global Council on Education for Congenital Heart Surgery as a nonprofit organization with the goal of assessing current training and certification and ultimately establishing standardized criteria for the training, evaluation, and certification of congenital heart surgeons around the world. The Global Council and the WSPCHS have reviewed the present status of training and certification for congenital cardiac surgery around the world. There is currently lack of consensus and standardized criteria for training in congenital heart surgery, with significant disparity between continents and countries. This represents significant obstacles to international job mobility of competent congenital heart surgeons and to the efforts to improve the quality of care for patients with Congenital Heart Disease worldwide. The purpose of this article is to summarize and document the present state of training and certification in congenital heart surgery around the world.

Published
2021

9. Multi-institutional Analysis of 100 Consecutive Patients with COVID-19 and Severe Pulmonary Compromise Treated with Extracorporeal Membrane Oxygenation: Outcomes and Trends Over Time

Author

Kirti Patel, Keshava Rajagopal, Eric A. Tesdahl, Alfred H. Stammers, Anthony K. Sestokas, Faisal H. Cheema, Vinay Badhwar, Michael S. Firstenberg, Marvin J. Slepian, J.W. Awori Hayanga, Feriel Esseghir, Jeffrey P. Jacobs, James D. St. Louis, Linda B. Mongero, and Tom Coley

Subjects
Adult, Male, pulmonary failure, Coronavirus disease 2019 (COVID-19), medicine.medical_treatment, Critical Illness, Biomedical Engineering, Biophysics, coronavirus, heart failure, Bioengineering, 030204 cardiovascular system & hematology, outcomes, Biomaterials, Cohort Studies, 03 medical and health sciences, 0302 clinical medicine, Extracorporeal membrane oxygenation, medicine, Humans, Prospective Studies, Prospective cohort study, Aged, business.industry, Management of COVID-19 Patients, SARS-CoV-2, COVID-19, Hydroxychloroquine, General Medicine, extracorporeal membrane oxygenation, acute respiratory distress syndrome, Middle Aged, medicine.disease, surgical procedures, operative, 030228 respiratory system, quality, Anesthesia, Heart failure, Cohort, Female, Intravenous steroids, business, medicine.drug, Cohort study
Abstract

The role of extracorporeal membrane oxygenation (ECMO) in the management of severely ill patients with coronavirus disease 2019 (COVID-19) continues to evolve. The purpose of this study is to review a multi-institutional clinical experience in 100 consecutive patients, at 20 hospitals, with confirmed COVID-19 supported with ECMO. This analysis includes our first 100 patients with complete data who had confirmed COVID-19 and were supported with ECMO. The first patient in the cohort was placed on ECMO on March 17, 2020. Differences by the mortality group were assessed using χ2 tests for categorical variables and Kruskal-Wallis rank-sum tests and Welch's analysis of variance for continuous variables. The median time on ECMO was 12.0 days (IQR = 8-22 days). All 100 patients have since been separated from ECMO: 50 patients survived and 50 patients died. The rate of survival with veno-venous ECMO was 49 of 96 patients (51%), whereas that with veno-arterial ECMO was 1 of 4 patients (25%). Of 50 survivors, 49 have been discharged from the hospital and 1 remains hospitalized at the ECMO-providing hospital. Survivors were generally younger, with a lower median age (47 versus 56.5 years, p = 0.014). In the 50 surviving patients, adjunctive therapies while on ECMO included intravenous steroids (26), anti-interleukin-6 receptor blockers (26), convalescent plasma (22), remdesivir (21), hydroxychloroquine (20), and prostaglandin (15). Extracorporeal membrane oxygenation may facilitate salvage and survival of selected critically ill patients with COVID-19. Survivors tend to be younger. Substantial variation exists in the drug treatment of COVID-19, but ECMO offers a reasonable rescue strategy.

Published
2021

10. Arthroplasty Rates Not Increasing in Young Patients With Rheumatoid Arthritis: A National Database Review, 2005 Versus 2014

Author

Djibril M. Ba, Rayford R. June, Major B. Burch, Douglas L. Leslie, John F. Nettrour, Nancy J. Olsen, Devin D St Clair, Bradley S. Bailey, and Guodong Liu

Subjects
musculoskeletal diseases, medicine.medical_specialty, Joint replacement, medicine.medical_treatment, Total knee arthroplasty, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, medicine, Orthopedics and Sports Medicine, 030212 general & internal medicine, Rheumatoid arthritis, Original Research, Orthopedic surgery, 030222 orthopedics, business.industry, medicine.disease, musculoskeletal system, Arthroplasty, Knee arthroplasty, DMARD, Utilization, surgical procedures, operative, Current Procedural Terminology, Hip arthroplasty, Surgery, National database, business, Antirheumatic drugs, RD701-811, Total hip arthroplasty
Abstract

Background: For 20 years, authors have predicted an expansion in total knee arthroplasty (TKA) and total hip arthroplasty (THA) utilization. Over this same period, the introduction of biological disease-modifying antirheumatic drugs has dramatically altered the treatment of rheumatoid arthritis (RA) with hopes of preventing articular damage and obviating the need for prosthetic replacement. The goal of our investigation was to evaluate TKA and THA utilization in young patients with RA (

Published
2021

11. Early vasopressor administration in pediatric blunt liver and spleen injury: An ATOMAC + study

Author

David M. Notrica, Shawn D. St. Peter, Charles M. Leys, Amina Bhatia, Nilda M. Garcia, Jeremy J. Johnson, Adam C. Alder, Lois W Sayrs, R. Todd Maxson, Todd A. Ponsky, Cynthia Greenwell, Jessica A. Naiditch, James W. Eubanks, Bethany L Sussman, Karla A. Lawson, and Daniel J. Ostlie

Subjects
endocrine system, medicine.medical_specialty, Wounds, Nonpenetrating, 03 medical and health sciences, 0302 clinical medicine, Blunt, Trauma Centers, 030225 pediatrics, Epidemiology, Humans, Medicine, Prospective Studies, Child, Prospective cohort study, Retrospective Studies, business.industry, General Medicine, Emergency department, medicine.disease, Liver, Spleen injury, Blunt trauma, 030220 oncology & carcinogenesis, Anesthesia, Pediatrics, Perinatology and Child Health, Propensity score matching, Surgery, business, Spleen, hormones, hormone substitutes, and hormone antagonists, Pediatric trauma
Abstract

No prior studies have examined the outcomes of early vasopressor use in children sustaining blunt liver or spleen injury (BLSI).A planned secondary analysis of vasopressor use from a 10-center, prospective study of 1004 children with BLSI. Inverse probability of treatment weighting (IPTW) was used to compare patients given vasopressors48 h after injury to controls based on pretreatment factors. A logistic regression was utilized to assess survival associated with vasopressor initiation factors on mortality and nonoperative management (NOM) failure.Of 1004 patients with BLSI, 128 patients were hypotensive in the Pediatric Trauma Center Emergency Department (ED); 65 total patients received vasopressors. Hypotension treated with vasopressors was associated with a sevenfold increase in mortality (AOR = 7.6 [p 0.01]). When excluding patients first given vasopressors for cardiac arrest, the risk of mortality increased to 11-fold (AOR = 11.4 [p = 0.01]). All deaths in patients receiving vasopressors occurred when started within the first 12 h after injury. Vasopressor administration at any time was not associated with NOM failure.After propensity matching, early vasopressor use for hypotension in the ED was associated with an increased risk of death, but did not increase the risk of failure of NOM.Level III prognostic and epidemiological, prospective.

Published
2021

12. Average Lumbar Hounsfield Units Predicts Osteoporosis-Related Complications Following Lumbar Spine Fusion

Author

Benjamin D. Elder, Mohamad Bydon, Brett A. Freedman, Taylor J. Jackson, Jeremy L. Fogelson, Jeffery D. St. Jeor, Arjun S. Sebastian, Bradford L. Currier, Ashley Xiong, and Ahmad Nassr

Subjects
medicine.diagnostic_test, Bone density, business.industry, Lumbar spine fusion, Osteoporosis, medicine.disease, Lumbar, Hounsfield scale, medicine, Orthopedics and Sports Medicine, Surgery, Neurology (clinical), business, Nuclear medicine, Dual-energy X-ray absorptiometry
Abstract

Study Design: Retrospective Study. Objective: To compare methods of assessing pre-operative bone density to predict risk for osteoporosis related complications (ORC), defined as proximal junctional kyphosis, pseudarthrosis, accelerated adjacent segment disease, reoperation, compression fracture, and instrument failure following spine fusions. Methods: Chart review of primary posterior thoracolumbar or lumbar fusion patients during a 7 year period. Inclusion criteria: preoperative dual-energy x-ray absorptiometry (DXA) test within 1 year and lumbar CT scan within 6 months prior to surgery with minimum of 1 year follow-up. Exclusion criteria: Results: 140 patients were included. The average age was 67.9 years, 83 (59.3%) were female, and 45 (32%) had an ORC. There were no significant differences in patient characteristics between those with and without an ORC. Multilevel fusions were associated with ORCs (46.7% vs 26.3%, p = 0.02). Patients with ORCs had lower DXA t-scores (-1.62 vs -1.10, p = 0.003) and average Hounsfield units (HU) (112.1 vs 148.1, p ≤ 0.001). Multivariable binary logistic regression analysis showed lower average HU (Adj. OR 0.00 595% CI 0.0001-0.1713, p = 0.001) was an independent predictor of an ORC. The odds of an ORC increased by 1.7-fold for every 25 point decrease in average HU. Conclusions: The gold standard for assessing bone mineral density has been DXA t-scores, but the best predictor of ORC remains unclear. While both lower t-scores and average HU were associated with ORC, only HU was an independent predictor of ORC.

Published
2020

13. Fetal Risk Stratification and Outcomes in Children with Prenatally Diagnosed Lung Malformations

Author

Monita Karmakar, Samir K. Gadepalli, Dave R. Lal, Michael A. Helmrath, Katherine J. Deans, Shawn D. St. Peter, Ronald B. Hirschl, Jacqueline M. Saito, Shaun M. Kunisaki, Mary E. Fallat, and Peter C. Minneci

Subjects
Pediatrics, medicine.medical_specialty, Risk Assessment, Asymptomatic, 03 medical and health sciences, 0302 clinical medicine, Pregnancy, Prenatal Diagnosis, Humans, Medicine, Child, Intensive care medicine, Lung, Fetus, Respiratory distress, business.industry, Area under the curve, Congenital pulmonary airway malformation, Retrospective cohort study, medicine.disease, Confidence interval, Institutional research, medicine.anatomical_structure, 030220 oncology & carcinogenesis, Risk stratification, Female, 030211 gastroenterology & hepatology, Surgery, medicine.symptom, business
Abstract

OBJECTIVE To assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes. SUMMARY BACKGROUND DATA Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery have not been well defined. METHODS A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at eleven children's hospitals from 2009-2016. Statistical analyses were performed using non-parametric bivariate or multivariable logistic regression. RESULTS Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection (p < 0.001). An initial CVR ≤ 1.4 was significantly correlated with a reduced risk for hydrops [area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87-1.00]. A maximum CVR < 0.9 (AUC, 0.72; 95% CI, 0.67-0.85) was associated with a low risk for respiratory symptoms at birth. CONCLUSION In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning.

Published
2020

14. Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium

Author

Kristine S. Corkum, Patrick A. Dillon, Matthew P. Landman, Ronald B. Hirschl, Amy E. Lawrence, Jason D. Fraser, Kathryn H Wilkinson, Rashmi Kabre, Kevin N. Johnson, Madeline Scannell, Shawn D. St. Peter, Bethany J. Slater, Cynthia D. Downard, Katherine J. Deans, R. Cartland Burns, Charles M Leys, Peter C. Minneci, Julia Grabowski, Jonathan E. Kohler, Grace Z. Mak, Thomas T. Sato, Rachel M. Landisch, Beth Rymeski, Mary E. Fallat, Edward Hernandez, Michael A. Helmrath, Tiffany Wright, and Samir K. Gadepalli

Subjects
medicine.medical_specialty, genetic structures, Birth weight, 03 medical and health sciences, Abdominal wall closure, 0302 clinical medicine, 030225 pediatrics, Pediatric surgery, Humans, Medicine, Prospective Studies, Closure (psychology), Prospective cohort study, Retrospective Studies, Gastroschisis, Sutures, Wound Closure Techniques, business.industry, Abdominal Wall, Infant, Newborn, Gestational age, Retrospective cohort study, General Medicine, medicine.disease, Sutureless Surgical Procedures, Surgery, Treatment Outcome, 030220 oncology & carcinogenesis, Pediatrics, Perinatology and Child Health, business
Abstract

Purpose To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. Methods A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. Results Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. Conclusion Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. Level of Evidence Level III.

Published
2020

15. Declining frequency of thoracoscopic decortication for empyema — redefining failure after fibrinolysis

Author

Robert M. Dorman, Wendy Jo Svetanoff, Tolulope A. Oyetunji, Shubhika Jain, Charlene Dekonenko, Kartik Depala, and Shawn D. St. Peter

Subjects
medicine.medical_specialty, Standard of care, medicine.medical_treatment, 03 medical and health sciences, 0302 clinical medicine, 030225 pediatrics, Fibrinolysis, medicine, Humans, Child, Empyema, Pleural, Retrospective Studies, Thoracic Surgery, Video-Assisted, business.industry, General Medicine, Decortication, medicine.disease, Thoracostomy, Empyema, Surgery, Chest tube, Chest Tubes, Child, Preschool, Tissue Plasminogen Activator, 030220 oncology & carcinogenesis, Pediatrics, Perinatology and Child Health, Fibrinolytic therapy, business
Abstract

Background Primary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol. Methods A database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded. Results Forty-eight patients were included. Median age was 4.5 years [IQR 2–9.3]. Median length of stay (LOS) was 8 days [IQR 6–11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5–6] and median number of doses of tPA was 3 [IQR 3–3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months. Conclusion Thoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay. Level of evidence IV

Published
2020

16. Intra-abdominal Abscess After Appendectomy—Are Drains Necessary in All Patients?

Author

Shawn D. St. Peter, Jason D. Fraser, Obiyo Osuchukwu, Tolulope A. Oyetunji, Robert M. Dorman, Charlene Dekonenko, Neal Talukdar, and Wendy Jo Svetanoff

Subjects
Perforated Appendicitis, medicine.medical_specialty, business.industry, Intra-abdominal Abscess, medicine.disease, Appendicitis, Surgery, 03 medical and health sciences, 0302 clinical medicine, 030220 oncology & carcinogenesis, Recurrent abscess, medicine, 030211 gastroenterology & hepatology, Abscess, business
Abstract

Background Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm2. We sought to determine the adherence to and effectiveness of this algorithm. Methods This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P Results Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess. Conclusions Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.

Published
2020

17. Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome

Author

Joshua A. Hill, Shawn D. St. Peter, Justin A. Sobrino, Charlene Dekonenko, Charles L. Snyder, and Tolulope A. Oyetunji

Subjects
medicine.medical_specialty, Adolescent, Rotation, Duodenum, Superior Mesenteric Artery Syndrome, Vomiting, Nausea, Pain, 03 medical and health sciences, 0302 clinical medicine, Recurrence, Interquartile range, Surveys and Questionnaires, Humans, Medicine, Child, Retrospective Studies, Ligaments, business.industry, medicine.disease, Surgery, Bowel obstruction, Treatment Outcome, medicine.anatomical_structure, 030220 oncology & carcinogenesis, Ligament, 030211 gastroenterology & hepatology, Median body, medicine.symptom, business, Superior mesenteric artery syndrome
Abstract

Background Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS. Materials and methods We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages. Results Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery. Conclusions Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.

Published
2020

18. Early Impact of the COVID-19 Pandemic on Congenital Heart Surgery Programs Across the World: Assessment by a Global Multi-Societal Consortium

Author

Emile A. Bacha, Erle H. Austin, James K. Kirklin, Mauro Lo Rito, Eleftherios M Protopapas, Jeffery P. Jacobs, Zdzislaw Tobota, Sachin Talwar, Zohair Al Halees, Yasutaka Hirata, George E. Sarris, Bistra Zheleva, Krishna S Iyer, Elizabeth H. Stephens, Hao Zhang, Marcello B Jatene, James S. Tweddell, Cheul Lee, Bohdan Maruszewski, Hiromi Kurosawa, Jorge Cervantes, Rajesh Sharma, Vladimiro L. Vida, James D. St. Louis, Nestor Sandoval, Christo I. Tchervenkov, Joseph A. Dearani, Frank Edwin, Kisaburo Sakamoto, and James E. O'Brien

Subjects
Heart Defects, Congenital, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Heart disease, morbidity), congenital heart surgery, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), congenital heart disease (CHD), outcomes (includes mortality, pediatric, 030204 cardiovascular system & hematology, Global Health, Article, 03 medical and health sciences, Extracorporeal Membrane Oxygenation, 0302 clinical medicine, Hospital Administration, Health care, Pandemic, medicine, Humans, 030212 general & internal medicine, Cardiac Surgical Procedures, Child, Pandemics, SARS-CoV-2, business.industry, International survey, COVID-19, General Medicine, medicine.disease, Organizational Policy, Patient Care Management, Surgery, Elective Surgical Procedures, Health Care Surveys, Pediatrics, Perinatology and Child Health, Infectious risk, Cardiology and Cardiovascular Medicine, business, Pediatric population
Abstract

The coronavirus disease 2019 (COVID-19) pandemic currently gripping the globe is impacting the entire health care system with rapidly escalating morbidities and mortality. Although the infectious risk to the pediatric population appears low, the effects on children with congenital heart disease (CHD) remain poorly understood. The closure of congenital heart surgery programs worldwide to address the growing number of infected individuals could have an unintended impact on future health for COVID-19-negative patients with CHD. Pediatric and congenital heart surgeons, given their small numbers and close relationships, are uniquely positioned to collectively assess the impact of the pandemic on surgical practice and care of children with CHD. We present the results of an international survey sent to pediatric and congenital heart surgeons characterizing the early impact of COVID-19 on the care of patients with CHD.

Published
2020

19. Protocol-driven Antibiotic Treatment of Pediatric Empyema After Fibrinolysis

Author

Shawn D. St. Peter, Kartik Depala, Obiyo Osuchukwu, Robert M. Dorman, Shubhika Jain, Angela L. Myers, Tolulope A. Oyetunji, Charlene Dekonenko, and Wendy Jo Svetanoff

Subjects
Microbiology (medical), Antibiotic regimen, business.industry, Supplemental oxygen, medicine.drug_class, medicine.medical_treatment, Antibiotics, After discharge, medicine.disease, Empyema, 03 medical and health sciences, 0302 clinical medicine, Infectious Diseases, 030225 pediatrics, Anesthesia, Pediatrics, Perinatology and Child Health, Fibrinolysis, Cohort, Medicine, 030212 general & internal medicine, business, Hospital stay
Abstract

Background The duration of antibiotic treatment after resolution of empyema in children is variable. We evaluated the efficacy and safety of a protocol-driven antibiotic regimen aimed to decrease antibiotic duration following treatment with fibrinolysis. Methods Our institutional protocol consisted of 7 further days of antibiotics upon removal of the thoracostomy tube, with the patient being afebrile, off supplemental oxygen, and having negative cultures. A prospective observational study was then performed between September 2014 and March 2019. Empyema recurrence and antibiotic-related complications were recorded. Results were compared with previously published data from the preprotocol era. Results A total of 37 patients were included. Mean total duration of antibiotics decreased from 26 ± 6.5 days in the preprotocol group to 22 ± 9.7 days in the postprotocol group (P = 0.004). This resulted in a significant decrease in hospital stay from the preprotocol cohort to the postprotocol cohort, respectively (9.3 ± 4.8 d versus 6.8 ± 3.1 d, P = 0.003). Sixty-two percentage of the patients were intended to treat according to the protocol, with a 50% adherence rate. Patients in which the protocol was followed had an average of 2.8 fewer days of antibiotics after discharge (P = 0.004), although overall duration was not statistically different. Significantly fewer antibiotic-related complications were noted after protocol initiation. There was no difference in empyema recurrence or readmissions. Conclusions Institution of a protocol-driven approach to antibiotic duration following resolution of pleural space disease may reduce antibiotic duration and complications without reducing efficacy.

Published
2020

20. Prognostic Value of Preoperative Imaging

Author

Marcella G Del Carmen, Annekathryn Goodman, Michelle Davis, Neil E Horowitz, Whitfield B. Growdon, Susanna I. Lee, Colleen M. Feltmate, and Jessica D. St. Laurent

Subjects
Adult, Cancer Research, medicine.medical_specialty, 03 medical and health sciences, 0302 clinical medicine, Fluorodeoxyglucose F18, Positron Emission Tomography Computed Tomography, medicine, Carcinoma, Humans, 030212 general & internal medicine, Positron emission, Progression-free survival, Survival analysis, Aged, Retrospective Studies, Proportional hazards model, business.industry, Endometrial cancer, Hazard ratio, Retrospective cohort study, Middle Aged, Prognosis, medicine.disease, Progression-Free Survival, Endometrial Neoplasms, Oncology, Lymphatic Metastasis, 030220 oncology & carcinogenesis, Female, Radiology, Radiopharmaceuticals, Tomography, X-Ray Computed, business
Abstract

OBJECTIVE 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) increases the sensitivity for preoperative detection of lymph nodes and distant metastases in endometrial cancer. The objective of this investigation was to determine the prognostic value of preoperative PET-CT compared with computed tomography (CT) alone for high-risk endometrial carcinoma. MATERIALS AND METHODS We performed a retrospective review of high-risk histology endometrial cancer from 2008 to 2015. Clinical variables including surgical procedure, preoperative imaging modality, and outcome were collected. Survival analysis was performed utilizing the Kaplan-Meier and Cox proportional hazards methodologies. RESULTS Of the 555 women treated for high-risk histology endometrial cancer, 88 (16%) had preoperative PET-CT, and 97 (17%) CT without PET available. PET-CT demonstrated positive findings in 37 women (42%) compared with 33 (30%) with preoperative CT alone. PET-CT had a positive predictive value of 96% for nodal metastasis compared with 60% for CT alone. The median follow-up time for the entire cohort was 59 months (range, 12 to 96 mo). Patients with a negative preoperative PET-CT (n=54) had a median progression-free survival (PFS) that was not reached, whereas the median PFS in the PET-CT positive group was 13 months (n=34). Women with a negative PET-CT had a longer median overall survival (OS) not yet reached compared with 34 months in the PET-CT positive cohort (hazard ratio, 2.4; P

Published
2020

21. Multifocal subacute osteomyelitis in adjacent bones in the ankle without septic joint

Author

Kristen B. Thomas, Nathan C. Hull, Paul G. Thacker, and Jeffery D. St. Jeor

Subjects
lcsh:Medical physics. Medical radiology. Nuclear medicine, medicine.medical_specialty, medicine.diagnostic_test, business.industry, Osteomyelitis, lcsh:R895-920, Aseptic joint, Magnetic resonance imaging, medicine.disease, Subacute osteomyelitis, Brodie's abscesses, medicine.anatomical_structure, Concomitant, Musculoskeletal, Joint capsule, Culture-negative, medicine, Radiology, Nuclear Medicine and imaging, Bone marrow, Radiology, Ankle, Presentation (obstetrics), business, Multifocal
Abstract

Osteomyelitis is an inflammation involving bone and/or bone marrow most often the result of bacterial infection of the bone. In children, osteomyelitis most often has an acute presentation and is caused by hematogenous spread. When osteomyelitis is seen in the extremities, conventional radiography is the first-line imaging modality preformed for diagnosis with magnetic resonance imaging employed for further delineation or as a problem-solving tool. A healthy 6-year-old female presented with a history of nonspecific left leg pain for 3-5 weeks which gradually progressed to focal left ankle pain and swelling. Further workup revealed multifocal subacute osteomyelitis with Brodie's abscesses seen on imaging in the absence of a septic joint. This was an uncommon presentation for the following reasons: Patients with multifocal osteomyelitis usually present in the acute setting, as opposed to the subacute setting. When osteomyelitis is multifocal or Brodie's abscesses are present adjacent to the joint capsule, concomitant septic joint is commonly seen.

Published
2020

22. Development of a multi-institutional registry for children with operative congenital lung malformations

Author

Jason D. Fraser, Dave R. Lal, Joseph J. Lopez, Rodrigo A. Mon, Michael A. Helmrath, Rashmi Kabre, Mary E. Fallat, Bola Aladegbami, Charles M. Leys, R. Cartland Burns, Kristine S. Corkum, Shawn D. St. Peter, Matthew P. Landman, Grace Z. Mak, Kevin N. Johnson, Ronald B. Hirschl, Jacqueline M. Saito, Aimen F. Shaaban, Tiffany Wright, Christina M Bence, Cynthia D. Downard, Cheryl Adams, Shaun M. Kunisaki, Katherine J. Deans, Samir K Gadepalli, Brooks L. Rademacher, Peter C. Minneci, Allison F. Linden, and Sarah K. Walker

Subjects
Pediatrics, medicine.medical_specialty, Asymptomatic, Interquartile range, Prenatal Diagnosis, Thoracoscopy, Humans, Medicine, Registries, Lung, Retrospective Studies, medicine.diagnostic_test, business.industry, Infant, Newborn, Infant, Congenital pulmonary airway malformation, Retrospective cohort study, General Medicine, medicine.disease, Congenital Lung Malformation, Pediatrics, Perinatology and Child Health, Cohort, Surgery, Respiratory System Abnormalities, medicine.symptom, business, Cohort study
Abstract

Introduction The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection. Methods After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative. Results Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1–12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6–11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%). Conclusion This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients. Level of evidence Level II.

Published
2020

23. Anaplastic ependymoma metastases though a ventriculoperitoneal shunt

Author

Nathan C. Hull, Paul G. Thacker, John C. Benson, and Jeffery D. St. Jeor

Subjects
Ependymoma, lcsh:Medical physics. Medical radiology. Nuclear medicine, Complications of Therapy, medicine.medical_specialty, lcsh:R895-920, Seeding, Abdominal cavity, 030218 nuclear medicine & medical imaging, Anaplastic Ependymoma, 03 medical and health sciences, 0302 clinical medicine, medicine, Radiology, Nuclear Medicine and imaging, Abdominal metastases, business.industry, Peritoneal seeding, Spinal cord, medicine.disease, Ventriculoperitoneal shunt, Shunt (medical), Hydrocephalus, medicine.anatomical_structure, Intracranial ependymoma, Radiology, Complication, business, 030217 neurology & neurosurgery
Abstract

Ependymomas are rare glial tumors that comprise 10% of intracranial pediatric malignancies. Primary central nervous system malignancies can rarely metastasize extracranially. When metastases occur, it usually does so in the setting of surgical manipulation of the central nervous system and can spread through the blood, lymph, or artificial means, for example, a ventriculoperitoneal shunt. We describe the presentation and progression of an 18-month-old boy diagnosed with an ependymoma. Initially managed with surgery, radiation, and ventriculoperitoneal shunt placement for symptomatic hydrocephalus, the tumor later recurred with drop metastasis to the thoracic spinal cord. The patient subsequently developed extensive metastases within the abdominal cavity, which were seeded through a ventriculoperitoneal shunt. We present a case of a rare complication of intra-abdominal tumor seeding and carcinomatosis from an intracranial ependymoma through a ventriculoperitoneal shunt. This is a rare presentation of a possible complication, which requires awareness of both surgeons and radiologists.

Published
2020

24. The Current Thoracoscopic Management of Esophageal Atresia

Author

Shawn D. St. Peter and Jason D. Fraser

Subjects
Postoperative Care, medicine.medical_specialty, business.industry, Thoracoscopy, General surgery, Infant, Newborn, MEDLINE, Tracheoesophageal fistula, medicine.disease, Review article, 03 medical and health sciences, 0302 clinical medicine, 030225 pediatrics, 030220 oncology & carcinogenesis, Atresia, Pediatrics, Perinatology and Child Health, medicine, Humans, Surgery, Abnormality, business, Minimally invasive procedures, Tracheoesophageal Fistula
Abstract

The thoracoscopic repair of esophageal atresia with tracheoesophageal fistula is a complex neonatal minimally invasive procedure. The thoracoscopic approach is now nearing its third decade of experience and but is overall still not widely utilized, only in skilled centers and by experienced surgeons. This article will summarize the recent advancements in technique and knowledge in the thoracoscopic approach to this challenging neonatal congenital abnormality.

Published
2020

25. Self-reported Outcomes After Cholecystectomy for Pediatric Hyperkinetic Biliary Dyskinesia

Author

Tolulope A. Oyetunji, Joseph A. Sujka, Shawn D. St. Peter, Robert M. Dorman, and Charlene Dekonenko

Subjects
Male, medicine.medical_specialty, Abdominal pain, Time Factors, Adolescent, medicine.medical_treatment, Biliary dyskinesia, Asymptomatic, Gallbladder ejection fraction, 03 medical and health sciences, 0302 clinical medicine, Internal medicine, Chart review, medicine, Humans, Patient Reported Outcome Measures, Laparoscopic cholecystectomy, Statistical software, Pain Measurement, Retrospective Studies, Pain, Postoperative, business.industry, Gallbladder, medicine.disease, Abdominal Pain, Treatment Outcome, Cholecystectomy, Laparoscopic, Patient Satisfaction, 030220 oncology & carcinogenesis, Female, 030211 gastroenterology & hepatology, Surgery, Cholecystectomy, Self Report, medicine.symptom, business, Biliary Dyskinesia, Follow-Up Studies
Abstract

Biliary dyskinesia (BD) is a common indication for cholecystectomy in children. Current literature demonstrates an improvement in symptoms after cholecystectomy in most pediatric patients with an EF35%; however, data supporting the efficacy of cholecystectomy for hyperkinetic BD (EF65%) is sparse. We sought to determine whether children with hyperkinetic BD (HBD) had resolution of their symptoms after laparoscopic cholecystectomy at our institution.We conducted a retrospective chart review of children who had undergone laparoscopic cholecystectomy for HBD at our institution between September 2010 and July 2015. Patients completed a phone survey about symptom resolution, whether they were happy to have undergone cholecystectomy, overall satisfaction on a 1-10 scale, and additional workup for those with ongoing pain. Analysis was performed using STATA statistical software with a P-value0.05 as statistically significant.Thirteen patients met inclusion criteria. Median gallbladder ejection fraction was 93% [IQR: 90, 97]. Median postoperative follow-up was 59 d [IQR: 25, 151] at which time 50% reported resolution of symptoms. Eight patients participated in the survey at a median follow-up of 45 mo [IQR: 40, 66]. Fifty percent reported ongoing abdominal pain. Frequency of pain varied among patients with pain, occurring from1 time per week to a few times per day. Five patients (63%), including one patient with ongoing pain, were happy that their gallbladder had been removed and overall satisfaction rating was 5 on a scale of 1-10.Only half of children with HBD were asymptomatic at long-term follow-up. Cholecystectomy for HBD may or may not improve symptoms.

Published
2020

26. The utility of computed tomography and diffusion-weighted magnetic resonance imaging fusion in cholesteatoma: illustration with a UK case series

Author

A Singh, Ravi Kumar Lingam, A Hall, and D St Leger

Subjects
Image fusion, Fusion, medicine.diagnostic_test, business.industry, Cholesteatoma, Magnetic resonance imaging, General Medicine, medicine.disease, Surgical planning, Otorhinolaryngology, Coronal plane, Temporal bone, Medicine, Tomography, business, Nuclear medicine
Abstract

ObjectivePost-processing imaging techniques allow high-resolution computed tomography and diffusion-weighted magnetic resonance imaging of the temporal bone to be superimposed and viewed simultaneously (fusion imaging). This study aimed to highlight the practical utility of fusion imaging for disease localisation and evaluation in a UK case series of primary and post-operative cholesteatoma.MethodFusion of computed tomography and diffusion-weighted magnetic resonance b1000 images was performed using specific software. Axial computed tomography images and coronal b1000 images were selected for fusion.ResultsA case series of primary and post-operative cholesteatoma in which computed tomography and magnetic resonance imaging fusion assisted the management of both the patient pathway and surgical approach is reviewed.ConclusionComputed tomography and magnetic resonance imaging fusion can assist in pre-operative surgical planning and patient counselling through assessment of disease in both primary and revision scenarios. Computed tomography and magnetic resonance imaging fusion can assist the operative surgeon through accurate localisation that can influence both the operative technique and optimise operation theatre utilisation.

Published
2020

27. Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation

Author

Michael A. Helmrath, Charles M Leys, Nicholas Marka, Mary E. Fallat, Peter C. Minneci, Amy E. Lawrence, Ninette Musili, Grace Z. Mak, Samir K. Gadepalli, Brad W. Warner, Shawn D. St. Peter, Beth Rymeski, Devin R. Halleran, Rashmi Kabre, Matthew P. Landman, Cynthia D. Downard, Ronald B. Hirschl, Jacqueline M. Saito, R. Cartland Burns, Linda Cherney-Stafford, Michelle Knezevich, Jason D. Fraser, Dave R. Lal, Thomas T. Sato, Daniel J. Ostlie, Julia Grabowski, Jonathan E. Kohler, and David S. Foley

Subjects
Male, medicine.medical_specialty, Adolescent, Thoracentesis, medicine.medical_treatment, Pilot Projects, 03 medical and health sciences, 0302 clinical medicine, Predictive Value of Tests, Recurrence, 030225 pediatrics, medicine, Humans, Prospective Studies, Treatment Failure, Child, Thoracic Surgery, Video-Assisted, business.industry, Pneumothorax, General Medicine, Primary spontaneous pneumothorax, Pigtail catheter, medicine.disease, Management algorithm, Surgery, Test (assessment), Chest tube, Chest Tubes, 030220 oncology & carcinogenesis, Pediatrics, Perinatology and Child Health, Persistent air leak, Female, Level iii, business
Abstract

Purpose Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. Methods A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children’s hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. Results Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P = 0.028]. Conclusion Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. Type of study Prospective pilot study Level of evidence Level III.

Published
2020

28. Predicting Morbidity and Mortality in Neonates Born With Gastroschisis

Author

Shawn D. St. Peter, Russell B. Hawkins, Paul D. Danielson, Faisal G. Qureshi, Elizabeth Renaud, Steven L. Raymond, Saleem Islam, and Cynthia D. Downard

Subjects
Male, Short Bowel Syndrome, Parenteral Nutrition, Pediatrics, medicine.medical_specialty, medicine.medical_treatment, Perforation (oil well), Gestational Age, Risk Assessment, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Sepsis, Humans, Medicine, Retrospective Studies, Gastroschisis, Mechanical ventilation, business.industry, Abdominal wall defect, Infant, Newborn, Retrospective cohort study, Infant, Low Birth Weight, Length of Stay, Prognosis, medicine.disease, Respiration, Artificial, Volvulus, Survival Rate, Parenteral nutrition, 030220 oncology & carcinogenesis, Cohort, Apgar Score, Feasibility Studies, Female, 030211 gastroenterology & hepatology, Surgery, business, Infant, Premature
Abstract

Gastroschisis is an increasingly common congenital abdominal wall defect. Due to advances in neonatal critical care and early surgical management, mortality from gastroschisis and associated complications has decreased to less than 10% in most series. However, it has been recognized that the outcome of gastroschisis has a spectrum and that the disorder affects a heterogeneous cohort of neonates. The goal of this study is to predict morbidity and mortality in neonates with gastroschisis using clinically relevant variables.A multicenter, retrospective observational study of neonates born with gastroschisis was conducted. Neonatal characteristics and outcomes were collected and compared. Prediction of morbidity and mortality was performed using multivariate clinical models.Five hundred and sixty-six neonates with gastroschisis were identified. Overall survival was 95%. Median hospital length of stay was 37 d. Sepsis was diagnosed in 107 neonates. Days on parenteral nutrition and mechanical ventilation were considerable with a median of 27 and 5 d, respectively. Complex gastroschisis (atresia, perforation, volvulus), preterm delivery (37 wk), and very low birth weight (1500 g) were associated with worse clinical outcomes including increased sepsis, short bowel syndrome, parenteral nutrition days, and length of stay. The composite metric of birth weight, Apgar score at 5 min, and complex gastroschisis was able to successfully predict mortality (area under the curve, 0.81).Clinical variables can be used in gastroschisis to distinguish those who will survive from nonsurvivors. Although these findings need to be validated in other large multicenter data sets, this prognostic score may aid practitioners in the identification and management of at-risk neonates.

Published
2020

29. Teriparatide treatment increases Hounsfield units in the lumbar spine out of proportion to DEXA changes

Author

Paul A. Anderson, A. Noelle Larson, Anthony L. Mikula, Ross C. Puffer, Michael J. Yaszemski, Jeffery D. St. Jeor, Jeremy L. Fogelson, James T. Bernatz, Brett A. Freedman, Bradford L. Currier, Benjamin D. Elder, Ahmad Nassr, Arjun S. Sebastian, and Mohamad Bydon

Subjects
musculoskeletal diseases, Bone mineral, business.industry, Osteoporosis, General Medicine, medicine.disease, 03 medical and health sciences, 0302 clinical medicine, Lumbar, medicine.anatomical_structure, 030220 oncology & carcinogenesis, Chart review, Hounsfield scale, Teriparatide, medicine, Lumbar spine, Nuclear medicine, business, 030217 neurology & neurosurgery, medicine.drug, Femoral neck
Abstract

OBJECTIVEThe authors sought to assess whether Hounsfield units (HU) increase following teriparatide treatment and to compare HU increases with changes in bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DEXA).METHODSA retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. The authors identified patients who had been treated with at least 6 months of teriparatide and compared HU and BMD as measured on DEXA scans before and after treatment.RESULTSFifty-two patients were identified for analysis (46 women and 6 men, average age 67 years) who underwent an average of 20.9 ± 6.5 months of teriparatide therapy. The mean ± standard deviation HU increase throughout the lumbar spine (L1–4) was from 109.8 ± 53 to 133.9 ± 61 HU (+22%, 95% CI 1.2–46, p value = 0.039). Based on DEXA results, lumbar spine BMD increased from 0.85 to 0.93 g/cm2 (+9%, p value = 0.044). Lumbar spine T-scores improved from −2.4 ± 1.5 to −1.7 ± 1.5 (p value = 0.03). Average femoral neck T-scores improved from −2.5 ± 1.1 to −2.3 ± 1.0 (p value = 0.31).CONCLUSIONSTeriparatide treatment increased both HU and BMD on DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the 9% improvement determined with DEXA. These results support some surgeons’ subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. To the authors’ knowledge, this is the first study demonstrating an increase in HU with teriparatide treatment.

Published
2020

30. Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation

Author

Michele C. Walsh, Rachel Geller, Ivan D. Frantz, David E. Skarda, Claudia Pedroza, Seetha Shankaran, Leif D. Nelin, Shawn D. St. Peter, Henry E. Rice, Isabell B. Purdy, Kara L. Calkins, Walter J. Chwals, Kimberly Yolton, Troy A. Markel, Brenda B. Poindexter, Christina M Shanti, Gail E. Besner, David K. Stevenson, Pablo J. Sánchez, William E Truog, Barry Eggleston, Myriam Peralta-Carcelen, Krisa P. Van Meurs, Nathalie L. Maitre, James C.Y. Dunn, R.A. Mosquera, Rebeccah L. Brown, Bradley A. Yoder, Howard W. Kilbride, Satyanarayana Lakshminrusimha, Carroll M. Harmon, Robin K. Ohls, Ricki F. Goldstein, Barbara J. Stoll, Kristi L. Watterberg, Abbey C. Hines, Ravi Mangal Patel, Matthew M. Laughon, Jon E. Tyson, Karl G. Sylvester, Kathryn D. Bass, Alan W. Flake, Carl T. D'Angio, Rosemary D. Higgins, Martin L. Blakely, Reed A. Dimmitt, Arlet G. Kurkchubasche, Colin A. Martin, Girija Natarajan, C. Michael Cotten, David G Lemon, Sarah Winter, Elisabeth C. McGowan, Edward F. Bell, Abhik Das, Diana L. Diesen, Kevin P. Lally, Waldemar A. Carlo, Kelley Yost, Walter Pegoli, Amina M. Bhatia, Susan R. Hintz, Tarah T. Colaizy, Myra H. Wyckoff, Gregory M Sokol, Betty R. Vohr, Sara B. DeMauro, Kathleen A. Kennedy, Abbot R. Laptook, Roy J. Heyne, and Joel Shilyansky

Subjects
Male, medicine.medical_specialty, medicine.medical_treatment, Perforation (oil well), Infant, Premature, Diseases, Article, law.invention, Randomized controlled trial, Enterocolitis, Necrotizing, law, Laparotomy, medicine, Humans, Survival rate, Enterocolitis, business.industry, Infant, Newborn, medicine.disease, Confidence interval, Surgery, Survival Rate, Treatment Outcome, Infant, Extremely Low Birth Weight, Intestinal Perforation, Neurodevelopmental Disorders, Relative risk, Necrotizing enterocolitis, Drainage, Feasibility Studies, Female, medicine.symptom, business, Infant, Premature
Abstract

OBJECTIVE: To determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18–22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage (adjusted relative risk [aRR] = 1.0; 95% confidence interval [CI]: 0.87–1.14). A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (p = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR=0.81; 95% CI: 0.64 to 1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference

Published
2021

31. Increasing phagocytosis of microglia by targeting CD33 with liposomes displaying glycan ligands

Author

Abhishek Bhattacherjee, Chris D. St. Laurent, Ghazaleh Eskandari-Sedighi, Gour Chand Daskhan, Anastassia Voronova, Arjun Bains, Adrianne E.S. Watson, and Matthew S. Macauley

Subjects
Glycan, Phagocytosis, media_common.quotation_subject, Pharmaceutical Science, Ligands, Mice, Alzheimer Disease, Polysaccharides, medicine, Animals, Internalization, media_common, Liposome, Microglia, biology, Chemistry, Neurodegeneration, SIGLEC, medicine.disease, Cell biology, medicine.anatomical_structure, Liposomes, biology.protein, Intracellular
Abstract

CD33 is an immunomodulatory receptor expressed by microglia and genetically linked to Alzheimer's disease (AD) susceptibility. While antibodies targeting CD33 have entered clinical trials to treat neurodegeneration, it is unknown whether the glycan-binding properties of CD33 can be exploited to modulate microglia. Here, we use liposomes that multivalently display glycan ligands of CD33 (CD33L liposomes) to engage CD33. We find that CD33L liposomes increase phagocytosis of cultured monocytic cells and microglia in a CD33-dependent manner. Enhanced phagocytosis strongly correlates with loss of CD33 from the cell surface and internalization of liposomes. Increased phagocytosis by treatment with CD33L liposomes is dependent on a key intracellular signaling motif on CD33 as well as the glycan-binding ability of CD33. These effects are specific to trans engagement of CD33 by CD33L liposomes, as cis engagement through insertion of lipid-linked CD33L into cells produces the opposite effect on phagocytosis. Moreover, intracerebroventricular injection of CD33L liposomes into transgenic mice expressing human CD33 in the microglial cell lineage enhances phagocytosis of microglia in a CD33-dependent manner. These results demonstrate that multivalent engagement of CD33 with glycan ligands can modulate microglial cell function.

Published
2021

32. Recurrence, death, and secondary malignancy after ovarian conservation for young women with early-stage low-grade endometrial cancer

Author

Audrey S. Garneau, Michelle Kuznicki, Mamoru Kakuda, Gretchen E. Glaser, Karime K. Machado, Mian M.K. Shahzad, Malcolm S. Ross, Rebecca L. Stone, Jiro Suzuki, Kosuke Yoshihara, James C. Cripe, Min K. Kim, Jason D. Wright, Jessica D. St. Laurent, Ting Tai Yen, Aikou Okamoto, Takayuki Enomoto, Shin Nishio, Bobbie S. Gostout, Kosei Hasegawa, Masako Shida, Yutaka Ueda, Tetsuro Oishi, Jenna Z. Marcus, Bobbie J. Rimel, Sosuke Adachi, Kimio Ushijima, P.T. Soliman, Shoji Nagao, Max Horowitz, Shinya Satoh, Frederick R. Ueland, Katherine C. Kurnit, Rachel M. Schillinger, Lynda D. Roman, Dwight D. Im, Premal H. Thaker, Mikio Mikami, Whitfield B. Growdon, Tetsuji Kurokawa, Denise M. Garofalo, Alexander Melamed, Shiori Yanai, Aaron Nizam, Michiko Kaneda, Saketh R. Guntupalli, Yoshio Yoshida, Marina Frimer, Akira Yabuno, Marian S. Johnson, Koji Matsuo, and Annie Y. Liu

Subjects
Adult, 0301 basic medicine, Oncology, medicine.medical_specialty, Population, Hysterectomy, Disease-Free Survival, Cohort Studies, 03 medical and health sciences, 0302 clinical medicine, Japan, Internal medicine, Humans, Medicine, Stage (cooking), education, Retrospective Studies, education.field_of_study, business.industry, Endometrial cancer, Ovary, Hazard ratio, Obstetrics and Gynecology, Neoplasms, Second Primary, Retrospective cohort study, medicine.disease, United States, Confidence interval, Endometrial Neoplasms, 030104 developmental biology, 030220 oncology & carcinogenesis, Cohort, Female, Neoplasm Grading, business, Ovarian cancer, Carcinoma, Endometrioid, Organ Sparing Treatments
Abstract

To examine the association between ovarian conservation and oncologic outcome in surgically-treated young women with early-stage, low-grade endometrial cancer.This multicenter retrospective study examined women aged50 with stage I grade 1-2 endometrioid endometrial cancer who underwent primary surgery with hysterectomy from 2000 to 2014 (US cohort n = 1196, and Japan cohort n = 495). Recurrence patterns, survival, and the presence of a metachronous secondary malignancy were assessed based on ovarian conservation versus oophorectomy.During the study period, the ovarian conservation rate significantly increased in the US cohort from 5.4% to 16.4% (P = 0.020) whereas the rate was unchanged in the Japan cohort (6.3-8.7%, P = 0.787). In the US cohort, ovarian conservation was not associated with disease-free survival (hazard ratio [HR] 0.829, 95% confidence interval [CI] 0.188-3.663, P = 0.805), overall survival (HR not estimated, P = 0.981), or metachronous secondary malignancy (HR 1.787, 95% CI 0.603-5.295, P = 0.295). In the Japan cohort, ovarian conservation was associated with decreased disease-free survival (HR 5.214, 95% CI 1.557-17.464, P = 0.007) and an increased risk of a metachronous secondary malignancy, particularly ovarian cancer (HR 7.119, 95% CI 1.349-37.554, P = 0.021), but was not associated with overall survival (HR not estimated, P = 0.987). Ovarian recurrence or metachronous secondary ovarian cancer occurred after a median time of 5.9 years, and all cases were salvaged.Our study suggests that adoption of ovarian conservation in young women with early-stage low-grade endometrial cancer varies by population. Ovarian conservation for young women with early-stage, low-grade endometrial cancer may be potentially associated with increased risks of ovarian recurrence or metachronous secondary ovarian cancer in certain populations; nevertheless, ovarian conservation did not negatively impact overall survival.

Published
2019

33. Migraine and the risk of all‐cause dementia, Alzheimer's disease, and vascular dementia: A prospective cohort study in community‐dwelling older adults

Author

Rebecca E Morton, Suzanne L. Tyas, and Philip D. St. John

Subjects
Male, Pediatrics, medicine.medical_specialty, Migraine Disorders, 03 medical and health sciences, 0302 clinical medicine, Alzheimer Disease, Risk Factors, Odds Ratio, medicine, Humans, Dementia, Prospective Studies, Prospective cohort study, Vascular dementia, Aged, Aged, 80 and over, 030214 geriatrics, business.industry, Dementia, Vascular, Manitoba, Odds ratio, medicine.disease, Psychiatry and Mental health, Logistic Models, Migraine, Female, Independent Living, Geriatrics and Gerontology, Headaches, medicine.symptom, Alzheimer's disease, business, Cohort study
Abstract

Objectives Dementia is the most common neurological disease in older adults; headaches, including migraines, are the most common neurological disorder across all ages. The objective of this study was to explore the relationship between migraines and dementia, including Alzheimer's disease (AD) and vascular dementia (VaD). Methods Analyses were based on 679 community-dwelling participants 65+ years from the Manitoba Study of Health and Aging, a population-based, prospective cohort study. Participants screened as cognitively intact at baseline had complete data on migraine history and all covariates at baseline and were assessed for cognitive outcomes (all-cause dementia, AD, and VaD) 5 years later. The association of exposure (lifetime history of migraines), confounding (age, gender, education, and depression), and intervening variables (hypertension, myocardial infarction, other heart conditions, stroke, and diabetes) with all-cause dementia and dementia subtypes (AD and VaD) was assessed using multiple logistic regression models. Results A history of migraines was significantly associated with both all-cause dementia (odds ratio [OR]=2.97; 95% confidence interval [CI]=1.25-6.61) and AD (OR=4.22; 95% CI=1.59-10.42), even after adjustment for confounding and intervening variables. Migraines were not significantly associated with VaD either before (OR=1.83; 95% CI=0.39-8.52) or after (OR=1.52; 95% CI=0.20-7.23) such adjustment. Conclusions Migraines were a significant risk factor for AD and all-cause dementia. Despite the vascular mechanisms involved in migraine physiology, migraines were not significantly associated with VaD in this study. Recognition of the long-term detrimental consequences of migraines for AD and dementia has implications for migraine management, as well as for our understanding of AD etiology.

Published
2019

34. Refining The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model With Enhanced Risk Adjustment for Chromosomal Abnormalities, Syndromes, and Noncardiac Congenital Anatomic Abnormalities

Author

Peter J. Gruber, Christian Pizarro, Sean M. O'Brien, Richard A. Jonas, James M. Meza, James D. St. Louis, Kevin D. Hill, Sara K. Pasquali, Jeffrey P. Jacobs, Erle H. Austin, S. Ram Kumar, David M. Shahian, J. William Gaynor, Dylan Thibault, John E. Mayer, and Marshall L. Jacobs

Subjects
Adult, Heart Defects, Congenital, Male, Pulmonary and Respiratory Medicine, Canada, medicine.medical_specialty, Down syndrome, Time Factors, Adolescent, Databases, Factual, Chromosome Disorders, 030204 cardiovascular system & hematology, Logistic regression, computer.software_genre, Risk Assessment, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Risk of mortality, medicine, Humans, Hospital Mortality, Cardiac Surgical Procedures, Young adult, Child, Societies, Medical, Retrospective Studies, Models, Statistical, Database, business.industry, Infant, Newborn, Infant, Thoracic Surgery, Retrospective cohort study, Odds ratio, medicine.disease, United States, Surgery, 030228 respiratory system, Cardiothoracic surgery, Child, Preschool, Atrioventricular canal, Female, Cardiology and Cardiovascular Medicine, business, computer, Follow-Up Studies
Abstract

Background The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model adjusts not only for procedure and age group pairings but also for additional patient factors, including the binary presence or absence of a chromosomal abnormality (CA), syndrome (S), and/or a noncardiac congenital anatomic abnormality (NCAA). This analysis refines case-mix adjustment by adding more granular adjustment for individual conditions (CA, S, and NCAA), consistent with a hypothesis that associated risk of mortality differs between individual conditions. Methods CA/S corresponding to the same condition were merged to a single condition code. Odds ratios were estimated for all CA/S. For CA/S associated with at least 10 deaths in neonates and infants and at least 10 deaths in children and adults, odds ratios were estimated for the effect of the CA/S separately in neonates/infants and in children/adults. In addition to these condition/age interactions, condition/age/procedure interactions were explored (eg, effect of Down syndrome was estimated based on age and procedure subgroups, including atrioventricular canal repair and single-ventricle palliation). Bayesian modeling was used to create 5 maximally homogeneous groups of CA/S from 81 candidate CA/S variables. A standard logistic regression model then incorporated indicator variables for the 5 categories of CAs/Ss, 7 unique NCAAs, and all other covariates in the previously published Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Model. Results Analysis included 107,062 operations in 100 centers (2010 to 2015). Operative Mortality was 3,629 (3.4%). In the development sample, the C statistics of the original nonaugmented model and the augmented model were 0.872 and 0.875, respectively. Conclusions The Society of Thoracic Surgeons Congenital Heart Surgery Database Mortality Risk Model has been augmented by addition of covariates representing individual CAs, Ss, and NCAAs.

Published
2019

35. Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study

Author

Melvin S. Dassinger, Shawn D. St. Peter, Sarah B. Cairo, Aaron P. Lesher, Russell B. Hawkins, Christopher P. Gayer, Katherine J. Baxter, Katherine J. Deans, Robert T. Russell, David H. Rothstein, Danielle Dorey, Matthew P. Landman, Joseph A. Sujka, Patrick C. Bonasso, Eunice Y. Huang, Brandy Gonzales, Pamela Emengo, Leah J. Schoel, Nakada Gusman, Kevin P. Lally, Jennifer Waterhouse, Elizabeth A. Fialkowski, Saleem Islam, Mehul V. Raval, Karen Herzing, Peter C. Minneci, Marisa A. Bartz-Kurycki, Arturo Aranda, Tim Jancelewicz, Bethany J. Slater, and Sohail R. Shah

Subjects
medicine.medical_specialty, medicine.medical_treatment, Biliary dyskinesia, Article, 03 medical and health sciences, 0302 clinical medicine, 030225 pediatrics, Internal medicine, Pediatric surgery, medicine, Humans, Cholecystectomy, Child, Retrospective Studies, business.industry, Gallbladder, Retrospective cohort study, General Medicine, Evidence-based medicine, Perioperative, medicine.disease, 030220 oncology & carcinogenesis, Pediatrics, Perinatology and Child Health, Surgery, Prospective research, business, Resource utilization, Biliary Dyskinesia
Abstract

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF < 15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Published
2019

36. Can fecal continence be predicted in patients born with anorectal malformations?

Author

Cynthia D. Downard, Marc A. Levitt, Jennifer S. McLeod, Jennifer N. Cooper, Katherine J. Deans, Shawn D. St. Peter, Jonathan E. Kohler, Thomas T. Sato, Amin Afrazi, Michael A. Helmrath, Peter C. Minneci, Peter F. Ehrlich, Beth McClure, Daniel L. Lodwick, Beth Rymeski, Samir K Gadepalli, Rashmi Kabre, Richard J. Wood, Charles M. Leys, Matthew P. Landman, Jacqueline M. Saito, Constance Lee, Casey M. Calkins, Kristine S. Corkum, Grace Z. Mak, Devin R. Halleran, Rachel M. Landisch, Jason D. Fraser, and Rodrigo A. Mon

Subjects
medicine.medical_specialty, Fistula, Bowel management, Logistic regression, 03 medical and health sciences, 0302 clinical medicine, 030225 pediatrics, Humans, Medicine, Fecal continence, In patient, Prospective Studies, Child, Prospective cohort study, business.industry, General Medicine, medicine.disease, Anorectal Malformations, Perineal fistula, Surgery, Logistic Models, 030220 oncology & carcinogenesis, Pediatrics, Perinatology and Child Health, business, Fecal Incontinence, Cohort study
Abstract

Purpose The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). Methods We performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥ 4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. Results Among 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). Conclusion Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM. Type of Study Prospective Cohort Study. Level of Evidence II.

Published
2019

37. Therapeutic Direction Versus Adverse Outcomes in Children Undergoing Lung Biopsy

Author

Justin A. Sobrino, Hanna Alemayehu, Shawn D. St. Peter, Joseph A. Sujka, Rebecca M. Rentea, Nhatrang Le, and Leo Andrew Benedict

Subjects
Lung Diseases, Reoperation, medicine.medical_specialty, Adolescent, Biopsy, Clinical Decision-Making, Lung biopsy, Risk Assessment, 03 medical and health sciences, Postoperative Complications, 0302 clinical medicine, Interquartile range, Thoracoscopy, Humans, Medicine, Child, Adverse effect, Lung, Retrospective Studies, medicine.diagnostic_test, business.industry, Infant, Perioperative, medicine.disease, Surgery, Respiratory failure, Pneumothorax, Child, Preschool, 030220 oncology & carcinogenesis, 030211 gastroenterology & hepatology, business, Follow-Up Studies
Abstract

Background Lung biopsy is part of the diagnostic workup for multiple diseases. Although the morbidity of the procedure has decreased with the use of thoracoscopy, lung biopsy still holds substantial risk for patients. Therefore, we evaluated the likelihood of lung biopsies impacting treatment compared to complications. Material and methods This was a single-institution, retrospective chart review of patients less than aged 18 y undergoing lung biopsy from 2010 to 2016. Details of demographics, hospital course, adverse events, complications, pathology, and follow-up were recorded. All values are reported as medians with interquartile range. Results Thirty-seven patients met inclusion criteria. Median age was 7 y old (interquartile range 1.4, 15). Eighty-seven percent (33) of biopsies were performed thoracoscopically, with a 3% conversion rate. Adverse events occurred in 25% (9) of cases with the majority involving prolonged respiratory failure (n = 7). Complications occurred in 16% (6) of cases including pneumothorax (13%, n = 5) and cardiac arrest (3%, n = 1). A third of these complications (n = 2) required reoperation, and both were decompressions of tension pneumothoraces. Pathology established a diagnosis in 62% (n = 23) of cases, yet treatment was changed in only 43% of cases. No preoperative variables were associated with the pathology establishing a diagnosis or changing treatment. Conclusions Lung biopsy for questionable pulmonary disease changed treatment in less than half of cases, with significant perioperative morbidity. Careful consideration should therefore be given to who would benefit most from lung biopsy.

Published
2019

38. Third Annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report: Preimplant Characteristics and Outcomes

Author

Angela Lorts, Pedimacs Investigators, Ryan S. Cantor, James D. St. Louis, Devin Koeh, Iki Adachi, David L.S. Morales, Christina VanderPluym, David N. Rosenthal, James K. Kirklin, David L Sutcliffe, Joseph W. Rossano, and Elizabeth D. Blume

Subjects
Male, Pulmonary and Respiratory Medicine, medicine.medical_specialty, Adolescent, medicine.medical_treatment, Population, Cardiomyopathy, 030204 cardiovascular system & hematology, Pediatrics, Risk Assessment, 03 medical and health sciences, 0302 clinical medicine, Preoperative Care, medicine, Humans, Registries, Child, education, Survival rate, Societies, Medical, Heart Failure, education.field_of_study, business.industry, Thoracic Surgery, Hospitals, Pediatric, medicine.disease, United States, Survival Rate, Treatment Outcome, 030228 respiratory system, Cardiothoracic surgery, Child, Preschool, Heart failure, Ventricular assist device, Emergency medicine, Cohort, Heart Transplantation, Female, Surgery, Heart-Assist Devices, Implant, Cardiology and Cardiovascular Medicine, business
Abstract

Background The influence of ventricular assist device (VAD) use in the care of children with end-stage heart failure is growing rapidly through increasing numbers, new devices, expanding indications, and improving outcomes. Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs), a National Institutes of Health–sponsored United States database, provides a platform to understand this emerging population. Methods Between September 19, 2012, and December 31, 2017, 30 hospitals implanted 508 devices in 423 patients aged younger than 19 years. This past year was one of evolution for the database as its management was transitioned to The Society of Thoracic Surgery; therefore, this report does not include data from institutions not under contract by August 1, 2018. Results Of the 423 patients, the diagnosis was cardiomyopathy in 261 (62%), myocarditis in 48 (11%), other in 28 (7%), and congenital heart disease (CHD) in 86 (20%), with 52 of these patients having single-ventricle physiology. The two most common support strategies included left VAD in 342 (81%) and biventricular assist device in 64 (15%). Positive outcome (alive on device or bridge to transplantation/recovery) was 80% at 6 months (overall mortality of 20%). The patient cohort for implantable continuous-flow (IC) pumps (n = 197; age at implant, 13.4 ± 3.8 years; 19% Interagency Registry for Mechanically Assisted Circulatory Support [Intermacs] profile 1, 21% intubated at implant, and 12% with CHD) was significantly different from the paracorporeal continuous-flow (PC) pump cohort (n = 79; age, 3.9 ± 5.2 years; 49% Intermacs profile 1, 86% intubated at implant, and 38% with CHD) and the paracorporeal pulsatile (PP) pump cohort (n = 121; age, 3.3 ± 3.9 years; 41% Intermacs profile 1, 77% intubated at implant, and 21% with CHD). Consistent with their cohort composition, device type positive outcomes at 6 months were PC, 63%; PP, 77%; and IC, 92%. Parametric hazard modeling showed an early hazard for death was associated with Intermacs profile 1, biventricular assist device, percutaneous devices, PC devices, small-volume institutions, low age, and low weight, whereas a constant hazard was associated with intubation and liver dysfunction at time of implant. Conclusions IC VADs are the most common VAD type placed in children. The positive outcomes for the IC VADs exceed 90% at 6 months, which may represent our field’s maturation in both patient selection and timing of implantation. The PP/PC devices are currently limited to supporting our most challenging patients, those weighing less than 20 kg and those with CHD. The introduction of new devices and our communities’ commitment to shared learning and improvement will lead to more pediatric lives saved by VAD support and will also focus on improving the quality of life of children supported with VADs.

Published
2019

39. Adherence to APSA activity restriction guidelines and 60-day clinical outcomes for pediatric blunt liver and splenic injuries (BLSI)

Author

David M. Notrica, Daniel J. Ostlie, R. Todd Maxson, Amina Bhatia, Nidhi Krishna, James W. Eubanks, Todd A. Ponsky, Nilda M. Garcia, Charles M. Leys, Shawn D. St. Peter, Robert W. Letton, Lois W Sayrs, Adam C. Alder, and David W. Tuggle

Subjects
Male, medicine.medical_specialty, Adolescent, Guidelines as Topic, Wounds, Nonpenetrating, Logistic regression, Patient Readmission, Blunt, Internal medicine, Humans, Medicine, Prospective Studies, Child, Prospective cohort study, Exercise, Liver injury, business.industry, General Medicine, Guideline, Emergency department, medicine.disease, Treatment Outcome, Liver, Abdominal trauma, Blunt trauma, Pediatrics, Perinatology and Child Health, Patient Compliance, Female, Surgery, Emergency Service, Hospital, business, Spleen, Follow-Up Studies
Abstract

After NOM for BLSI, APSA guidelines recommend activity restriction for grade of injury +2 in weeks. This study evaluates activity restriction adherence and 60 day outcomes.Non-parametric tests and logistic regression were utilized to assess difference between adherent and non-adherent patients from a 3-year prospective study of NOM for BLSI (≤18 years).Of 1007 children with BLSI, 366 patients (44.1%) met the inclusion criteria of a completed 60 day follow-up; 170 (46.4%) had liver injury, 159 (43.4%) had spleen injury and 37 (10.1%) had both. Adherence to recommended activity restriction was claimed by 279 (76.3%) patients; 49 (13.4%) reported non-adherence and 38 (10.4%) patients had unknown adherence. For 279 patients who adhered to activity restrictions, unplanned return to the emergency department (ED) was noted for 35 (12.5%) with 16 (5.7%) readmitted; 202 (72.4%) returned to normal activity by 60 days. No patient bled after discharge. There was no statistical difference between adherent patients (n = 279) and non-adherent (n = 49) for return to ED (χ2 = 0.8 [p 0.4]) or readmission (χ2 = 3.0 [p 0.09]); for 216 high injury grade patients, there was no difference between adherent (n = 164) and non-adherent (n = 30) patients for return to ED (χ2 = 0.6 [p 0.4]) or readmission (χ2 = 1.7 [p 0.2]).For children with BLSI, there was no difference in frequencies of bleeding or ED re-evaluation between patients adherent or non-adherent to the APSA activity restriction guideline.Level II, Prognosis.

Published
2019

40. Negative Focused Abdominal Sonography for Trauma examination predicts successful nonoperative management in pediatric solid organ injury: A prospective Arizona-Texas-Oklahoma-Memphis-Arkansas + Consortium study

Author

Daniel J. Ostlie, Robert W. Letton, Paul McGaha, David W. Tuggle, Zoona Sarwar, Maria E. Linnaus, Prasenjeet Motghare, James W. Eubanks, Todd A. Ponsky, Crystal S. Langlais, Amina Bhatia, Karla A. Lawson, Charles W. Leys, Adam C. Alder, R. Todd Maxson, Nilda M. Garcia, David M. Notrica, and Shawn D. St. Peter

Subjects
Male, medicine.medical_specialty, Adolescent, Abdominal Injuries, Wounds, Nonpenetrating, Critical Care and Intensive Care Medicine, 03 medical and health sciences, Injury Severity Score, 0302 clinical medicine, Trauma Centers, Predictive Value of Tests, medicine, Humans, Focused assessment with sonography for trauma, Prospective Studies, Treatment Failure, Nonoperative management, Child, Prospective cohort study, Retrospective Studies, Arkansas, biology, business.industry, General surgery, Arizona, Oklahoma, Shock, 030208 emergency & critical care medicine, Retrospective cohort study, Prognosis, biology.organism_classification, medicine.disease, Texas, Liver, Case-Control Studies, Child, Preschool, Predictive value of tests, Female, Surgery, Memphis, business, Spleen, Focused Assessment with Sonography for Trauma, Pediatric trauma
Abstract

Focused Abdominal Sonography for Trauma (FAST) examination has long been proven useful in the management of adult trauma patients, however, its utility in pediatric trauma patients is not as proven. Our goal was to evaluate the utility of a FAST examination in predicting the success or failure of nonoperative management (NOM) of blunt liver and/or spleen (BLSI) in the pediatric trauma population.A retrospective analysis of a prospective observational study of patients younger than 18 years presenting with BLSI to one of ten Level I pediatric trauma centers between April 2013 and January 2016. 1,008 patients were enrolled and 292 had a FAST examination recorded. We analyzed failure of NOM of BLSI in the pediatric trauma population. We then compared FAST examination alone or in combination with the pediatric age adjusted shock index (SIPA) as it relates to success of NOM of BLSI.Focused Abdominal Sonography for Trauma examination had a negative predictive value (NPV) of 97% and positive predictive value (PPV) of 13%. The odds ratio of failing with a positive FAST examination was 4.9 and with a negative FAST was 0.20. When combined with SIPA, a positive FAST examination and SIPA had a PPV of 17%, and an odds ratio for failure of 4.9. The combination of negative FAST and SIPA had an NPV of 96%, and the odds ratio for failure was 0.20.Negative FAST is predictive of successful NOM of BLSI. The addition of a positive or negative SIPA score did not affect the PPV or NPV significantly. Focused Abdominal Sonography for Trauma examination may be useful clinically in determining which patients are not at risk for failure of NOM of BLSI and do not require monitoring in an intensive care setting.Prognostic study, level IV; therapeutic/care management, level IV.

Published
2019

41. Withholding Urinary Catheters in Children Receiving Patient-Controlled Analgesia for Appendicitis

Author

Daniel L. Millspaugh, Joseph A. Sujka, Leo Andrew Benedict, Justin A. Sobrino, Lisa Wedel, Shawn D. St. Peter, and Jason R. Axt

Subjects
Male, medicine.medical_specialty, Time Factors, Adolescent, medicine.medical_treatment, Urinary system, Urinary Catheters, 03 medical and health sciences, Catheters, Indwelling, 0302 clinical medicine, Appendectomy, Humans, Medicine, Prospective Studies, Child, Perforated Appendicitis, Pain, Postoperative, business.industry, Patient-controlled analgesia, Urinary retention, Incidence (epidemiology), Analgesia, Patient-Controlled, Length of Stay, Urinary Retention, Appendicitis, medicine.disease, Discontinuation, Surgery, Analgesics, Opioid, Catheter, Treatment Outcome, Child, Preschool, 030220 oncology & carcinogenesis, Practice Guidelines as Topic, Female, 030211 gastroenterology & hepatology, medicine.symptom, Urinary Catheterization, business
Abstract

Background In some institutions, urinary catheters (UCs) have been placed in all patients receiving opioid patient-controlled analgesia (PCA) because of the increased incidence of urinary retention. Our institutional data demonstrated no UC replacements in 48 children who had PCA for perforated appendicitis who had their catheters removed before discontinuation of the PCA. As part of a quality improvement initiative, we discontinued the practice of requiring UC with PCA for perforated appendicitis. Materials and methods A prospective list of patients with perforated appendicitis was maintained. Data were gathered regarding 60 consecutive patients. UC placement was allowed for specific indications including urinary retention and surgeon discretion. Results Sixteen patients (27%) received a UC with 14 of these being placed in the operating room (OR). Two UCs were placed outside the OR for urinary retention. Patients who underwent UC placement in the OR weighed significantly more than those who did not (33 versus 42 kg, P = 0.05). No patients required replacement of the catheter once removed. There were no postoperative urinary tract infections. Median PCA duration was 68 h (50, 98) for patients with UC placed in the OR compared with 60 h (47, 78) (P = 0.42). Median postoperative length of stay for patients with UC placed in the OR was 95 h (76, 140) compared with 90 h (70, 113) (P = 0.09). Conclusions UC can be withheld from patients with perforated appendicitis who are placed on PCA with a very low placement rate. UC placement at time of operation did not lengthen time receiving PCA or length of stay.

Published
2019

42. Outcomes of Mechanical Mitral Valve Replacement in Children

Author

Lazaros Kochilas, James H. Moller, Omar Qayum, Jessica H. Knight, Amber Leila Sarvestani, Courtney McCracken, Geetha Raghuveer, Noor Alshami, James D. St. Louis, Elizabeth M. Turk, and Chizitam F Ibezim

Subjects
Male, Reoperation, Pulmonary and Respiratory Medicine, Pediatrics, medicine.medical_specialty, Adolescent, Heart disease, medicine.medical_treatment, Heart Valve Diseases, 030204 cardiovascular system & hematology, Prosthesis Design, National Death Index, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Mechanical Mitral Valve, Mitral valve, medicine, Humans, Child, Survival rate, Retrospective Studies, Heart Valve Prosthesis Implantation, business.industry, Age Factors, Mitral valve replacement, Infant, Retrospective cohort study, medicine.disease, United States, Survival Rate, Transplantation, Treatment Outcome, medicine.anatomical_structure, 030228 respiratory system, Child, Preschool, Heart Valve Prosthesis, Mitral Valve, Female, Surgery, Cardiology and Cardiovascular Medicine, business, Follow-Up Studies
Abstract

Mitral valve anomalies in children are rare but frequently severe, recalcitrant, and not often amenable to primary repair, necessitating mechanical mitral valve replacement (M-MVR). This study examined outcomes of a cohort undergoing a first M-MVR at age younger than 21 years.We queried the Pediatric Cardiac Care Consortium, a multi-institutional United States-based cardiac intervention registry, for patients undergoing first M-MVR for 2-ventricle congenital heart disease. Survival and transplant status through 2014 were obtained from Pediatric Cardiac Care Consortium and linkage with the National Death Index and the Organ Procurement and Transplantation Network.We identified 441 patients (median age, 4.3 years; interquartile range, 1.3 to 10.1 years) meeting study criteria. The commonest disease necessitating M-MVR was atrioventricular canal (44.3%). Early mortality (death90 days after M-MVR) was 11.1%; there was increased risk of early death if age at M-MVR was younger than 2 years (odds ratio, 7.8; 95% confidence interval [CI], 1.1 to 56.6) and with concurrent other mechanical valve placement (odds ratio, 8.5; 95% CI, 2.0 to 35.6). In those surviving more than 90 days after M-MVR, transplant-free survival was 76% at 20 years of follow-up (median follow-up, 16.6 years; interquartile range, 11.9 to 21.3 years). Adjusted analysis in those who survived more than 90 days showed elevated risk of death/transplant for boys (hazard ratio, 1.5; 95% CI, 1.0 to 2.3), age at M-MVR younger than 2 years (10-year survival: hazard ratio, 4.3; 95% CI, 1.2 to 15.1), and nonbileaflet prosthesis placement (hazard ratio, 2.4; 95% CI, 1.3 to 4.3).M-MVR is a viable strategy in children with unrepairable mitral valve disease. Age younger than 2 years at the first M-MVR is associated with significant early risk of death and poorer long-term survival.

Published
2019

43. Increasing phagocytosis of microglia through targeting CD33 with liposomes displaying glycan ligands

Author

Chris D. St. Laurent, Anastassia Voronova, Matthew S. Macauley, Adrianne E.S. Watson, Abhishek Bhattacherjee, Arjun Bains, Gour Chand Daskhan, and Ghazaleh Eskandari-Sedighi

Subjects
Glycan, Liposome, Microglia, biology, Chemistry, media_common.quotation_subject, Phagocytosis, Neurodegeneration, Cell, medicine.disease, Cell biology, medicine.anatomical_structure, medicine, biology.protein, Internalization, Intracellular, media_common
Abstract

CD33 is an immunomodulatory receptor expressed on microglia and genetically linked to Alzheimer’s disease (AD) susceptibility. While antibodies targeting CD33 have entered clinical trials to treat neurodegeneration, it is unknown whether the glycan-binding properties of CD33 can be exploited to modulate microglia. Here, we use liposomes that multivalently display glycan ligands of CD33 (CD33L liposomes) to engage CD33. We find that CD33L liposomes increase phagocytosis of cultured monocytic cells and microglia in a CD33-dependent manner. Enhanced phagocytosis strongly correlates with loss of CD33 from the cell surface and internalization of liposomes. Increased phagocytosis by treatment with CD33L liposomes is dependent on a key intracellular signaling motif on CD33 as well as the glycan-binding ability of CD33. These effects are specific to trans engagement of CD33 by CD33L liposomes, as cis engagement through insertion of lipid-linked CD33L into cells produces the opposite effect on phagocytosis. Moreover, intracerebroventricular injection of CD33L liposomes in mice enhances phagocytosis of microglia in a CD33-dependent manner. These results demonstrate that multivalent engagement of CD33 with glycan ligands can modulate microglial cell function.

Published
2021

44. Multicentre comparative analysis of long-term outcomes after aortic valve replacement in children

Author

James H. Moller, Chizitam F Ibezim, Elizabeth Turk, Geetha Raghuveer, James D. St. Louis, Bahaaldin Alsoufi, Courtney McCracken, Jessica H. Knight, Amber Leila Sarvestani, and Lazaros Kochilas

Subjects
Adult, Male, medicine.medical_specialty, Adolescent, medicine.medical_treatment, National Death Index, Article, Young Adult, Valve replacement, Aortic valve replacement, Cardiac interventions, medicine, Long term outcomes, Humans, Child, Retrospective Studies, Heart Valve Prosthesis Implantation, business.industry, Hazard ratio, Infant, Newborn, Infant, Retrospective cohort study, medicine.disease, Aortic Valve Disease, Surgery, surgical procedures, operative, Treatment Outcome, Aortic Valve, Child, Preschool, Heart Valve Prosthesis, Female, Cardiology and Cardiovascular Medicine, business, Cardiac transplants
Abstract

ObjectiveThe ideal valve substitute for surgical intervention of congenital aortic valve disease in children remains unclear. Data on outcomes beyond 10–15 years after valve replacement are limited but important for evaluating substitute longevity. We aimed to describe up to 25-year death/cardiac transplant by type of valve substitute and assess the potential impact of treatment centre. Our hypothesis was that patients with pulmonic valve autograft would have better survival than mechanical prosthetic.MethodsThis is a retrospective cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional US-based registry of paediatric cardiac interventions, linked with the National Death Index and United Network for Organ Sharing through 2019. Children (0–20 years old) receiving aortic valve replacement (AVR) from 1982 to 2003 were identified. Kaplan-Meier transplant-free survival was calculated, and Cox proportional hazard models estimated hazard ratios for mechanical AVR (M-AVR) versus pulmonic valve autograft.ResultsAmong 911 children, the median age at AVR was 13.4 years (IQR=8.4–16.5) and 73% were male. There were 10 cardiac transplants and 153 deaths, 5 after transplant. The 25-year transplant-free survival post AVR was 87.1% for autograft vs 76.2% for M-AVR and 72.0% for tissue (bioprosthetic or homograft). After adjustment, M-AVR remained related to increased mortality/transplant versus autograft (HR=1.9, 95% CI=1.1 to 3.4). Surprisingly, survival for patients with M-AVR, but not autograft, was lower for those treated in centres with higher in-hospital mortality.ConclusionPulmonic valve autograft provides the best long-term outcomes for children with aortic valve disease, but AVR results may depend on a centre’s experience or patient selection.

Published
2021

45. Pleuropulmonary Blastoma in Pediatric Lung Lesions

Author

Peter C. Minneci, Matthew P. Landman, Ronald B. Hirschl, Jacqueline M. Saito, Katherine J. Deans, Dave R. Lal, Shaun M. Kunisaki, Amer Heider, Zachary D. Fox, Grace Z. Mak, Rashmi Kabre, Sherwin S. Chan, R. Cartland Burns, Charles M. Leys, Michael A. Helmrath, Mary E. Fallat, Shawn D. St. Peter, Samir K. Gadepalli, Tiffany Wright, and Kevin P. Boyd

Subjects
Ribonuclease III, medicine.medical_specialty, Lung Neoplasms, Pleuropulmonary blastoma, Prenatal care, Malignancy, Preoperative care, Cohort Studies, DEAD-box RNA Helicases, Pregnancy, Prenatal Diagnosis, Humans, Medicine, Neoplasm Metastasis, Retrospective Studies, Respiratory Distress Syndrome, Newborn, Lung, business.industry, Infant, Newborn, Infant, Cancer, Retrospective cohort study, Length of Stay, medicine.disease, medicine.anatomical_structure, Child, Preschool, Mutation, Pediatrics, Perinatology and Child Health, Female, Histopathology, Radiology, Tomography, X-Ray Computed, business, Pulmonary Blastoma
Abstract

BACKGROUND: Pediatric lung lesions are a group of mostly benign pulmonary anomalies with a broad spectrum of clinical disease and histopathology. Our objective was to evaluate the characteristics of children undergoing resection of a primary lung lesion and to identify preoperative risk factors for malignancy. METHODS: A retrospective cohort study was conducted by using an operative database of 521 primary lung lesions managed at 11 children’s hospitals in the United States. Multivariable logistic regression was used to examine the relationship between preoperative characteristics and risk of malignancy, including pleuropulmonary blastoma (PPB). RESULTS: None of the 344 prenatally diagnosed lesions had malignant pathology (P < .0001). Among 177 children without a history of prenatal detection, 15 (8.7%) were classified as having a malignant tumor (type 1 PPB, n = 11; other PPB, n = 3; adenocarcinoma, n = 1) at a median age of 20.7 months (interquartile range, 7.9–58.1). Malignancy was associated with the DICER1 mutation in 8 (57%) PPB cases. No malignant lesion had a systemic feeding vessel (P = .0427). The sensitivity of preoperative chest computed tomography (CT) for detecting malignant pathology was 33.3% (95% confidence interval [CI]: 15.2–58.3). Multivariable logistic regression revealed that increased suspicion of malignancy by CT and bilateral disease were significant predictors of malignant pathology (odds ratios of 42.15 [95% CI, 7.43–340.3; P < .0001] and 42.03 [95% CI, 3.51–995.6; P = .0041], respectively). CONCLUSIONS: In pediatric lung masses initially diagnosed after birth, the risk of PPB approached 10%. These results strongly caution against routine nonoperative management in this patient population. DICER1 testing may be helpful given the poor sensitivity of CT for identifying malignant pathology.

Published
2021

46. Distinct microRNA profiles for complete hydatidiform moles at risk of malignant progression

Author

Kevin M. Elias, Izildinha Maestá, Sue Yazaki Sun, Lawrence Hsu Lin, Bradley J. Quade, Rosemary A. Fisher, Donald P. Goldstein, Neil S. Horowitz, Ross S. Berkowitz, Kathleen Hasselblatt, Antonio Braga, Jessica D. St. Laurent, Universidade de São Paulo (USP), Universidade Estadual Paulista (Unesp), Harvard Med Sch, Universidade Federal do Rio de Janeiro (UFRJ), Universidade Federal Fluminense (UFF), Imperial Coll London, and NYU

Subjects
Adult, Genetic Markers, small untranslated, BCL2, Adolescent, Trophoblastic Tumor, trophoblastic neoplasms, Human chorionic gonadotropin, 03 medical and health sciences, Young Adult, 0302 clinical medicine, Pregnancy, microRNA, Trophoblastic neoplasm, choriocarcinoma, Medicine, Humans, 030212 general & internal medicine, gestational trophoblastic disease, Gestational Trophoblastic Disease, reproductive and urinary physiology, 030219 obstetrics & reproductive medicine, MicroRNA sequencing, business.industry, Gestational trophoblastic disease, Choriocarcinoma, apoptosis, Obstetrics and Gynecology, Cancer, High-Throughput Nucleotide Sequencing, Hydatidiform Mole, Middle Aged, medicine.disease, trophoblastic tumors, microRNAs, hydatidiform mole, MicroRNAs, cell death, Proto-Oncogene Proteins c-bcl-2, Uterine Neoplasms, embryonic structures, Cancer research, Disease Progression, RNA, Female, business
Abstract

Made available in DSpace on 2021-06-25T15:01:29Z (GMT). No. of bitstreams: 0 Previous issue date: 2021-04-01 Trophoblastic Tumor Registry Endowment Dyett Family Trophoblastic Disease Research and Registry Endowment Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) BACKGROUND: MicroRNAs are small noncoding RNAs with important regulatory functions. Although well-studied in cancer, little is known about the role of microRNAs in premalignant disease. Complete hydatidiform moles are benign forms of gestational trophoblastic disease that progress to gestational trophoblastic neoplasia in up to 20% of cases; however, there is no well-established biomarker that can predict the development of gestational trophoblastic neoplasia. OBJECTIVE: This study aimed to investigate possible differences in microRNA expression between complete moles progressing to gestational trophoblastic neoplasia and those regressing after surgical evacuation. STUDY DESIGN: Total RNA was extracted from fresh frozen tissues from 39 complete moles collected at the time of uterine evacuation in Brazil. In the study, 39 cases achieved human chorionic gonadotropin normalization without further therapy, and 9 cases developed gestational trophoblastic neoplasia requiring chemotherapy. Total RNA was also extracted from 2 choriocarcinoma cell lines, JEG-3 and JAR, and an immortalized normal placenta cell line, 3A-subE. MicroRNA expression in all samples was quantified using microRNA sequencing. Hits from the sequencing data were validated using a quantitative probe-based assay. Significantly altered microRNAs were then subjected to target prediction and gene ontology analyses to search for alterations in key signaling pathways. Expression of potential microRNA targets was assessed by quantitative real-time polymerase chain reaction and western blot. Finally, potential prognostic protein biomarkers were validated in an independent set of formalin-fixed paraffin-embedded patient samples from the United States (15 complete moles progressing to gestational trophoblastic neoplasia and 12 that spontaneously regressed) using quantitative immunohistochemistry. RESULTS: In total, 462 microRNAs were identified in all samples at a threshold of

Published
2021

47. Risk factors for perioperative hypothermia and infectious outcomes in gastroschisis patients

Author

Shirli Tay, Shilvi Joshi, Shawn D. St. Peter, Christina M Bence, Rachel M. Landisch, Charles M. Leys, Joseph B. Lillegard, Amy J. Wagner, Ruizhe Wu, Jason D. Fraser, Aimee G. Kim, Mary T. Austin, Aniko Szabo, Erin E. Perrone, Brad W. Warner, Kathryn McElhinney, and Jonathan E. Kohler

Subjects
Hypothermia, Logistic regression, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, 030225 pediatrics, medicine, Humans, Surgical Wound Infection, Child, Retrospective Studies, Gastroschisis, business.industry, Infant, Newborn, Infant, General Medicine, Odds ratio, Perioperative, medicine.disease, Increased risk, Treatment Outcome, 030220 oncology & carcinogenesis, Anesthesia, Pediatrics, Perinatology and Child Health, Cohort, Surgery, medicine.symptom, business, Surgical site infection
Abstract

Prior data suggest that infants with gastroschisis are at high risk for hypothermia and infectious complications (ICs). This study evaluated the associations between perioperative hypothermia (PH) and ICs in gastroschisis using a multi-institutional cohort.Retrospective review of infants with gastroschisis who underwent abdominal closure from 2013-2017 was performed at 7 children's hospitals. Any-IC and surgical site infection (SSI) were stratified against the presence or absence of PH, and perioperative characteristics associated with PH and SSI were determined using multivariable logistic regression.Of 256 gastroschisis neonates, 42% developed PH, with 18% classified as mild hypothermia (35.5-35.9 °C), 10.5% as moderate (35.0-35.4 °C), and 13% severe (35 °C). There were 82 (32%) ICs with 50 (19.5%) being SSIs. No associations between PH and any-IC (p = 0.7) or SSI (p = 0.98) were found. Pulmonary comorbidities (odds ratio (OR)=3.76, 95%CI:1.42-10, p = 0.008) and primary closure (OR=0.21, 95%CI:0.12-0.39, p0.001) were associated with PH, while silo placement (OR=2.62, 95%CI:1.1-6.3, p = 0.03) and prosthetic patch (OR=3.42, 95%CI:1.4-8.3, p = 0.007) were associated with SSI on multivariable logistic regression.Primary abdominal closure and pulmonary comorbidities are associated with PH in gastroschisis, however PH was not associated with increased risk of ICs. Independent risk factors for SSI include silo placement and prosthetic patch closure.

Published
2021

48. Tisagenlecleucel infusion in patients with relapsed/refractory ALL and concurrent serious infection

Author

Terrie G Flatt, Atif A. Ahmed, Richard J. Hendrickson, G Doug Myers, Shawn D. St. Peter, Rakesh Goyal, Ibrahim A. Ahmed, Weijie Li, Erin M Hall, Keith J. August, Grace S Mitchell, and Dwight E Yin

Subjects
Pharmacology, Cancer Research, Chemotherapy, medicine.medical_specialty, Septic shock, business.industry, medicine.medical_treatment, Immunology, Neoplasms. Tumors. Oncology. Including cancer and carcinogens, Neutropenia, medicine.disease, Clinical trial, Cytokine release syndrome, Oncology, Internal medicine, medicine, Molecular Medicine, Immunology and Allergy, Young adult, Adverse effect, business, RC254-282, Hemorrhagic cystitis
Abstract

BackgroundTisagenlecleucel, an anti-CD19 chimeric antigen receptor T (CAR-T) cell therapy, has demonstrated durable efficacy and a manageable safety profile in pediatric and young adult patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) in the ELIANA pivotal trial and real-world experience. Experience from investigator-led studies prior to ELIANA suggests that infections and inflammatory conditions may exacerbate the severity of cytokine release syndrome (CRS) associated with CAR-T cell therapy, leading to extreme caution and strong restrictions for on-study and commercial infusion of tisagenlecleucel in patients with active infection. CRS intervention with interleukin (IL)-6 blockade and/or steroid therapy was introduced late in the course during clinical trials due to concern for potential negative effect on efficacy and persistence. However, earlier CRS intervention is now viewed more favorably. Earlier intervention and consistency in management between providers may promote broader use of tisagenlecleucel, including potential curative therapy in patients who require remission and recovery of hematopoiesis for management of severe infection.Main bodyPatient 1 was diagnosed with B-ALL at 23 years old. Fourteen days before tisagenlecleucel infusion, the patient developed fever and neutropenia and was diagnosed with invasive Mucorales infection and BK virus hemorrhagic cystitis. Aggressive measures were instituted to control infection and to manage prolonged cytopenias during CAR-T cell manufacturing. Adverse events, including CRS, were manageable despite elevated inflammatory markers and active infection. The patient attained remission and recovered hematopoiesis, and infections resolved. The patient remains in remission ≥1 year postinfusion.Patient 2 was diagnosed with pre–B-ALL at preschool age. She developed severe septic shock 3 days postinitiation of lymphodepleting chemotherapy. After receiving tisagenlecleucel, she experienced CRS with cardiac dysfunction and extensive lymphadenopathy leading to renovascular compromise. The patient attained remission and was discharged in good condition to her country of origin. She remained in remission but expired on day 208 postinfusion due to cardiac arrest of unclear etiology.ConclusionsInfusion was feasible, and toxicity related to tisagenlecleucel was manageable despite active infections and concurrent inflammation, allowing attainment of remission in otherwise refractory pediatric/young adult ALL. This may lead to consideration of tisagenlecleucel as a potential curative therapy in patients with managed active infections.

Published
2021

49. Elective Cancer Surgery in COVID-19-Free Surgical Pathways during the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study

Author

Writing Group (denotes joint first author) James, C Glasbey (UK), Dmitri Nepogodiev (UK), Joana FF Simoes (Portugal), Omar Omar (UK), Elizabeth Li (UK), Mary, L Venn (UK), Mohammad Abou Chaar (Jordan), Vita Capizzi (Italy), Daoud Chaudhry (UK), Anant Desai (UK), Jonathan, G Edwards (UK), Jonathan, P Evans (UK), Marco Fiore (Italy), Jose Flavio Videria (Portugal), Samuel, J Ford (UK), Ian Ganyli (USA), Ewen, A Griffiths (UK), Rohan, R Gujjuri (UK), Angelos, G Kolias (UK), Haytham MA Kaafarani (USA), Ana Minaya-Bravo (Spain), Siobhan, C McKay (UK), Helen, M Mohan (Ireland), Keith Roberts (UK), Carlos San Miguel-M&#233, ndez (Spain), Peter Pockney (Australia), Richard Shaw (UK), Neil, J Smart (UK), Grant, D Stewart (UK), Sudha Sundar (UK), Raghavan Vidya (UK), Aneel, A Bhangu (UK, Statistical analysis Glasbey JC, Overall guarantor)., Omar, O (Lead statistician), Bhangu, A CovidSurg Operations Committee Kwabena Siaw-Acheampong, Ruth, A Benson, Edward, Bywater, Daoud, Chaudhry, Brett, E Dawson, Jonathan, P Evans, James, C Glasbey, Rohan, R Gujjuri, Emily, Heritage, Conor, S Jones, Sivesh, K Kamarajah, Chetan, Khatri, Rachel, A Khaw, James, M Keatley, Andrew, Knight, Samuel, Lawday, Elizabeth, Li, Harvinder, S Mann, Ella, J Marson, Kenneth, A McLean, Siobhan, C Mckay, Emily, C Mills, Dmitri, Nepogodiev, Gianluca, Pellino, Maria, Picciochi, Elliott, H Taylor, Abhinav, Tiwari, Joana FF Simoes, Isobel, M Trout, Mary, L Venn, Richard JW Wilkin, International Cancer Leads (denotes specialty Principal Investigators) James C Glasbey (Chair), Aneel Bhangu., Colorectal: Neil, J Smart, Ana, Minaya-Bravo, Susan, Moug, Dale, Vimalchandran, Abigail, Vallance, Peter, Pockney, Oesophagogastric: Ewen, A Griffiths, Richard PT Evans, Philip, Townend, Hepatopancreatobilary: Keith Roberts, Siobhan, McKay, John, Isaac, Sohei, Satoi, Thoracic: John Edwards, Aman, S Coonar, Adrian, Marchbank, Edward, J Caruana, Georgia, R Layton, Akshay, Patel, Alessandro, Brunelli, Sarcoma: Samuel Ford, Anant, Desai, Alessandro, Gronchi, Marco, Fiore, Max, Almond, Fabio, Tirotta, Sinziana, Dumitra, Neurosurgery: Angelos Kolias, Stephen, J Price, Daniel, M Fountain, Michael, D Jenkinson, Peter, Hutchinson, Hani, J Marcus, Rory, J Piper, Laura, Lippa, Franco, Servadei, Ignatius, Esene, Christian, Freyschlag, Iuri, Neville, Gail, Rosseau, Karl, Schaller, Andreas, K Demetriades, Faith, Robertson, Alex, Alamri, Head and neck: Richard Shaw, Andrew, G Schache, Stuart, C Winter, Michael, Ho, Paul, Nankivell, Juan Rey Biel, Martin, Batstone, Ian, Ganly, Breast: Raghavan Vidya, Alex, Wilkins, Jagdeep, K Singh, Dinesh, Thekinkattil, Gynaecology: Sudha Sundar, Christina, Fotopoulou, Elaine, Leung, Tabassum, Khan, Luis, Chiva, Jalid, Sehouli, Anna, Fagotti, Paul, Cohen, Murat, Gutelkin, Rahel, Ghebre, Thomas, Konney, Rene, Pareja, Rob, Bristow, Sean, Dowdy, Shylasree TS Rajkumar, Joe, Ng, Keiiji, Fujiwara, Urology: Grant, D Stewart, Benjamin, Lamb, Krishna, Narahari, Alan, McNeill, Alexandra, Colquhoun, John, McGrath, Steve, Bromage, Ravi, Barod, Veeru, Kasivisvanathan, Dissemination Committee Joana FF Simoes (Chair), Tobias Klatte., Tom EF Abbott, Michel, Adamina, Adesoji, O Ademuyiwa, Arnav, Agarwal, Ehab, Alameer, Derek, Alderson, Felix, Alakaloko, Markus, Albertsmeiers, Osaid, Alser, Muhammad, Alshaar, Sattar, Alshryda, Alexis, P Arnaud, Knut Magne Augestad, Faris, Ayasra, Jos&#233, Azevedo, Brittany, K Bankhead-Kendall, Emma, Barlow, Ruth, Blanco-Colino, Amanpreet, Brar, Kerry, A Breen, Chris, Bretherton, Igor Lima Buarque, Joshua, Burke, Mohammad, Chaar, Sohini, Chakrabortee, Peter, Christensen, Daniel, Cox, Moises, Cukier, Miguel, F Cunha, Giana, H Davidson, Salomone Di Saverio, Thomas, M Drake, John, G Edwards, Muhammed, Elhadi, Sameh, Emile, Shebani, Farik, J Edward Fitzgerald, Samuel, Ford, Tatiana, Garmanova, Gaetano, Gallo, Dhruv, Ghosh, Gustavo Mendon&#231, a Ata&#237, de Gomes, Gustavo, Grecinos, Ewen, A Griffiths, Madalegna, Gr&#252, ndl, Constantine, Halkias, Ewen, M Harrison, Intisar, Hisham, Peter, J Hutchinson, Shelley, Hwang, Arda, Isik, Pascal, Jonker, Haytham MA Kaafarani, Angelos, Kolias, Schelto, Kruijff, Ismail, Lawani, Hans, Lederhuber, Sezai, Leventoglu, Andrey, Litvin, Andrew, Loehrer, Markus, W L&#246, ffler, Maria Aguilera Lorena, Maria Marta Madolo, Piotr, Major, Janet, Martin, Hassan, N Mashbari, Dennis, Mazingi, Symeon, Metallidis, Helen, M Mohan, Rachel, Moore, David, Moszkowicz, Joshua, S Ng-Kamstra, Mayaba, Maimbo, Milagros, Niquen, Faustin, Ntirenganya, Maricarmen, Olivos, Kacimi, Oussama, Oumaima, Outani, Marie Dione Parreno-Sacdalanm, Francesco, Pata, Carlos Jose Perez Rivera, Thomas, D Pinkney, Willemijn van der Plas, Ahmad, Qureshi, Dejan, Radenkovic, Antonio Ramos- De la Medina, Keith, Roberts, April, C Roslani, Martin, Ruteg&#229, Ir&#232, ne, Santos, Raza, Sayyed, Andrew, Schache, Andreas, A Schnitzbauer, Seyi-Olajide, Justina O., Neil, Sharma, Richard, Shaw, Sebastian, Shu, Kjetil, Soreide, Antonino, Spinelli, Grant, D Stewart, Malin, Sund, Sudha, Sundar, Stephen, Tabiri, Georgios, Tsoulfas, Gabrielle, H van Ramshorst, Raghavan, Vidya, Dale, Vimalachandran, Oliver, J Warren, Duane, Wedderburn, Naomi, Wright, EuroSurg, European Society of Coloproctology (ESCP), Global Initiative for Children&#8217, s Surgery (GICS), GlobalSurg, GlobalPaedSurg, ItSURG, PTSurg, SpainSurg, Italian Society of Colorectal Surgery (SICCR), Association of Surgeons in Training (ASiT), Irish Surgical Research Collaborative (ISRC), Transatlantic Australasian Retroperitoneal Sarcoma Working Group (TARPSWG), Collaborators (denotes Site Principal Investigators) Argentina: Allemand C, Italian Society of Surgical Oncology (SICO)., Boccalatte, L, Figari, M, Lamm, M, Larra&#241, aga, J, Marchitelli, C, Noll, F, Odetto, D, Perrotta, M, Saadi, J, Zamora, L (Hospital Italiano De Buenos Aires), Alurralde, C, Caram, El, Eskinazi, D, Mendoza, Jp, Usandivaras M (Sanatorio, 9 De Julio Sa), Badra, R, Esteban, A, Garc&#237, a, Js, a, Pm, Gerchunoff, Ji, Lucchini, Sm, NIgra, Ma, Armenia: Hovhannisyan T, Vargas L (Sanatorio Allende)., Australia: Gould T, Stepanyan A (Nairi Medical Center)., Gourlay, R, Griffiths, B (Calvary Mater Newcastle), Gananadha S, McLaren M (Canberra Hospital), Cecire, J, Joshi, N, Salindera, S, Sutherland, A (Coffs Harbour Health Campus), Ahn, Jh, Charlton, G, Chen, S, Gauri, N, Hayhurst, R, Jang, S, Jia, F, Mulligan, C, Yang, W, Ye, G, Zhang, H (Concord Repatriation General Hospital), Ballal, M, Gibson, D, Hayne, D, Moss, J, Richards, T, Viswambaram, P, Vo UG (Fiona Stanley Hospital), Bennetts, J, Bright, T, Brooke-Smith, M, Fong, R, Gricks, B, Lam, Yh, Ong, Bs, Szpytma, M, Watson, D (Flinders Medical Centre), Bagraith, K, Caird, S, Chan, E, Dawson, C, Ho, D, Jeyarajan, E, Jordan, S, Lim, A, Nolan, Gj, Oar, A, Parker, D, Puhalla, H, Quennell, A, Rutherford, L, Townend, P, Von Papen, M, Wullschleger, M (Gold Coast University Hospital), Blatt, A, Cope, D, Egoroff, N, Fenton, M, Gani, J, Lott, N, Pockney, P, Shugg, N (John Hunter Hospital), Elliott M, Phung D (Lifehouse), Phan D, Townend D (Lismore Base Hospital), Bong C, Gundara J (Logan Hospital), Frankel, A (Princess Alexandra Hospital), Bowman S, Guerra GR (Queen Elizabeth Ii Jubilee Hospital), Bolt, J, Buddingh, K, Dudi-Venkata, Nn, Jog, S, Kroon, Hm, Sammour, T, Smith, R, Stranz, C (Royal Adelaide Hospital), Batstone, M, Lah, K, McGahan, W, Mitchell, D, Morton, A, Pearce, A, Roberts, M, Sheahan, G, Swinson, B (Royal Brisbane And Women&#8217, s Hospital), Alam, N, Banting, S, Chong, L, Choong, P, Clatworthy, S, Foley, D, Fox, A, Hii, Mw, Knowles, B, Mack, J, Read, M, Rowcroft, A, Ward, S, Austria: Lanner M (Kardinal Schwarzenberg Klinikum), Wright G (St Vincent&#8217, s Hospital)., K&#246, nigsrainer, I (Landeskrankenhaus Feldkirch), Bauer, M, Freyschlag, C, Kafka, M, Messner, F, 214, fner, D, Tsibulak, I (Medical University Of Innsbruck), Emmanuel, K, Grechenig, M, Gruber, R, Harald, M, hlberger, L, Presl, J, Azerbaijan: Namazov &#304, Wimmer A (Paracelsus Medical University Salzburg)., Barbados: Barker D, Samadov E (Leyla Medical Centerl)., Boyce, R, Corbin, S, Doyle, A, Eastmond, A, Gill, R, Haynes, A, Millar, S, O&#8217, Shea, M, Padmore, G, Paquette, N, Phillips, E, John S, St., Belgium: Flamey N, Walkes K (Queen Elizabeth Hospital)., Pattyn, P (Az Delta), Oosterlinck, W, Van den Eynde, J, Brazil: Gatti A, Van den Eynde R (Uz Leuven)., Nardi, C, Oliva, R (Hospital Geral De Pirajussara), De Cicco, R (Instituto De C&#226, ncer Dr Arnaldo Vieira De Carvalho), Cecconello, I, Gregorio, P, Pontual Lima, L, Ribeiro Junior, U, Takeda, F, Canada: Kidane B, Terra RM (Instituto Do C&#226, ncer De Estado De S&#227, o Paulo). Bulgaria: Sokolov M (University Hospital Alexandrovska)., Srinathan, S (Health Sciences Centre), Boutros, M, Caminsky, N, Ghitulescu, G, Jamjoum, G, Moon, J, Pelletier, J, Vanounou, T, Wong, S (Jewish General Hospital), Dumitra, S, Kouyoumdjian, A (Mcgill University Health Center), Johnston B, Russell C (Saint John Regional Hospital), Demyttenaere, S, Mary&#8217, s Hospital), Garfinkle R (St., Abou-Khalil, J, Nessim, C, Colombia: Almeciga A, Stevenson J (The Ottawa Hospital). Chile: Heredia F (Cl&#237, nica Universitaria De Concepci&#243, n)., Fletcher, A, Merchan A (Centro De Investigaciones Oncol&#243, gicas Cl&#237, nica San Diego, - Ciosad), Puentes LO (Hospital San Jos&#233, Croatia: Ba&#269, i&#263, G, Mendoza Quevedo J (Subred Sur Occidente De Kennedy (Hospital De Kennedy))., Karlovi&#263, D, Kr&#353, ul, D, Zeli&#263, M (University Hospital Center Rijeka), Luksic I, Mamic M (University Hospital Dubrava), Bakmaz, B, 262, oza, I, Dijan, E, Katusic, Z, Mihanovic, J, Cyprus: Frantzeskou K, Rakvin I (Zadar General Hospital)., Gouvas, N, Kokkinos, G, Papatheodorou, P, Pozotou, I, Stavrinidou, O, Czechia: Martinek L, Yiallourou A (Nicosia General Hospital)., Skrovina, M, Szubota, I (Hospital &amp, amp, Oncological Centre Novy Jicin), 381, ateck&#253, J (Slezsk&#225, Nemocnice V Opav&#283, P. o. ), Javurkova, V, Denmark: Avlund T, Klat J (University Hospital Ostrava)., Christensen, P, Harbjerg, Jl, Iversen, Lh, Kjaer, Dw, Kristensen, H&#248, Mekhael, M (Aarhus University Hospital), Ebbeh&#248, j, Al, Krarup, P, Schlesinger, N, Egypt: Abdelsamed A, Smith H (Bispebjerg Hospital)., Azzam, Ay, Salem, H, Seleim, A (Al Azhar University Hospitals), Abdelmajeed, A, Abdou, M, Abosamak, Ne, AL Sayed, M, Ashoush, F, Atta, R, Elazzazy, E, Elhoseiny, M, Elnemr, M, Elqasabi, Ms, Elsayed Hewalla ME, Elsherbini, I, Essam, E, Eweda, M, Ghallab, I, Hassan, E, Ibrahim, M, Metwalli, M, Mourad, M, Qatora, Ms, Ragab, M, Sabry, A, Saifeldin, H, Saleh Mesbah Mohamed Elkaffas, M, Samih, A, Samir Abdelaal, A, Shehata, S, Shenit, K (Alexandria Main University Hospital), Attia, D, Kamal, N, Osman, N (Alexandria Medical Research Institute), Abbas, Am, Abd Elazeem HAS, Abdelkarem, Mm, Alaa, S, Ali, Ak, Ayman, A, Azizeldine, Mg, Elkhayat, H, elghazaly S, M., Monib, Fa, Nageh, Ma, Saad, Mm, Salah, M, Shahine, M, Yousof, Ea, Youssef, A (Assiut University Hospital), Eldaly, A (El-Menshawy Hospital), ElFiky, M, Nabil, A (Kasr Alainy Faculty Of Medicine, Cairo, University), Amira, G, Sallam, I, Sherief, M, Sherif, A (Misr Cancer Center), Abdelrahman, A, Aboulkassem, H, Ghaly, G, Hamdy, R, Morsi, A, Sherif, G (National Cancer Institute), Abdeldayem, H, Abdelkader Salama, I, Balabel, M, Fayed, Y, Sherif AE (National Liver Institute, Finland: Kauppila J, Menoufia University). Ethiopia: Bekele D (Maddawalabu University Goba Referral Hospital)., Sarjanoja, E (L&#228, nsi-Pohja Central Hospital), Helminen, O, Huhta, H, France: Beyrne C, Kauppila JH (Oulu University Hospital)., Jouffret, L, Lugans, L, Marie-Macron, L (Centre Hospitalier Avignon), Chouillard E, De Simone B (Centre Hospitalier Intercommunal Poissy Saint Germain En Laye), Bettoni, J, Dakp&#233, S, Devauchelle, B, Lavagen, N, Testelin, S (Chu Amiens), Boucher, S, Breheret, R, Gueutier, A, Kahn, A, K&#252, n-Darbois, J (Chu Angers), Barrabe, A, Lakkis, Z, Louvrier, A, Manfredelli, S, Mathieu, P (Chu Besan&#231, on), Chebaro, A, Drubay, V, El amrani, M, Eveno, C, Lecolle, K, Legault, G, Martin, L, Piessen, G, Pruvot, Fr, Truant, S, Zerbib, P (Chu Lille), Ballouhey, Q, Barrat, B, Laloze, J, Salle, H, Taibi, A, Usseglio, J (Chu Limoges), Bergeat D, Merdrignac A (Chu Rennes - General Surgery), Le Roy, B, Perotto, Lo, Scalabre, A (Chu Saint Etienne), Aim&#233, A, Ezanno, A, Malgras, B (Hia Begin), Bouche P, Tzedakis S (H&#244, pital Cochin - Aphp), Cotte, E, Glehen, O, Lifante, J (Hopital Lyon Sud), D&#8217, Urso, A, Felli, E, Mutter, D, Pessaux, P, Seeliger, B (Hus, Pole H&#233, pato-Digestif, / Ihu- Strasbourg), Bardet, J, Berry, R, Boddaert, G, Bonnet, S, Brian, E, Denet, C, Fuks, D, Gossot, D, Grigoroiu, M, Laforest, A, Levy-Zauberman, Y, Louis-Sylvestre, C, Moumen, A, Pourcher, G, Seguin-givelet, A, Tribillon, E (Institut Mutualiste Montsouris), Duchalais, E, Espitalier, F, Ferron, C, Germany: Bork U, Malard O (Nantes University Hospital)., Distler, M, Fritzmann, J, Kirchberg, J, Praetorius, C, Riediger, C, Weitz, J, Welsch, T, Wimberger, P (Carl-Gustav-Carus University, Dresden), Tu, Beyer, K, Kamphues, C, Lauscher, J, Loch, Fn, Schineis, C (Charit&#233, University Medicine, Campus Benjamin Franklin), Albertsmeier, M, Angele, M, Kappenberger, A, Niess, H, Schiergens, T, Werner, J (Department of General, Visceral and Transplantation Surgery, Ludwig- Maximilians-Universitat Munich), Becker R, Jonescheit J (Heilig-Geist Hospital Bensheim), Pergolini I, Reim D (Klinikum Rechts Der Isar Tum School Of Medicine), Boeker, C, Hakami, I, Mall, J (Krh Nordstadt-Siloah Hospitals), Liokatis P, Smolka W (LMU Klinikum Campus Innenstadt), Nowak K, Reinhard T (Romed Klinikum Rosenheim), H&#246, lzle, F, Modabber, A, Winnand, P (University Hospital Aachen), Knitschke, M (University Hospital Giessen And Marburg), Kauffmann P, Wolfer S (University Hospital Goettingen / Universit&#228, tsmedizin Goettingen), Kleeff, J, Lorenz, K, Michalski, C, Ronellenfitsch, U, Schneider, R (University Hospital Halle (Saale)), Bertolani, E, nigsrainer, A, L&#246, ffler, Mw, Quante, M, Steidle, C, 220, berr&#252, ck, L, Yurttas, C (University Hospital Tuebingen), Betz, Cs, Bewarder, J, B&#246, ttcher, A, Burg, S, Busch, C, Gosau, M, Heuer, A, Izbicki, J, Klatte, To, Koenig, D, Moeckelmann, N, Nitschke, C, Priemel, M, Smeets, R, Speth, U, Thole, S, Uzunoglu, Fg, Vollkommer, T, Zeller, N (University Medical Center Hamburg- Eppendorf), Battista, Mj, Gillen, K, Hasenburg, A, Krajnak, S, Linz, V, Schwab, R (University Of Mainz, Greece: Angelou K, Department Of Gynaecology And Obstetrics)., Haidopoulos, D, Rodolakis, A (Alexandra General Hospital), Antonakis, P, Bramis, K, Chardalias, L, Contis, I, Dafnios, N, Dellaportas, D, Fragulidis, G, Gklavas, A, Konstadoulakis, M, Memos, N, Papaconstantinou, I, Polydorou, A, Theodosopoulos, T, Vezakis, A (Aretaieion Hospital), Antonopoulou, Mi, Manatakis, Dk, Tasis, N (Athens Naval And Veterans Hospital), Arkadopoulos, N, Danias, N, Economopoulou, P, Kokoropoulos, P, Larentzakis, A, Michalopoulos, N, Selmani, J, Sidiropoulos, T, Tsaousis, V, Vassiliu, P (Attikon University General Hospital), Bouchagier, K, Klimopoulos, S, Paspaliari, D, Stylianidis, G (Evaggelismos General Hospital), Baxevanidou, K, Bouliaris, K, Chatzikomnitsa, P, Efthimiou, M, Giaglaras, A, Kalfountzos, C, Koukoulis, G, Ntziovara, Am, Petropoulos, K, Soulikia, K, Tsiamalou, I, Zervas, K, Zourntou, S (General Hospital Of Larissa &#8220, Koutlimpaneio And Triantafylleio&#8221, Baloyiannis, I, Diamantis, A, Gkrinia, E, Hajiioannou, J, Korais, C, Koukoura, O, Perivoliotis, K, Saratziotis, A, Skoulakis, C, Symeonidis, D, Tepetes, K, Tzovaras, G, Zacharoulis, D (General University Hospital Of Larissa), Alexoudi, V, Antoniades, K, Astreidis, I, Christidis, P, Deligiannidis, D, Grivas, T, Ioannidis, O, Kalaitsidou, I, Loutzidou, L, Mantevas, A, Michailidou, D, Paraskevopoulos, K, Politis, S, Stavroglou, A, Tatsis, D, Tilaveridis, I, Vahtsevanos, K, Venetis, G (George Papanikolaou General Hospital Of Thessaloniki), Karaitianos I, Tsirlis T (Henry Dunant Hospital Center), Charalabopoulos, A, Liakakos, T, Mpaili, E, Schizas, D, Spartalis, E, Syllaios, A, Zografos, C (Laiko University Hospital), Anthoulakis, C, Christou, C, Papadopoulos, V, Tooulias, A, Tsolakidis, D, Tsoulfas, G, Zouzoulas, D (Papageorgiou General Hospital), Athanasakis, E, Chrysos, E, Tsiaousis, J, Xenaki, S, Hong Kong: Futaba K, Xynos E (University Hospital Of Heraklion Crete And Interclinic Hospital Of Crete)., Ho, Mf, Hon, Sf, Mak, Twc, Ng SSM (Prince Of Wales Hospital), Hungary: Banky B, Foo CC (Queen Mary Hospital)., Ireland: Aremu M, Suszt&#225, k N (Szent Borb&#225, la K&#243, rh&#225, z)., Canas-Martinez, A, Cullivan, O, Murphy, C, Owens, P, Pickett, L (Connolly Hospital Blanchardstown), Akmenkalne, L, Byrne, J, Corrigan, M, Cullinane, C, Daly, A, Fleming, C, Jordan, P, Killeen, S, Lynch, N, McCarthy, A, Mustafa, H, Brien, S, Leary, P, Syed, Was, Vernon, L (Cork University Hospital), Callanan, D, Huang, L, Ionescu, A, Sheahan, P (South Infirmary Victoria University Hospital), Balasubramanian, I, Boland, M, Conlon, K, Evoy, D, Fearon, N, Gallagher, T, Geraghty, J, Heneghan, H, Kennedy, N, Maguire, D, McCartan, D, McDermott, Ew, Prichard, Rs, Winter, D (St Vincent&#8217, s University Hospital), Alazawi, D, Barry, C, Boyle, T, Butt, W, Connolly, Em, Donlon, N, Donohue, C, Fahey, Ba, Farrell, R, Fitzgerald, C, Kinsella, J, Larkin, Jo, Lennon, P, Maguire, Pj, Mccormick, P, Mehigan, Bj, Mohan, H, Nugent, T, Sullivan, H, Ravi, N, Reynolds, Jv, Rogers, A, Shokuhi, P, Smith, J, Smith, La, James&#8217, s Hospital), Timon C (St., Bashir, Y, Bass, G, Connelly, T, Earley, H, Elliott, Ja, Gillis, A, Kavanagh, D, Neary, P, riordan, J, Reynolds, Is, Rice, D, Ridgway, P, Umair, M, Whelan, M (Tallaght Hospital), Carroll, P, Collins, C, Corless, K, Finnegan, L, Fowler, A, Hogan, A, Kerin, M, Lowery, A, McAnena, P, McKevitt, K, Nizami, K, Ryan, &#201, Samy, A (University Hospital Galway), Coffey, Jc, Cunningham, R, Devine, M, Nally, D, Peirce, C, Tormey, S (University Hospital Limerick), Hardy, N, Malley, S, Italy: Macina S (Asst Mantua), Ryan M (University Hospital Waterford/University College Cork)., Mariani, Nm, Opocher, E, Pisani Ceretti A (Asst Santi Paolo, E Carlo), Ferrari, F, Odicino, F, Sartori, E (Asst Spedali Civili, Ospedale Di Brescia), Cotsoglou C, Granieri S (Asst Vimercate), Bianco, F, Camillo&#8217, Colledan, M, Tornese, S, Zambelli MF (Asst-Papa Giovanni Xxiii- Bergamo), Bissolotti, G, Fusetti, S, Lemma, F (Azienda Ospedaliera Di Padova), Marino, M, Mirabella, A, Vaccarella, G (Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo), Agostini, C, Alemanno, G, Bartolini, I, Bergamini, C, Bruscino, A, Checcucci, C, De Vincenti, R, Di Bella, A, Fambrini, M, Fortuna, L, Maltinti, G, Muiesan, P, Petraglia, F, Prosperi, P, Ringressi, Mn, Risaliti, M, Sorbi, F, Taddei, A, Tucci, R (Azienda Ospedaliera Universitaria Careggi), Bassi, C, Campagnaro, T, Casetti, L, De Pastena, M, Esposito, A, Fontana, M, Guglielmi, A, Landoni, L, Malleo, G, Marchegiani, G, Nobile, S, Paiella, S, Pedrazzani, C, Rattizzato, S, Ruzzenente, A, Salvia, R, Turri, G, Tuveri, M (Azienda Ospedaliera Universitaria Integrata Di Verona), Bellora, P, Aloisio, G, Ferrari, M, Francone, E, Gentilli, S, Nikaj, H (Azienda Ospedaliero Universitaria Maggiore Della Carit&#224, Bianchini, M, Chiarugi, M, Coccolini, F, Di Franco, G, Furbetta, N, Gianardi, D, Guadagni, S, Morelli, L, Palmeri, M, Tartaglia, D (Azienda Ospedaliero Universitaria Pisana), Anania, G, Carcoforo, P, Chiozza, M, De Troia, A, Koleva Radica, M, Portinari, M, Sibilla, Mg, Urbani, A (Azienda Ospedaliero Universitaria Sant&#8217, anna), Fabbri, N, Feo, Cv, Gennari, S, Parini, S, Righini E (Azienda Unit&#224, Sanitaria Locale di Ferrara, - University of Ferrara), Ampollini, L, Bellanti, L, Bergonzani, M, Bertoli, G, Bocchialini, G, Angelo, G, Lanfranco, D, Musini, L, Poli, T, Santoro, Gp, Varazzani, A (Azienda Ospedaliero-Universitaria Di Parma), Aguzzoli, L, Borgonovo, G, Castro Ruiz, C, Coiro, S, Falco, G, Mandato, Vd, Mastrofilippo, V, Montella, Mt, Annessi, V, Zizzo M (Azienda Unit&#224, Sanitaria Locale, - Irccs Di Reggio Emilia), Grossi, U, Novello, S, Romano, M, Rossi, S, Zanus, G (Ca&#8217, Foncello Treviso-DISCOG-Universit Di Padova), Esposito, G, Frongia, F, Pisanu, A, Podda, M (Cagliari University Hospital), Belluco, C, Lauretta, A, Montori, G, Moras, L, Olivieri, M (Centro Di Riferimento Oncologico Di Aviano (Cro) Irccs), Bussu, F, Carta, Ag, Cossu, Ml, Cottu, P, Fancellu, A, Feo, Cf, Ginesu, Gc, Giuliani, G, Madonia, M, Perra, T, Piras, A, Porcu, A, Rizzo, D, Scanu, Am, Tedde, A, Tedde, M (Cliniche San Pietro, Sassari), A. o. u., Delrio, P, Rega D (Colorectal Surgical Oncology Unit, - Istituto Nazionale Tumori Fondazione, Pascale-I. r. c. c. s., ), Badalamenti, G, Campisi, G, Cordova, A, Franza, M, Maniaci, G, Rinaldi, G, Toia, F (Department Of Surgical, University Of Palermo), Oncological And Oral Sciences., Calabr&#242, M, Farnesi, F, Lunghi, Eg, Muratore, A, Pipitone Federico NS (Edoardo Agnelli), B&#224, mbina, F, Andrea, G, Familiari, P, Picotti, V (Fabrizio Spaziani), De Palma, G, Luglio, G, Pagano, G, Tropeano FP (Federico Ii University Hospital), Baldari, L, Beltramini, Ga, Boni, L, Cassinotti, E, Gianni&#8217, Pignataro, L, Torretta S (Fondazione Irccs Ca&#8217, Granda, - Ospedale Maggiore Policlinico), Abatini, C, Baia, M, Biasoni, D, Bogani, G, Cadenelli, P, Capizzi, V, Cioffi, Spb, Citterio, D, Comini, Lv, Cosimelli, M, Fiore, M, Folli, S, Gennaro, M, Giannini, L, Gronchi, A, Guaglio, M, Macchi, A, Martinelli, F, Mazzaferro, V, Mosca, A, Pasquali, S, Piazza, C, Raspagliesi, F, Rolli, L, Salvioni, R, Sarpietro, G, Sarre, C, Sorrentino, L (Fondazione Irccs Istituto Nazionale Dei Tumori, Milano), Agnes, A, Alfieri, S, Belia, F, Biondi, A, Cozza, V, Amore, A, Ugo, D, De Simone, V, Fagotti, A, Gasparini, G, Gordini, L, Litta, F, Lombardi, Cp, Lorenzon, L, Marra, Aa, Marzi, F, Moro, A, Parello, A, Perrone, E, Persiani, R, Ratto, C, Rosa, F, Saponaro, G, Scambia, G, Scrima, O, Sganga, G, Tudisco, R (Fondazione Policlinico Universitario Agostino Gemelli), Belli, A, Granata, V, Izzo, F, Palaia, R, Patrone R (Hpb Surgical Oncology Unit, - Istituto Nazionale Tumori Fondazione, Pascale- I. r. c. c. s., ), Carrano, Fm, Carvello, Mm, De Virgilio, A, Di Candido, F, Ferreli, F, Gaino, F, Mercante, G, Rossi, V, Spinelli, A, Spriano, G (Humanitas Clinical And Research Center Irccs, Rozzano (Mi) &amp, Humanitas, University, Department Of Biomedical Sciences, Pieve Emanuele (Mi)), Donati, Dm, Frisoni, T, Palmerini, E (Irccs Istituto Ortopedico Rizzoli), Aprile, A, Barra, F, Batistotti, P, Ferrero, S, Fregatti, P, Scabini, S, Sparavigna, M (Irccs Ospedale Policlinico San Martino), Asti, E, Bernardi, D, Bonavina, L, Lovece, A (University of Milan, IRCCS Policlinico San Donato), Adamoli, L, Ansarin, M, Cenciarelli, S, Chu, F, De Berardinis, R, Fumagalli Romario, U, Mastrilli, F, Pietrobon, G, Tagliabue M (Istituto Europeo Di Oncologia, - Irccs -Milano), Badellino, E, Ferrero, A, Massobrio, R (Mauriziano Hospital Torino, Italy), De Manzoni Garberini, A (Ospedale Civile Spirito Santo), Federico, P, Maida, P, Marra, E, Marte, G, Petrillo, A, Tammaro, T, Tufo, A (Ospedale Del Mare), Berselli, M, Borroni, G, Cocozza, E, Conti, L, Desio, M, Livraghi, L, Quintodei, V, Rizzi, A, Zullo A (Ospedale Di Circolo, E Fondazione Macchi (Varese)), Baldi, C, Corbellini, C, Sampietro GM (Ospedale Di Rho, - Asst Rhodense), Cellerino P (Ospedale Fatebenefratelli, E Oftalmico), Baldini, E, Capelli, P, Isolani, Sm, Ribolla, M (Ospedale Guglielmo Da Saliceto Piacenza), Bondurri, A, Colombo, F, Ferrario, L, Guerci, C, Maffioli, A (Ospedale Luigi Sacco Milano), Armao, T, Ballabio, M, Bisagni, P, Gagliano, A, Longhi, M, Madonini, M, Pizzini, P (Ospedale Maggiore Di Lodi), Baietti, Am, Biasini, M, Maremonti, P, Neri, F, Prucher, Gm, Ricci, S, Ruggiero, F, Zarabini AG (Ospedale Maggiore/Bellaria Carlo Alberto Pizzardi Ausl Bologna), Barmasse, R, Mochet, S, Usai, A (Ospedale Regionale Umberto Parini), Leonardo - Asl Napoli 3 Sud, Incollingo P (Ospedale S., Castellammare Di Stabia), Mancini, S, Marino Cosentino, L, Sagnotta, A (Ospedale San Filippo Neri), Fruscio, R, Grassi, T, Nespoli, Lc, Tamini, N (Ospedale San Gerardo), Anastasi, A, Bartalucci, B, Bellacci, A, Canonico, G, Capezzuoli, L, Di Martino, C, Ipponi, P, Linari, C, Montelatici, M, Nelli, T, Spagni, G, Tirloni, L, Vitali, A (Ospedale San Giovanni Di Dio), Abate, E, Casati, M, Casiraghi, T, Laface, L, Schiavo M (Ospedale Vittorio Emanuele Iii, - Carate Brianza), Arminio, A, Cotoia, A, Lizzi, V, Vovola, F (Ospedali Riuniti Azienda Ospedaliera Universitaria Foggia), Vergari, R (Ospedali Riuniti Di Ancona), Ugo, S, Depalma, N, 8220, Vito Fazzi&#8221, Spampinato MG (P. o., Bartolucci, P, Brachini, G, Bruzzaniti, P, Chiappini, A, Chiarella, V, Ciccarone, F, Cicerchia, Pm, Cirillo, B, De Toma, G, Di bartolomeo, A, Fiori, E, Fonsi, Gb, Franco, G, Frati, A, Giugliano, M, Iannone, I, La Torre, F, Lapolla, P, Leonardo, C, Marruzzo, G, Meneghini, S, Mingoli, A, Ribuffo, D, Salvati, M, Santoro, A, Sapienza, P, Scafa, Ak, Simonelli, L, Zambon M (Policlinico Umberto, I Sapienza University Of Rome), Capolupo, Gt, Carannante, F, Caricato, M, Mascian&#224, G, Mazzotta, E (Policlinico Universitario Campus Bio Medico Of Rome), Gattolin, A, Migliore, M, Rimonda, R, Sasia, D, Travaglio, E (Regina Montis Regalis Hospital, Mondov&#236, Cervellera, M, Gori, A, Sartarelli, L, orsola-Malpighi Hospital), Tonini V (S., Giacometti, M, Zonta, S (Ospedale San Biagio, Asl, VCO), Chessa, A, Fiorini, A, Norcini, C (San Giovanni Di Dio), Colletti, G, Confalonieri, M, Costanzi, A, Frattaruolo, C, Mari, G, Monteleone, M (San Leopoldo Mandic), Bandiera, A, Bocciolone, L, Bonavina, G, Candiani, M, De Nardi, P, Gagliardi, F, Medone, M, Mortini, P, Negri, G, Ottolina, J, Parise, P, Piloni, M, Sileri, P, Vignali, A (San Raffaele Scientific Institute, Milan), Belvedere, A, Bernante, P, Bertoglio, P, Boussedra, S, Brunocilla, E, Cipriani, R, Cisternino, G, De Crescenzo, E, De Iaco, P, Dondi, G, Frio, F, Jovine, E, Mineo Bianchi, F, Neri, J, Parlanti, D, Perrone, Am, Pezzuto, Ap, Pignatti, M, Pinto, V, Poggioli, G, Ravaioli, M, Rottoli, M, Schiavina, R, Serenari, M, Serra, M, Solli, P, Taffurelli, M, Tanzanu, M, Tesei, M, Violante, T, Zanotti, S (Sant&#8217, orsola Hospital, Alma Mater Studiorum University Of Bologna, Borghi, F, Cianflocca, D, Di Maria Grimaldi, S, Donati, D, Gelarda, E, Geretto, P, Giraudo, G, Giuffrida, Mc, Marano, A, Palagi, S, Pellegrino, L, Peluso, C, Testa V (Santa Croce, E Carle Hospital, Cuneo), Agresta, F, Prando, D, Zese M (Santa Maria Degli Angeli Hospital Ulss5, - Adria), Aquila, F, Gambacciani, C, Lippa, L, Pieri, F, Santonocito OS (Spedali Riuniti Di Livorno), Armatura, G, Bertelli, G, Frena, A, Marinello, P, Notte, F, Patauner, S, Moritz Hospital), Scotton G (St., Fulginiti, Sf, Gallo, G, Sammarco, G, Vescio, G (University &#8216, Magna Graecia&#8217, Of Catanzaro), Balercia, P, Catarzi, L, Consorti G (University Hospital Umberto, I Ancona), Di Marzo, F (Valtiberina), Japan: Daiko H, Fontana T (Vittorio Emanuele)., Ishikawa, M, Ishiyama, K, Iwata, S, Kanematsu, K, Kanemitsu, Y, Kato, T, Kawai, A, Kobayashi, E, Kobayashi Kato, M, Moritani, K, Nakatani, F, Oguma, J, Tanase, Y, Jordan: Al Abdallah M, Uno M (National Cancer Center Hospital)., Ayasra, F, Ayasra, Y, Qasem, A (Al-Basheer Hospital), Abu Za&#8217, nouneh FJ, Fahmawee, T, Hmedat, A, Ibrahim, A, Obeidat, K (King Abdullah University Hospital), Abdel Al, S, Abdel Jalil, R, Abou Chaar MK, Al-Masri, M, Al-Najjar, H, Alawneh, F, Alsaraireh, O, Elayyan, M, Ghanem, R, Libya: Alkadeeki G (Al-Jalaa Hospital), Lataifeh I (King Hussein Cancer Center)., Aldokali, N, Senossi, O, Subhi MT (Alkhadra Hospital), Burgan, D, Kamoka, E, Kilani, Ai, Salamah, A, Salem, M, Shuwayyah, A (National Cancer Institute, Sabratha, - Libya), Abdulwahed, E, Alshareea, E, Aribi, N, Aribi, S, Biala, M, Ghamgh, R, Morgom, M (Tripoli Central Hospital), Aldayri, Z, Ellojli, I, Lithuania: Bradulskis S, Kredan A (Tripoli University Hospital)., Dainius, E, Kubiliute, E, Kutkevi&#269, ius, J, Parseliunas, A, Subocius, A, Madagascar: Rasoaherinomenjanahary F, Venskutonis D (Lithuanian University Of Health Sciences Kaunas Clinical Hospital)., Razafindrahita, Jb, Malaysia: Ong EC (Bintulu), Samison LH (Joseph Ravoahangy Andrianavalona Hospital)., Hamdan, Kh, Ibrahim, Mr, Tan, Ja, Thanapal MR (Hospital Kuala Lumpur), Amin Sahid, N, Hayati, F, Jayasilan, J, Sriram, Rk, Subramaniam, S (Queen Elizabeth Hospital &amp, Universiti Malaysia Sabah, Kota, Kinabalu, Sabah, Malaysia), Che Jusoh, A, Hussain, Ah, Mohamed Sidek AS, Mohd Yunus MF, Soh, Jy, Wong, Mpk, Zakaria, Ad, Zakaria, Z (School Of Medical Sciences &amp, Hospital, Universiti Sains Malaysia), Fadzli, A, Fathi, Nq, Koh, Ps, Liew, Yt, Roslani, Ac, Tang, Cy, Teoh, Ly, Wong, Wj, Mexico: Alvarez MR, Yahaya AS (University Malaya Medical Centre)., Arrangoiz, R, Cordera, F, De la Rosa Abaroa MA, G&#243, mez-Pedraza, A, Hernandez, R, Maffuz-Aziz, A, Posada JA (Abc Medical Center), Becerra Garc&#237, a FC (Hospital San &#193, ngel Inn Chapultepec), Alfaro-Goldaracena, A, Buerba, Ga, Castillejos- Molina RA, Chan, C, Dominguez-Rosado, I, Medina-Franco, H, Mercado, M&#225, Oropeza- Aguilar, M, Pe&#241, a G&#243, mez Portugal, E, Posadas-Trujillo, Oe, Rodriguez-Covarrubias, F, Salgado-Nesme, N, Morocco: Arkha Y, Vilatoba M (Instituto Nacional De Ciencias M&#233, dicas Y Nutrici&#243, n &#8220, Salvador Zubir&#225, n&#8221, Bechri, H, El Ouahabi, A, Oudrhiri MY (Centre Hospitalier Universitaire Ibn Sina Rabat), Derkaoui hassani F, El abbadi N (Cheikh Zaid International University Hospital), Amrani, L, Belkhadir, Zh, Benkabbou, A, Chakib, O, El Ahmadi, B, El Bouazizi, Y, Essangri, H, Ghannam, A, Majbar, Am, Mohsine, R, Netherlands: Hompes R, Souadka A (Institut National D&#8217, oncologie)., Meima-van Praag, E, Pronk, Ajm, Sharabiany, S (Amsterdam Umc, University Of Amsterdam), Grotenhuis, B, Hartveld, L, Reijers, S, Van Houdt, W (Antoni Van Leeuwenhoek Ziekenhuis), Baaij, J, Bolster-van Eenennaam, M, De Graaff, M, Sloothaak, D, Van Duijvendijk, P (Gelre Ziekenhuis), Posma-Bouman, L (Slingeland Ziekenhuis), Derksen, T, Franken, J, Oosterling, S (Spaarne Gasthuis), De Bree, R (University Medical Center Utrecht), Konsten, J, Nigeria: Fidelis L, Van Heinsbergen M (Viecuri Medisch Centrum)., Sholadoye, Tt, Tolani, M (Ahmadu Bello University Teaching Hospital), Olaogun, J (Ekiti State University Teaching Hospital), Egbuchulem, Ik, Lawal, Ta, Ogundoyin, O, Olulana DI (University College Hospital), Abdur-Rahman, L, Adeyeye, A, Aremu, I, Bello, J, Olasehinde, O, Oman: Massoud J, Popoola A (University Of Ilorin Teaching Hospital)., Massoud, R, Pakistan: Jamal A, Sorour TM (Khoula Hospital)., Kerawala AA (Cancer Foundation Hospital), Memon, As, Nafees Ahmed, R, Pfau Civil Hospital), Rai L (Dr Ruth K. m., Ayub, B, Hassan, N, Martins, Rs, Ramesh, P, Sayyed, R (Patel Hospital), Butt, U, Kashif, M, Khan, Wh, Qureshi, A, Umar, M, Waris Farooka, M, Wasim, T (Services Hospital Lahore), Ayubi, A, Rashid, I, Peru: Falcon GM, Waqar SH (The Pakistan Institute Of Medical Sciences)., Philippines: Jocson R, Robles R (Instituto Regional De Enfermedades Neopl&#225, sicas Del Sur)., Teh, C (National Kidney &amp, Poland: Major P (Jagiellonian University Medical College), Transplant Institute)., Bobi&#324, ski, M, Kotarski, J, Rasoul-Peli&#324, ska, K (Medical University Of Lublin, Portugal: Azevedo C, Chair And Department Of Gynaecological Oncology And Gynaecology)., Machado, D, Mendes, F (Centro Hospitalar Cova Da Beira), De Sousa, X (Centro Hospitalar De Set&#250, bal), Fernandes, U, Ferreira, C, Guidi, G, Leal, C, Mar&#231, al, A, Marques, R, Martins, D, Melo, A, Tenreiro, N, Vaz Pereira, R, Vieira B (Centro Hospitalar De Tr&#225, s-Os-Montes, E Alto Douro, E. p. e., ), Almeida, Ji, Correia de S&#225, T, Costa, Mjma, Fernandes, V, Ferraz, I, Gil, Cg, Lima da Silva, C, Lopes, L, Machado, N, Marialva, J, Nunes Coelho, M, Pedro, J, Pereira, C, Reis, R, Ribeiro, A, Santos, R, Saraiva, P, Silva, R, Tavares, F, Teixeira M (Centro Hospitalar Do Tamega, E Sousa), Almeida, Ac, Amaral, Mj, Andrade, R, Athayde Nem&#233, sio, R, Breda, D, Camacho, C, Canhoto, C, Colino, M, Correia, S, Costa, M, De Barros, J, De Oliveira L&#243, pez AL, Duque, M, Garrido, S, Guerreiro, P, Guimar&#227, es, A, L&#225, zaro, A, Lopes, C, Martins, R, Nogueira, O, Oliveira, A, Oliveira, Jm, Rodrigues, M, Ruivo, A, Santos, E, Silva, M, Sim&#245, es, J, Valente da Costa A (Centro Hospitalar, E Universit&#225, rio De Coimbra), Almeida, A, Cavaleiro, S, Devezas, V, Faria, Cs, J&#225, come, F, Magalh&#227, es Maia, M, Nogueiro, J, Pereira, A, Pereira-Neves, A, Pina-Vaz, T, Santos-Sousa, H, Silveira, H, Vaz, S, Vieira P (Centro Hospitalar, E Universit&#225, rio De S&#227, o Jo&#227, Gomes da Costa A, Lobo Antunes I (Centro Hospitalar Lisboa Norte), Pinto J, Tojal A (Centro Hospitalar Tondela-Viseu), Cardoso, N, Cardoso, P, Domingues, Jc, Henriques, P, Manso, Mi, Martins dos Santos, G, Morais, H, Pereira, R, Revez, T, Ribeiro, R, Ribeiro, Vi, Soares, A, Sousa, S, Teixeira J (Centro Hospitalar Universit&#225, rio Do Algarve, - Unidade De Faro), Amorim, E, Baptista, Vh, Cunha, Mf, Dias, B, Fazenda, A, Melo Neves JP, Policarpo, F, Sampaio da N&#243, voa Gomes Miguel II, Veiga D (Centro Hospitalar Universitario Do Algarve, - Unidade De Portim&#227, Andrade, Ak, Bandovas, Jp, Borges, N, Branquinho, A, Chumbinho, B, Correia, J, Fidalgo, H, Figueiredo de Barros, I, Frade, S, Gomes, J, Maciel, J, Pina, S, Rodrigues, A, Silva, N, Silveira Nunes, I, Sousa, R (Centro Hospitalar Universit&#225, rio Lisboa Central), Ascens&#227, o, J, Azevedo, P, Costeira, B, Cunha, C, Garrido, R, Gomes, H, Louren&#231, o, I, Mendinhos, G, Miranda, P, Nobre Pinto, A, Peralta Ferreira, M, Ribeiro, J, Rio Rodrigues, L, Sousa Fernandes, M (Hospital Beatriz Angelo), Azevedo J (Hospital Da Horta, E. p. e. ), Galv&#227, o, D, Soares, Ac, Vieira, A, Vieira, B (Hospital De Santo Espirito Da Ilha Terceira), Patr&#237, cio, B, Santos, Pmdd, Vieira Paiva Lopes AC (Hospital De Torres Vedras, - Centro Hospitalar Do Oeste), Cunha, R, Faustino, A, Freitas, A, Martins, Ab, Mendes, Jr, Parreira, R, Rosa, J, Teves, M (Hospital Do Divino Esp&#237, rito Santo), Abreu da Silva, A, Claro, M, Costa Santos, D, Deus, Ac, Grilo JV (Hospital Do Litoral Alentejano), Borges, F, Corte Real, J, Henriques, S, Lima, Mj, Matos Costa, P (Hospital Garcia De Orta), Brito da Silva, F, Caiado, A, Fonseca, F (Instituto Portugu&#234, s De Oncologia De Lisboa Francisco Gentil), 194, ngelo, M, Baiao, Jm, Martins Jord&#227, Vieira Caro&#231, o, T (Ipo Coimbra), Messias, J, Millan, A, Salgado, I, Santos, P (Ipo Lisboa), Ba&#237, a, C, Canotilho, R, Correia, Am, Ferreira Pinto AP, Peyroteo, M, Puerto Rico: Escobar P, Videira JF (Ipo Porto)., R&#233, union: Kassir R, Maldonado Santiago M (Instituto Gineco Oncologico)., Romania: Bezede C, Sauvat F (Chu Reunion)., Chitul, A, Ciofic, E, Cristian, D, Grama, F (Coltea Clinical Hospital), Pirtea L, Secosan C (Emergency Clinical City Hospital), Bonci, E, Gata, V, Ion Chiricuta Institute Of Oncology), Titu S (Prof. Dr., Ginghina, O, Iordache, N, Russia: Garmanova T, Iosifescu RV (Saint John Emergency Hospital)., Kazachenko, E, Markaryan, D, Rodimov, S, Tsarkov, P, Tulina, I (Clinic Of Coloproctology And Minimally Invasive Surgery, Sechenov Medical State University), Litvina, Y, Provozina, A (Immanuel Kant Baltic Federal University, Regional Clinical Hospital), Agapov, M, Galliamov, E, Kakotkin, V, Kubyshkin, V, 1050, 1072, 1084, 1083, 1086, 1074, &#1040, (Moscow Research And Educational Center, Saudi Arabia: Alshahrani M, Lomonosov Moscow State University)., Alsharif, F, Eskander, M (Aseer Central Hospital), Al Raddadi, R, Majrashi, S, Mashat, A (East Jeddah General Hospital), Akeel, N, Alharthi, M, Aljiffry, M, Basendowah, M, Farsi, A, Ghunaim, M, Khoja, A, Maghrabi, A, Malibary, N, Nassif, M, Nawawi, A, Saleem, A, Samkari, A, Trabulsi, N (King Abdulaziz University Hospital), Al Awwad, S, Alghamdi, M, Alnumani, T, Nasser, M, Said bayazeed, A (King Fahad General Hospital), Alhefdhi, A, Almalik, O, Alomair, A, Alotaibi, N, Alresaini, F, Alsalamah, R, Alsobhi, S, Mahasin, Z, Othman, E, Velagapudi, S (King Faisal Specialist Hospital), Al Habes, H, Alamri, A, Alkarak, S, Alqannas, M, Alyami, M, Alzamanan, M, Cort&#233, s Guiral, D, Elawad, A (King Khalid Hospital), AlAamer, O, Alriyees, L, Alselaim, N (King Saud Bin Abdulaziz University For Health Sciences, King Abdullah International Medical Research Center, Ministry Of National Guard, Health, Affairs, General Surgery Department., ), Abdulkareem, A, Ajlan, A, Akkour, K, Al-Habib, A, Al-Khayal, K, Alatar, A, Alburakan, A, Alhalal, H, Alhassan, B, Alhassan, N, Alobeed, O, Alsaif, A, Alsaif, F, Alshammari, S, Alshaygy, I, Barry, M, Bin Nasser, A, Bin Traiki, T, Bokhari, A, Elwatidy, S, Helmi, H, Madkhali, A, Nouh, T, Rabah, Pd, Serbia: Paunovic I, Zubaidi A (King Saud University)., Slijepcevic, N (Centre For Endocrine Surgery, Clinical Centre Of Serbia), Aleksi&#263, L, Antic, A, Barisic, G, Ceranic, M, Galun, D, Gruba&#269, &#381, Jelenkovic, J, Kecmanovi&#263, Kmezi&#263, Knezevic, D, Krivokapic, Z, Latin&#269, Markovic, V, Mati&#263, Miladinov, M, Pavlov, M, Pejovic, I, Radenkovic, D, Tadic, B, Vasljevi&#263, J, Velickovic, D, Zivanovic, M (Clinic For Digestive Surgery, Perovic M, Srbinovic L (Clinic For Gynecology And Obstetrics Narodni Front), Andrijasevic, S, Bozanovic, T, Cerovic Popovic, R, Dokic, M, Janjic, T, Jeremic, K, Kadija, S, Ladjevic Likic, I, Mirkovic, L, Pantovic, S, Pilic, I, Radojevic, M, Stefanovic, A, Vidakovic, S, Vilendecic, Z (Clinic For Gynecology And Obstetrics, Clinical Center Of Serbia), Antic, S, Dun&#273, erovi&#263, Jelovac, D, Jezdic, Z, Konstantinovic, V, Kotlar, B, Kuzmanovic, C, Lazi&#263, Petrovic, M, Popovic, F, Pucar, A, Romic, M, Sumrak, S, Vujanac, V (Clinic For Maxillofacial Surgery, School Of Dental Medicine, University Of Belgrade), Bascarevic, V, Bogdanovi&#263, I, Gruji&#269, Ilic, R, Mili&#263, evi&#263, Milisavljevi&#263, F, Miljkovi&#263, Paunovic, A, 352, 263, epanovi&#263, V, Stanimirovic, A, Todorovic, M (Clinic For Neurosurgery, Jotic, A, Milovanovic, J, Trivic, A (Clinic For Otorhinolaryngology And Maxillofacial Surgery, Bumbasirevic, U, Dzamic, Z, Kajmakovi&#263, B, Prijovi&#263, N, Zivkovic, M (Clinic Of Urology, Buta, M, Cvetkovic, A, Djurisic, I, Gacic, S, Goran, M, Inic, Z, Jeftic, N, Jevric, M, Jokic, V, Markovic, I, Milanovi&#263, Nikolic, S, Pejnovic, L, Savkovi&#263, Spurnic, I, Stevic, D, Stojiljkovic, D, Vucic, N, Zegarac, M (Institute For Oncology And Radiology Of Serbia), Karamarkovic, A, Kenic, M, Kovacevic, B, Krdzic, I, Singapore: Chan CW, Milutinovi&#263, V (Zvezdara University Medical Center)., Slovakia: G&#225, lis B, Lieske B (National University Hospital)., South Africa: Almgla N, &#352, imko K (University Hospital Bratislava)., Bernon, M, Boutall, A, Cairncross, L, Herman, A, Hilton, T, Jonas, E, Kloppers, C, Malherbe, F, Mugla, W, Nel, D, Rayamajhi, S, Van Wyngaard, T, Spain: Casta&#241, o-Leon AM, Vogel J (Groote Schuur Hospital)., Delgado Fernandez, J, Eiriz Fernandez, C, Espino Segura-Illa, M, Esteban Sinovas, O, Garcia Perez, D, Gomez, P, Jimenez-Roldan, L, Lagares, A, Moreno- Gomez, L, Paredes, I, P&#233, rez N&#250, 241, ez, A, S&#225, nchez Aniceto, G, Santas, M (12 De Octubre University Hospital), Fern&#225, ndez Rodr&#237, guez, P, Paniagua Garc&#237, a Se&#241, orans, M, Sanchez- Santos, R, Vigorita, V (&#193, lvaro Cunqueiro Hospital), Acrich, E, Baena Sanfeliu, E, Barrios, O, Golda, T, Santanach, C, Serrano-Navidad, M, Sorribas Grifell, M, Vives RV (Bellvitge University Hospital), Escol&#224, D, Jim&#233, nez A (Comarcal Alt Pened&#233, Cayetano Paniagua L, G&#243, mez Fern&#225, ndez L (Consorci Sanitari De Terrassa), Artigues, E, Bernal-Sprekelsen, Jc, Catal&#225, Bauset JC (Consorcio Hospital General Universitario), Collera, P, Diaz Del Gobbo, R, Farre Font, R, Flores Clotet, R, mez D&#237, az CJ, Gu&#224, rdia, N, Guariglia, Ca, Osorio, A, Sanchez Jimenez, R, Sanchon, L, Soto Montesinos C (Fundaci&#243, Althaia, - Xarxa Assistencial Universit&#224, ria De Manresa), Albi Martin B, Garc&#237, a Villayz&#225, n JE (Fundaci&#243, n Jimenez Diaz University Hospital), Alonso-Lamberti, L, Assaf, M, Baeza Pintado, N, Carabias, A, a-Quijada, J, Huertas Fernandez MA, Jimenez Miram&#243, n, J, Jimenez, V, Jover, Jm, Landeo Ag&#252, ero SA, Leon, R, Mart&#237, n Salamanca MB, rez Sim&#243, n, V, Ponce, S, Rodriguez, Jl, Salazar, A, Valle Rubio, A (Getafe University Hospital), Aguado, H (Hell&#237, n Hospital), Aldecoa Ansorregui, I, Bravo Infante, R, De Lacy FB, Di Somma, A, D&#237, az-Feijoo, B, Ense&#241, at Nora, J, Fabregas, N, Ferr&#233, s, A, Gil Iba&#241, ez, B, Gonzalez Sanchez JJ, Gracia, I, Hoyos Castro JA, Lacy, Am, Langdon, C, Mombl&#225, n, D, Morales, X, Oleaga, L, Otero, A, Pedrosa, L, Poblete Carrizo, J, Reyes Figueroa LA, Roldan Ramos, P, Rumia-Arboix, J, Tercero-Uribe, Ai, Topczewski, Te, Torales, J, Torne, A, Torn&#233, R, Turrado-Rodriguez, V, Valero, R, Valverde, S (Hospital Clinic Barcelona), Anula, R, Cano-Valderrama, O, Del Campo Mart&#237, n, M, ez-Valladares, L, Dom&#237, nguez, I, Dziakova, J, a Alonso, M, a Romero, E, mez Latorre, L, Muguerza, Jm, Pizarro, Mj, Saez Carlin, P, nchez del Pueblo, C, nchez-Pernaute, A, Sanz Ortega, G, Sanz-Lopez, R, Torres, A (Hospital Cl&#237, nico De Madrid), Garc&#233, s-Albir, M, Lopez, F, n-Ar&#233, valo, J, Moro-Valdezate, D, Pla-Marti, V (Hospital Cl&#237, nico Universitario De Valencia), Beltr&#225, n de Heredia, J, De Andr&#233, s Asenjo, B, mez Sanz, T, Jezieniecki, C, Nu&#241, ez Del Barrio, H, Ortiz de Sol&#243, rzano Aurusa FJ, Romero de Diego, A, Ruiz Soriano, M, Trujillo D&#237, az, J, Vazquez fernandez, A (Hospital Cl&#237, nico Universitario De Valladolid), Lora-Cumplido P, Sosa MV (Hospital De Cabue&#241, es), Gonzalez-Gonzalez E, Minaya Bravo AM (Hospital Del Henares), Alonso de la Fuente, N, Cazador Labat, M, Cecchini, L, Espinosa, Ca, Jimenez Toscano, M, L&#243, pez Campillo, A, Mancebo, G, Martorell, P, Munarriz, M (Hospital Del Mar), Grau-Talens EJ, Martin-Perez B (Hospital Don Benito-Villanueva), Benavides Buleje JA, Carrasco Prats, M, ndez, Pv, ndez-L&#243, pez, A, a Escudero, D, a Porcel VJ, Garcia Soria, V, Gim&#233, nez Franc&#233, s, C, Gonz&#225, lez Valverde FM, Gurrea, E, pez-Morales, P, Marco Garrido, A, nez Alonso JA, Medina, E, Mu&#241, oz Camarena JM, Parra Ba&#241, os PA, a Ros, E, Ramirez Faraco, M, Ruiz-Mar&#237, Sanchez Rodriguez, C, Valero Soriano, M (Hospital General Reina Sof&#237, Estaire G&#243, mez, M, ndez Camu&#241, as, &#193, Garcia Santos EP, Jimenez Higuera, E, nez-Pinedo, C, oz-Atienza, V, Padilla-Valverde, D, Pic&#243, n Rodr&#237, guez, R, Redondo Calvo FJ, nchez-Garc&#237, a, S, Sanchez-Pelaez, D (Hospital General Universitario De Ciudad Real), Colombari, Rc, Del valle, E, ndez, M, Lozano Lominchar, P, n, L, Rey Valcarcel, C, Steiner, Ma, Tudela, M, Zorrilla Ort&#250, zar, J (Hospital General Universitario Gregorio Mara&#241, 243, Alcaide Matas, F, a P&#233, rez JM, Troncoso Pereira, P (Hospital Mateu Orfila), Mora-Guzm&#225, n, I (Hospital Santa B&#225, rbara), Abell&#225, Achalandabaso Boira, M, Jorba, R, Memba Ikuga, R, Olona, C, Sales Mallafr&#233, R (Hospital Universitari De Tarragona Joan Xxiii), Cavall&#233, Busquets, P, Gavalda Pellice MGP, Salinas Pe&#241, a, J (Hospital Universitari Sant Joan), Aragon Achig EJ, Barbier, L, Caja Vivancos, P, Gainza, A, a Gutierrez JJ, Mallabiabarrena Ormaechea, G, Mar&#237, n, H, Martin Playa, P, Melchor Corc&#243, stegui, I, Prieto Calvo, M, Rodriguez Fraga, A, Villalabeitia Ateca, I (Hospital Universitario Cruces), De Andres Olabarria, U, Dur&#225, n Ballesteros, M, ndez Pablos FJ, Ib&#225, ez-Aguirre, Fj, Sanz Larrainzar, A, Ugarte-Sierra, B (Hospital Universitario De Galdakao), De la Hoz Rodr&#237, guez, &#193, Di Martino, M, a Septiem, J, Martin-Perez, E, oz de Nova JL (Hospital Universitario De La Princesa), Calvo Espino P, Guillamot Ruano P (Hospital Universitario De M&#243, stoles), Colao Garc&#237, a, L, az P&#233, rez, D, Esteban Agust&#237, E, Galindo Jara, P, Gutierrez Samaniego, M, Hernandez Bartolome MA, Serrano Gonz&#225, lez, J (Hospital Universitario De Torrej&#243, n De Ardoz), Alonso Poza, A, Di&#233, guez, B, a-Conde, M, Hern&#225, ndez-Garc&#237, a, M, Losada, M (Hospital Universitario Del Sureste), Chiesa-Estomba, Cm, lez Garc&#237, a J&#193, Larruscain, E, Sistiaga-Su&#225, rez JA (Hospital Universitario Donostia), Alvarez, E, Chavarrias, N, Fr&#237, as, L, a Pineda, V, Geg&#250, ndez Sim&#243, n, A, Gort&#225, zar, S, Gracia, M, Guevara, J, ndez Gutierrez, A, Loayza, A, a Dolores DT, C, Melendez, M, Moreno-Palacios, E, Perez, Y, Prieto Nieto MI, Ramos- Mart&#237, n, P, Rubio-Perez, I, Saavedra, J, Sanchez-Mendez, Ji, Siegrist Ridruejo, J, Urbieta, A, Zapardiel, I (Hospital Universitario La Paz), Cantalejo diaz, M, De Miguel Ardevines MDC, Duque-Mall&#233, Gascon Ferrer, I, lez-Nicol&#225, s Tr&#233, bol MT, Gracia-Roche, C, Herrero Lopez, M, Jariod Ferrer UM, Lanzon, A, Martinez German, A, Matute, M, Redondo, C, nchez Fuentes, N, nchez-Rubio, M, Santero-Ramirez, Ms, Saud&#237, Sim&#243, n Sanz MV, Uson-Bouthelier, T (Hospital Universitario Miguel Servet), Blazquez Martin, A, Diez Alonso, M, a Rico, E, Garcia-Loarte Gomez, E, Garcia-Moreno Nisa, F, Gutierrez Calvo, A, Hernandez, P, Lasa, I, Mendoza-Moreno, F, Morales Palacios, N, Ovejero Merino, E, Vera Mansilla, C (Hospital Universitario Principe De Asturias), Acebes Garc&#237, a, F, Bail&#243, Bueno Ca&#241, ones AD, Choolani Bhojwani, E, Marcos-Santos, P, Miguel, T, Pacheco S&#225, nchez, D, rez-Saborido, B, Sanchez Gonzalez, J, Tejero-Pintor FJ (Hospital Universitario R&#237, o Hortega), Alconchel, F, Conesa, A, Gil Mart&#237, nez, J, Guti&#233, rrez Fern&#225, ndez AI, Lopez Abad, A, Nicol&#225, s-L&#243, pez, T, Ramirez Romero, P, Roca Calvo MJ, Rodrigues, K, Ruiz Manzanera JJ, Soriano AI (Hospital Universitario Virgen De La Arrixaca), Cano, A, Capitan-Morales, L, Cintas Catena, J, Gomez-Rosado, J, Oliva Mompean, F, rez S&#225, nchez MA, R&#237, o Lafuente FD, Torres Arcos, C, Valdes-Hernandez, J (Hospital Universitario Virgen Macarena), Cholewa, H, Domingo, S, Frasson, M, Lago, V, Marina Martin, T, nez Chicote, C, Sancho-Muriel J (Hospital Universitario, Y Polit&#233, cnico La Fe), Landaluce-olavarria A, Lecumberri D (Hospital Urduliz), Abad Gurumeta, A, Abad-Motos, A, nez-Hurtado, E, Ripoll&#233, s-Melchor, J, Ruiz Escobar, A (Infanta Leonor University Hospital), Cuadrado- Garc&#237, a, A, Garcia-Sancho Tellez, L, Heras Aznar, J, Mat&#233, P, Ortega V&#225, zquez, I, Picardo, Al, Rojo L&#243, pez JA, Sanchez Cabezudo Noguera, F, Serralta de Colsa, D (Infanta Sof&#237, a University Hospital), Anchuelo Latorre, J, Cagigas Fernandez, C, Cai&#241, a Ruiz, R, Gomez Ruiz, M, Hernanz, F, Jimeno Fraile, J, nez-P&#233, rez, P, Poch, C, Santarrufina Martinez, S, Valbuena Jabares, V (Marqu&#233, s De Valdecilla University Hospital), Moliner-S&#225, nchez, C, Pingarron-Martin, L, Rey-Biel, J, Ruiz Martin, I (Rey Juan Carlos University Hospital), Blas Laina JL, Cros, B, Escartin, J, Garcia Egea, J, Nogu&#233, Talal El-Abur, I, Y&#225, nez, C (Royo Villanova), Cagigal Ortega EP, Cervera, I, az Pe&#241, a, P, Elena, Gdcr, Enjuto, D, ndez Bernab&#233, s Garc&#237, a, R, Gonzalez, J, ndez, I, Herrera-Merino, N, Marqueta De Salas, M, Martinez Pascual, P, Perez Gonzalez, M, Ramos Bonilla, A, Rodr&#237, guez G&#243, mez, L (Severo Ochoa University Hospital), Besc&#243, Blanco-Colino, R, Brana, I, Caimari, B, De Pablo Garc&#237, a-Cuenca, A, Duran-Valles, F, Espin-Basany, E, Giralt L&#243, pez de Sagredo, J, Pamias, J, Pellino, G, Prat, N, Pujol Pina, R, Sri Lanka: Arulanantham A, Saez barba M (Vall D&#8217, hebron University Hospital)., Bandara, Gbk, Jayarajah, U, Ravindrakumar, S, Rodrigo VS (District General Hospital Chilaw), Srishankar S (Teaching Hospital Anuradhapura). Sudan: Ali karar AA (Al-Rajhi). Sweden: Elbe P, Lindqvist EK (Karolinska University Hospital), Taflin, H (Sahlgrenska University Hospital), 196, lg&#229, Heinius, G, Nordberg, M, Pieniowski, E (South General Hospital), Gkekas, I, fgren, N, Ruteg&#229, rd, M, Switzerland: Arigoni M, Sund M (Umea University Hospital)., Bernasconi, M, Christoforidis, D, Di Giuseppe, M, La Regina, D, Mongelli, F (Ente Ospedaliero Cantonale), Chevallay, M, Dwidar, O, Gialamas, E, Sauvain, M (Hopital De Pourtales), Klenke, F, Koll&#224, r, A, Kurze, C (Inselspital, Bern University Hospital, University Of Bern), Adamina, M, B&#228, chler, T, Crugnale, As, Giardini, M, Guglielmetti, L, Peros, G, Turkey: Aghayeva A, Solimene F (Kantonsspital Winterthur)., Hamzaoglu, I, Sahin, I (Acibadem Altunizade Hospital), Akaydin, E, Aliyeva, Z, Aytac, E, Baca, B, D&#252, lgero&#287, lu, O, Ozben, V, Ozmen, Bb, Uras, C (Acibadem Atakent Hospital), Arikan, Ae, Bilgin, Ia, Bozk&#305, rl&#305, Ceyhan, Go, Kara, H, Karahasano&#287, lu, T, Uras, C (Acibadem Maslak Hospital), Celik, H (Adana Baskent University), Meydanli MM (Ankara City Hospital), Akilli, H, Ayhan, A, Kuscu, E (Baskent University), Onan MA (Gazi University Medical Faculty Hospital), Akgor, U, Dincer, Ha, Erol, T, Gultekin, M, Orhan, N, Ozgul, N, Salman, Mc, Soyak, B (Hacettepe University Hospital), Alhamed, A, Erg&#252, n, S, OZcel&#305, k, Mf, Sanli, An, Uluda&#287, Velidedeoglu, M, Zengin AK (Istanbul Universty, - Cerrahpa&#351, a Medical Faculty), Bozkurt, Ma, Kara, Y, Kocata&#351, A (Kanuni Sultan Suleyman Training And Research Hospital), Cimenoglu, B, Demirhan, R, Lutfi Kirdar Training And Research Hospital), Saracoglu K (Kartal Dr., Azamat, I&#775, f, Balik, E, Bu&#287, ra, D, Giray, B, Kulle, Cb, Taskiran, C, Vatansever, D (Ko&#231, University Medical School), G&#246, zal, K, G&#252, ler, Sa, ken, H, Tatar, Oc, Utkan, Nz, Y&#305, ld&#305, r&#305, m, A, Y&#252, ksel, E (Kocaeli University Teaching Hospital), Akin, E, Altintoprak, F, Bayhan, Z, Cakmak, G, 199, apo&#287, lu, R, elebi, F, Demir, H, Dikicier, E, Firat, N, n&#252, ll&#252, Kamburo&#287, lu, Mb, Kocer, B, 231, 252, k, If, Mantoglu, B (Sakarya University Faculty Of Medicine), olak, E, Kucuk, Go, Uyanik MS (Samsun Training And Research Hospital), 304, lhan Varank Training And Research Hospital), G&#246, ksoy B (Sehit Prof. dr., Bozkurt, E, Citgez, B, Mihmanli, M, Tanal, M, Yetkin, G (Sisli Hamidiye Etfal Training And Research Hospital), Akalin, M, Arican, C, Avci, Ek, Aydin, C, Demirli At&#305, c&#305, Emiroglu, M, Kaya, T, Kebab&#231, 305, Kilinc, G, Kirmizi, Y, 287, c&#252, H, Salimo&#287, lu, S, Sert, I&#775, Tugmen, C, Tuncer, K, Uslu, G, Ye&#351, ilyurt, D (University Of Health Sciences Tepecik Training And Research Hospital), Karaman, E, Kolusar&#305, A (Van Yuzuncu Yil University, Medical, Faculty), Uganda: Benson O, Yildiz A (Yildirim Beyazit University Yenimahalle Training And Research Hospital)., United Kingdom: Agilinko J, Lule H (Kampala International University Teaching Hospital)., Ahmeidat, A, Barabasz, M, Bekheit, M, Cheung, Lk, Colloc, T, Cymes, W, Elhusseini, M, Gradinariu, G, Hannah, A, Kamera, Bs, Mignot, G, Shaikh, S, Sharma, P (Aberdeen Royal Infirmary), Abu-Nayla, I, Agrawal, A, Al-Mohammad, A, Ali, S, Ashcroft, J, Azizi, A, Baker, O, Balakrishnan, A, Byrne, M, Colquhoun, A, Cotter, A, Coughlin, P, Davies, Rj, Durrani, A, Elshaer, M, Fordington, S, Forouhi, P, Georgiades, F, Grimes, H, Habeeb, A, Hudson, V, Hutchinson, P, Irune, E, Jah, A, Khan, Dz, Kolias, A, Kyriacou, H, Lamb, B, Liau, S, Luke, L, Mahmoud, R, Mannion, R, Masterson, L, Mitrofan, Cg, Mohan, M, Morris, A, Murphy, S, Neill, R, Price, S, Pushpa-rajah, J, Raby-Smith, W, Ramzi, J, Rooney, S, Santarius, T, Singh, A, Stewart, Gd, Tan, Xs, Townson, A, Tweedle, E, Walker, C, Waseem, S, Yordanov, S (Addenbrooke&#8217, Jones, T, Kattakayam, A, Loh, C, Lunevicius, R, Pringle, S, Schache, A, Shaw, R, Sheel, A (Aintree University Hospital), Rossborough, C (Altnagelvin Area Hospital), Angelou, D, Choynowski, M, McAree, B, McCanny, A, Neely, D (Antrim Area Hospital- Northern Health And Social Care Trust), Tutoveanu, G (Barnsley Hospital Nhs Foundation Trust), Ahad, S, De La Cruz Monroy MFI, Mosley, F, Oktseloglou, V (Bradford Royal Infirmary), Alanbuki, A, Patel, M, Shabana, A (Brighton And Sussex Nhs Trust, Princess Royal Hospital), Perera, E, Raveendran, D, Ravi- Shankar, K, Thiruchelvam, J (Broomfield Hospital), Arrowsmith L, Campbell W (Causeway Hospital), Grove, T, Kontovounisios, C, Warren, O (Chelsea And Westminster Hospital), Rolland, P (Cheltenham General Hospital), Aggarwal, A, Brown, S, Jelley, C, Neal, N (Churchill Hospital), Clifford, R, Eardley, N, Krishnan, E, Manu, N, Martin, E, Roy Mahapatra, S, Serevina, Ol, Smith, C, Vimalachandran, D (Countess Of Chester Hospital), Bordenave, M, Houston, R, Putnam, G, Robson, A, Tustin, H (Cumberland Infirmary), Emslie, K, Labib, Pl, Marchbank, A, Miller, D, Minto, G, Natale, J, Nwinee, H, Panahi, P, Rogers, L (Derriford Hospital), Abubakar, A, Akhter Rahman MM, Kyk, Ko, Brien, H, Sasapu, K, Woodun, H (Diana Princess Of Wales Hospital Grimsby), Inglis R, Ng HJ (Dumfries And Galloway Royal Infirmary), De Gea Rico, A, Ghazali, N, Lambert, J, Markose, G, Math, S, Sarantitis, I, Shrestha, D, Sultana, A, Taggarsi, M, Timbrell, S, Vaz, Op, Vitone, L (East Lancashire Hospitals Nhs Trust), Day, A, Dent, H, Fahim, M, Waheed, S (East Surrey Hospital), Hunt A, Laskar N (East Sussex Healthcare (Conquest Hospital And Eastbourne District General Hospital)), Gupta, A, Steinke, J, Thrumurthy, S (Epsom &amp, St Helier University Hospitals Nhs Trust), Massie, E, McGivern, K, Rutherford, D, Wilson, M (Forth Valley Royal Hospital), Hardie J, Kazzaz S (Frimley Health Nhs Ft - Frimley Park), Handa, S, Kaushal, M, Kler, A, Patel, P, Redfern, J, Tezas, S (Furness General Hospital), Aawsaj, Y, Amonkar, S, Blackwell, L, Blake, D, Carter, J, Emerson, H, Fisher, A, Katory, M, Korompelis, P, McCormick, W, Mustafa, A, Pearce, L, Ratnavelu, N, Reehal, R (Gateshead Health Nhs Foundation Trust), Kretzmer, L, Lalou, L, Manku, B, Parwaiz, I, Stafford, J (George Eliot Hospital), Abdelkarim, M, Asqalan, A, Gala, T, Ibrahim, S, Maw, A, Mithany, R, Morgan, R, Sundaram Venkatesan, G (Glan Clwyd Hospital), Ang, K, Caruana, Ej, Chowdhry, Mf, Mohammad, A, Nakas, A, Rathinam, S (Glenfield Hospital), Boal, M, Brown, O, Dwerryhouse, S, Higgs, S, Vallance, A (Gloucestershire Royal Hospital), Boyd, E, Irvine, V, Kirk, A (Golden Jubilee National Hospital), Bakolas, G, Boulton, A, Chandock, A, Khan, T, Kumar, M (Good Hope Hospital), Agoston, P, Bill&#232, Challacombe, B, Fraser, S, Harrison-Phipps, K, King, J, Mehra, G, Mills, L, Najdy, M, Nath, R, Okiror, L, Pilling, J, Rizzo, V, Routledge, T, Sayasneh, A, Stroman, L, Wali, A (Guy&#8217, Fehervari, M, Fotopoulou, C, Habib, N, Hamrang-Yousefi, S, Jawad, Z, Jiao, L, Pai, M, Ploski, J, Rajagopal, P, Saso, S, Sodergren, M, Spalding, D (Hammersmith Hospital), Laws, S (Hampshire Hospitals Nhs Trust), Hardie C, McNaught C (Harrogate District Hospital), Alam, R, Budacan, A, Cahill, J, Kalkat, M, Karandikar, S, Kenyon, L, Naumann, D, Patel, A (Heartlands Hospital), Ayorinde, J, Chase, T, Cuming, T, Ghanbari, A, Humphreys, L, Tayeh, S (Homerton University Hospital), Aboelkassem Ibrahim, A, Bichoo, R, Cao, H, Chai, Akw, Choudhury, J, Evans, C, Fitzjohn, H, Ikram, H, Langstroth, M, Loubani, M, McMillan, A, Nazir, S, Qadri, Ssa, Robinson, A, Ross, E, Sehgal, T, Wilkins, A (Hull University Teaching Hospitals Nhs Trust), Dixon, J, Dunning, J, Freystaetter, K, Jha, M, Lester, S, Madhavan, A, Thulasiraman, Sv, Viswanath, Y (James Cook University Hospital), Curl-Roper, T, Delimpalta, C, Liao, Ccl, Velchuru, V, Westwood, E (James Paget Univeristy Nhs Foundation Trust Hospital), Belcher, E, Bond-Smith, G, Chidambaram, S, Di Chiara, F, Fasanmade, K, Fraser, L, Fu, H, Ganau, M, Gore, S, Graystone, J, Jeyaretna, D, Khatkar, H, Lami, M, Maher, M, Mastoridis, S, Mihai, R, Piper, R, Prabhu, S, Risk, Obf, Selbong, U, Shah, K, Smillie, R, Soleymani majd, H, Sravanam, S, Stavroulias, D, Tebala, Gd, Vatish, M, Verberne, C, Wallwork, K, Winter, S (John Radcliffe Hospital), Bhatti, Mi, Boyd-Carson, H, Elsey, E, Gemmill, E, Herrod, P, Jibreel, M, Lenzi, E, Saafan, T, Sapre, D, Sian, T, Watson, N (King&#8217, s Mill Hospital), Athanasiou, A, Bourke, G, Bradshaw, L, Brunelli, A, Burke, J, Coe, P, Costigan, F, Elkadi, H, Ho, M, Johnstone, J, Kanatas, A, Kantola, V, Kaufmann, A, Laios, A, Lam, S, MacInnes, E, Munot, S, Nahm, C, Otify, M, Pompili, C, Smith, I, Theophilou, G, Toogood, G, Wade, R, Ward, D, West, C (Leeds Teaching Hospitals Trust), Annamalai, S, Ashmore, C, Boddy, A, Hossain, T, Kourdouli, A (Leicester Royal Infirmary), Gvaramadze, A, Jibril, A, Prusty, L, Thekkinkattil, D (Lincoln County Hospital), Harky A, Shackcloth M (Liverpool Heart And Chest Hospital), Askari, A, Cirocchi, N, Kudchadkar, S, Patel, K, Sagar, J, Shaw, S, Talwar, R (Luton And Dunstable University Hospital), Abdalla, M, Edmondson, R, Ismail, O, Jones, D, Newton, K, Stylianides, N (Manchester Royal Infirmary), Aderombi, A, Andaleeb, U, Bajomo, O, Beatson, K, Garrett, W, Mehmood, M, V (Medway Hospital), Ng, Al-Habsi, R, Divya, Gs, Keeler, B (Milton Keynes University Hospital), Al- Sarireh, B, Egan, R, Harries, R, Henry, A, Kittur, M, Li, Z, Parkins, K, Soliman, F, Spencer, N, Thompson, D (Morriston Hospital Swansea), Burgess, C, Gemmell, C, Grieco, C, Hollyman, M, Hunt, L, Morrison, J, Ojha, S, Ryan, N (Musgrove Park Hospital), Abbadessa, F, Barnard, S, Dawe, N, Hammond, J, Mahmoud Ali, F, McPherson, I, Mellor, C, Moir, J, Pandanaboyana, S, Powell, J, Rai, B, Roy, C, Sachdeva, A, Saleh, C, Tingle, S, Williams T (Newcastle Upon Tyne Hospitals Nhs Foundation Trust., ), Manickavasagam, J, McDonald, C, McGrath, N, McSorley, N, Ragupathy, K, Ramsay, L, Solth, A (Ninewells Hospital), Kakisi, O, Seebah, K, Shaikh, I, Sreedharan, L, Youssef, M (Norfolk And Norwich University Hospital), Shah, J (North Manchester General Hospital), Ameerally, P (Northampton General Hospital), McLarty, N, Mills, S, Shenfine, A (Northumbria Nhs Hospital Trust), Sahnan, K (Northwick Park Hospital), Abu, J, Addae-Boateng, E, Bratt, D, Brock, L, Burnside, N, Cadwell-Sneath, S, Gajjar, K, Gan, C, Grundy, C, Hallam, K, Hassell, K, Hawari, M, Joshi, A, Khout, H, Konstantinidi, K, Lee, Rxn, Nunns, D, Schiemer, R, Walton, T, Weaver, H, Whisker, L, Williamson, K (Nottingham City Hospital), McVeigh, J, Myatt, R, Williams MA (Nuffield Orthopaedic Centre), Kaur, R, Leung, E, Sundar, S (Pan- Birmingham Gynaecological Cancer Centre), Michel, M, Patil, S, Ravindran, S, Sarveswaran, J, Scott, L (Pinderfields Hospital), Edmond M, King E (Poole Hospital), Almond, M, Bhangu, A, Breik, O, Cato, Ld, Desai, A, Ford, S, Griffiths, E, Idle, M, Kamal, M, Kisiel, A, Kulkarni, R, Mak, Jkc, Martin, T, Nankivell, P, Parente, A, Parmar, S, Pathanki, Am, Phelan, L, Praveen, P, Saeed, S, 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M., Petropoulos, K., Soulikia, K., Tsiamalou, I., Zervas, K., Zourntou, S., Baloyiannis, I., Diamantis, A., Gkrinia, E., Hajiioannou, J., Korais, C., Koukoura, O., Perivoliotis, K., Saratziotis, A., Skoulakis, C., Symeonidis, D., Tepetes, K., Tzovaras, G., Zacharoulis, D., Alexoudi, V., Antoniades, K., Astreidis, I., Christidis, P., Deligiannidis, D., Grivas, T., Ioannidis, O., Kalaitsidou, I., Loutzidou, L., Mantevas, A., Michailidou, D., Paraskevopoulos, K., Politis, S., Stavroglou, A., Tatsis, D., Tilaveridis, I., Vahtsevanos, K., Venetis, G., Karaitianos, I., Tsirlis, T., Charalabopoulos, A., Liakakos, T., Mpaili, E., Schizas, D., Spartalis, E., Syllaios, A., Zografos, C., Anthoulakis, C., Christou, C., Papadopoulos, V., Tooulias, A., Tsolakidis, D., Tsoulfas, G., Zouzoulas, D., Athanasakis, E., Chrysos, E., Tsiaoussis, J., Xenaki, S., Xynos, E., Futaba, K., Ho, M. F., Hon, S. F., Mak, T. W. C., Ng, S. S. M., Foo, C. C., Banky, B., Susztak, N., Aremu, M., Canas-Martinez, A., Cullivan, O., Murphy, C., Owens, P., Pickett, L., Akmenkalne, L., Byrne, J., Corrigan, M., Cullinane, C., Daly, A., Fleming, C., Jordan, P., Killeen, S., Lynch, N., Mccarthy, A., Mustafa, H., O'Brien, S., O'Leary, P., Syed, W. A. S., Vernon, L., Callanan, D., Huang, L., Ionescu, A., Sheahan, P., Balasubramanian, I., Boland, M., Conlon, K., Evoy, D., Fearon, N., Gallagher, T., Geraghty, J., Heneghan, H., Kennedy, N., Maguire, D., Mccartan, D., Mcdermott, E. W., Prichard, R. S., Winter, D., Alazawi, D., Barry, C., Boyle, T., Butt, W., Connolly, E. M., Donlon, N., Donohue, C., Fahey, B. A., Farrell, R., Fitzgerald, C., Kinsella, J., Larkin, J. O., Lennon, P., Maguire, P. J., Mccormick, P., Mehigan, B. J., Nugent, T., O'Sullivan, H., Ravi, N., Reynolds, J. V., Rogers, A., Shokuhi, P., Smith, J., Smith, L. A., Timon, C., Bashir, Y., Bass, G., Connelly, T., Creavin, B., Earley, H., Elliott, J. 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T., Annessi, V., Zizzo, M., Grossi, U., Novello, S., Romano, M., Rossi, S., Zanus, G., Esposito, G., Frongia, F., Pisanu, A., Podda, M., Belluco, C., Lauretta, A., Montori, G., Moras, L., Olivieri, M., Bussu, F., Carta, A. G., Cossu, M. L., Cottu, P., Fancellu, A., Feo, C. F., Ginesu, G. C., Giuliani, G., Madonia, M., Perra, T., Piras, A., Porcu, A., Rizzo, D., Scanu, A. M., Tedde, A., Tedde, M., Delrio, P., Rega, D., Badalamenti, G., Campisi, G., Cordova, A., Franza, M., Maniaci, G., Rinaldi, G., Toia, F., Calabro, M., Farnesi, F., Lunghi, E. G., Muratore, A., Pipitone Federico, N. S., Bambina, F., D'Andrea, G., Familiari, P., Picotti, V., De Palma, G., Luglio, G., Pagano, G., Tropeano, F. P., Baldari, L., Beltramini, G. A., Boni, L., Cassinotti, E., Gianni, A., Pignataro, L., Torretta, S., Abatini, C., Baia, M., Biasoni, D., Bogani, G., Cadenelli, P., Cioffi, S. P. B., Citterio, D., Comini, L. V., Cosimelli, M., Folli, S., Gennaro, M., Giannini, L., Gronchi, A., Guaglio, M., Macchi, A., Martinelli, F., Mazzaferro, V., Mosca, A., Pasquali, S., Piazza, C., Raspagliesi, F., Rolli, L., Salvioni, R., Sarpietro, G., Sarre, C., Sorrentino, L., Agnes, A., Alfieri, S., Belia, F., Biondi, A., Cozza, V., D'Amore, A., D'Ugo, D., De Simone, V., Fagotti, A., Gasparini, G., Gordini, L., Litta, F., Lombardi, C. P., Lorenzon, L., Marra, A. A., Marzi, F., Moro, A., Parello, A., Perrone, E., Persiani, R., Ratto, C., Rosa, F., Saponaro, G., Scambia, G., Scrima, O., Sganga, G., Tudisco, R., Belli, A., Granata, V., Izzo, F., Palaia, R., Patrone, R., Carrano, F. M., Carvello, M. M., De Virgilio, A., Di Candido, F., Ferreli, F., Gaino, F., Mercante, G., Rossi, V., Spinelli, A., Spriano, G., Donati, D. M., Frisoni, T., Palmerini, E., Aprile, A., Barra, F., Batistotti, P., Ferrero, S., Fregatti, P., Scabini, S., Sparavigna, M., Asti, E., Bernardi, D., Bonavina, L., Lovece, A., Adamoli, L., Ansarin, M., Cenciarelli, S., Chu, F., De Berardinis, R., Fumagalli Romario, U., Mastrilli, F., Pietrobon, G., Tagliabue, M., Badellino, E., Ferrero, A., Massobrio, R., De Manzoni Garberini, A., Federico, P., Maida, P., Marra, E., Marte, G., Petrillo, A., Tammaro, T., Tufo, A., Berselli, M., Borroni, G., Cocozza, E., Conti, L., Desio, M., Livraghi, L., Quintodei, V., Rizzi, A., Zullo, A., Baldi, C., Corbellini, C., Sampietro, G. M., Cellerino, P., Baldini, E., Capelli, P., Isolani, S. M., Ribolla, M., Bondurri, A., Colombo, F., Ferrario, L., Guerci, C., Maffioli, A., Armao, T., Ballabio, M., Bisagni, P., Gagliano, A., Longhi, M., Madonini, M., Pizzini, P., Baietti, A. M., Biasini, M., Maremonti, P., Neri, F., Prucher, G. M., Ricci, S., Ruggiero, F., Zarabini, A. G., Barmasse, R., Mochet, S., Usai, A., Incollingo, P., Mancini, S., Marino Cosentino, L., Sagnotta, A., Fruscio, R., Grassi, T., Nespoli, L. C., Tamini, N., Anastasi, A., Bartalucci, B., Bellacci, A., Canonico, G., Capezzuoli, L., Di Martino, C., Ipponi, P., Linari, C., Montelatici, M., Nelli, T., Spagni, G., Tirloni, L., Vitali, A., Abate, E., Casati, M., Casiraghi, T., Laface, L., Schiavo, M., Arminio, A., Cotoia, A., Lizzi, V., Vovola, F., Vergari, R., D'Ugo, S., Depalma, N., Spampinato, M. G., Bartolucci, P., Brachini, G., Bruzzaniti, P., Chiappini, A., Chiarella, V., Ciccarone, F., Cicerchia, P. M., Cirillo, B., De Toma, G., Di bartolomeo, A., Fiori, E., Fonsi, G. B., Franco, G., Frati, A., Giugliano, M., Iannone, I., La Torre, F., Lapolla, P., Leonardo, C., Marruzzo, G., Meneghini, S., Mingoli, A., Ribuffo, D., Salvati, M., Santoro, A., Sapienza, P., Scafa, A. K., Simonelli, L., Zambon, M., Capolupo, G. T., Carannante, F., Caricato, M., Masciana, G., Mazzotta, E., Gattolin, A., Migliore, M., Rimonda, R., Sasia, D., Travaglio, E., Cervellera, M., Gori, A., Sartarelli, L., Tonini, V., Giacometti, M., Zonta, S., Chessa, A., Fiorini, A., Norcini, C., Colletti, G., Confalonieri, M., Costanzi, A., Frattaruolo, C., Mari, G., Monteleone, M., Bandiera, A., Bocciolone, L., Bonavina, G., Candiani, M., Candotti, G., De Nardi, P., Gagliardi, F., Medone, M., Mortini, P., Negri, G., Parise, P., Piloni, M., Sileri, P., Vignali, A., Belvedere, A., Bernante, P., Bertoglio, P., Boussedra, S., Brunocilla, E., Cipriani, R., Cisternino, G., De Crescenzo, E., De Iaco, P., Dondi, G., Frio, F., Jovine, E., Mineo Bianchi, F., Neri, J., Parlanti, D., Perrone, A. M., Pezzuto, A. P., Pignatti, M., Pinto, V., Poggioli, G., Ravaioli, M., Rottoli, M., Schiavina, R., Serenari, M., Serra, M., Solli, P., Taffurelli, M., Tanzanu, M., Tesei, M., Violante, T., Zanotti, S., Borghi, F., Cianflocca, D., Di Maria Grimaldi, S., Gelarda, E., Geretto, P., Giraudo, G., Giuffrida, M. C., Marano, A., Palagi, S., Pellegrino, L., Peluso, C., Testa, V., Agresta, F., Prando, D., Zese, M., Aquila, F., Gambacciani, C., Lippa, L., Pieri, F., Santonocito, O. S., Armatura, G., Bertelli, G., Frena, A., Marinello, P., Notte, F., Patauner, S., Scotton, G., Fulginiti, S. F., Gallo, G., Sammarco, G., Vescio, G., Balercia, P., Catarzi, L., Consorti, G., Di Marzo, F., Fontana, T., Daiko, H., Ishikawa, M., Ishiyama, K., Iwata, S., Kanematsu, K., Kanemitsu, Y., Kato, T., Kawai, A., Kobayashi, E., Kobayashi Kato, M., Moritani, K., Nakatani, F., Oguma, J., Tanase, Y., Uno, M., Al Abdallah, M., Ayasra, F., Ayasra, Y., Qasem, A., Abu Za'nouneh, F. 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M., Sharabiany, S., Grotenhuis, B., Hartveld, L., Reijers, S., Van Houdt, W., Baaij, J., Bolster-Van Eenennaam, M., De Graaff, M., Sloothaak, D., Van Duijvendijk, P., Posma-Bouman, L., Derksen, T., Franken, J., Oosterling, S., De Bree, R., Konsten, J., Van Heinsbergen, M., Fidelis, L., Sholadoye, T. T., Tolani, M. A., Olaogun, J., Egbuchulem, I. K., Lawal, T. A., Ogundoyin, O., Olulana, D. I., Abdur-Rahman, L., Adeyeye, A., Aremu, I., Bello, J., Olasehinde, O., Popoola, A., Massoud, J., Massoud, R., Sorour, T. M., Jamal, A., Kerawala, A. A., Memon, A. S., Nafees Ahmed, R., Rai, L., Ayub, B., Hassan, N., Martins, R. S., Ramesh, P., Sayyed, R., Butt, U., Kashif, M., Khan, W. H., Qureshi, A., Umar, M., Waris Farooka, M., Wasim, T., Ayubi, A., Rashid, I., Waqar, S. H., Falcon, G. M., Robles, R., Jocson, R., Teh, C., Major, P., Bobinski, M., Kotarski, J., Rasoul-Pelinska, K., Azevedo, C., Machado, D., Mendes, F., De Sousa, X., Fernandes, U., Ferreira, C., Guidi, G., Leal, C., Marcal, A., Marques, R., Martins, D., Melo, A., Tenreiro, N., Vaz Pereira, R., Vieira, B., Almeida, J. I., Correia de Sa, T., Costa, M. J. M. A., Fernandes, V., Ferraz, I., Gil, C. G., Lima Da Silva, C., Lopes, L., Machado, N., Marialva, J., Nunes Coelho, M., Pedro, J., Pereira, C., Reis, R., Ribeiro, A., Santos, R., Saraiva, P., Silva, R., Tavares, F., Teixeira, M., Almeida, A. C., Amaral, M. J., Andrade, R., Athayde Nemesio, R., Breda, D., Camacho, C., Canhoto, C., Colino, M., Correia, S., De Barros, J., De Oliveira Lopez, A. L., Duque, M., Garrido, S., Guerreiro, P., Guimaraes, A., Lazaro, A., Lopes, C., Nogueira, O., Oliveira, A., Oliveira, J. M., Rodrigues, M., Ruivo, A., Santos, E., Silva, M., Simoes, J., Valente Da Costa, A., Almeida, A., Cavaleiro, S., Devezas, V., Faria, C. S., Jacome, F., Magalhaes Maia, M., Nogueiro, J., Pereira, A., Pereira-Neves, A., Pina-Vaz, T., Santos-Sousa, H., Silveira, H., Vaz, S., Vieira, P., Gomes Da Costa, A., Lobo Antunes, I., Pinto, J., Tojal, A., Cardoso, N., Cardoso, P., Domingues, J. C., Henriques, P., Manso, M. I., Martins Dos Santos, G., Morais, H., Pereira, R., Revez, T., Ribeiro, R., Ribeiro, V. I., Sousa, S., Teixeira, J., Amorim, E., Baptista, V. H., Cunha, M. F., Dias, B., Fazenda, A., Melo Neves, J. P., Policarpo, F., Sampaio Da Novoa Gomes Miguel, I. I., Veiga, D., Andrade, A. K., Bandovas, J. P., Borges, N., Branquinho, A., Chumbinho, B., Correia, J., Fidalgo, H., Figueiredo De Barros, I., Frade, S., Gomes, J., Maciel, J., Pina, S., Rodrigues, A., Silva, N., Silveira Nunes, I., Sousa, R., Ascensao, J., Azevedo, P., Costeira, B., Cunha, C., Garrido, R., Gomes, H., Lourenco, I., Mendinhos, G., Miranda, P., Nobre Pinto, A., Peralta Ferreira, M., Ribeiro, J., Rio Rodrigues, L., Sousa Fernandes, M., Azevedo, J., Galvao, D., Soares, A. C., Vieira, A., Patricio, B., Santos, P. M. D. D., Vieira Paiva Lopes, A. C., Cunha, R., Faustino, A., Freitas, A., Martins, A. B., Mendes, J. R., Parreira, R., Rosa, J., Teves, M., Abreu Da Silva, A., Claro, M., Costa Santos, D., Deus, A. C., Grilo, J. V., Borges, F., Corte Real, J., Henriques, S., Lima, M. J., Matos Costa, P., Brito da Silva, F., Caiado, A., Fonseca, F., Angelo, M., Baiao, J. M., Martins Jordao, D., Vieira Caroco, T., Messias, J., Millan, A., Salgado, I., Baia, C., Canotilho, R., Correia, A. M., Ferreira Pinto, A. 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V., Garmanova, T., Kazachenko, E., Markaryan, D., Rodimov, S., Tsarkov, P., Tulina, I., Litvina, Y., Provozina, A., Agapov, M., Galliamov, E., Kakotkin, V., Kubyshkin, V., Alshahrani, M., Alsharif, F., Eskander, M., Al Raddadi, R., Majrashi, S., Mashat, A., Akeel, N., Alharthi, M., Aljiffry, M., Basendowah, M., Farsi, A., Ghunaim, M., Khoja, A., Maghrabi, A., Malibary, N., Nassif, M., Nawawi, A., Saleem, A., Samkari, A., Trabulsi, N., Al Awwad, S., Alghamdi, M., Alnumani, T., Nasser, M., Said bayazeed, A., Alhefdhi, A., Almalik, O., Alomair, A., Alotaibi, N., Alresaini, F., Alsalamah, R., Alsobhi, S., Mahasin, Z., Othman, E., Velagapudi, S., Ghedan, S., Alharthi, R., Awad, S., Sharara, M., Abdelrahman, S., Althobaiti, W., Al Habes, H., Alamri, A., Alkarak, S., Alqannas, M., Alyami, M., Alzamanan, M., Cortes Guiral, D., Elawad, A., Alaamer, O., Alriyees, L., Alselaim, N., Abdulkareem, A., Ajlan, A., Akkour, K., Al-Habib, A., Al-Khayal, K., Alatar, A., Alburakan, A., Alhalal, H., Alhassan, B., Alhassan, N., Alobeed, O., Alsaif, A., Alsaif, F., Alshammari, S., Alshaygy, I., Barry, M., Bin Nasser, A., Bin Traiki, T., Bokhari, A., Elwatidy, S., Helmi, H., Madkhali, A., Nouh, T., Rabah, P. D., Zubaidi, A., Paunovic, I., Slijepcevic, N., Aleksic, L., Antic, A., Barisic, G., Ceranic, M., Galun, D., Grubac, Z., Jelenkovic, J., Kecmanovic, D., Kmezic, S., Knezevic, D., Krivokapic, Z., Latincic, S., Markovic, V., Matic, S., Miladinov, M., Pavlov, M., Pejovic, I., Radenkovic, D., Tadic, B., Vasljevic, J., Velickovic, D., Zivanovic, M., Perovic, M., Srbinovic, L., Andrijasevic, S., Bozanovic, T., Cerovic Popovic, R., Dokic, M., Janjic, T., Jeremic, K., Kadija, S., Ladjevic Likic, I., Mirkovic, L., Pantovic, S., Pilic, I., Radojevic, M., Stefanovic, A., Vidakovic, S., Vilendecic, Z., Antic, S., Dunderovic, D., Jelovac, D., Jezdic, Z., Konstantinovic, V., Kotlar, B., Kuzmanovic, C., Lazic, M., Petrovic, M., Popovic, F., Pucar, A., Romic, M., Sumrak, S., Vujanac, V., Bascarevic, V., Bogdanovic, I., Grujicic, D., Ilic, R., Milicevic, M., Milisavljevic, F., Miljkovic, A., Paunovic, A., Scepanovic, V., Stanimirovic, A., Todorovic, M., Jotic, A., Milovanovic, J., Trivic, A., Bumbasirevic, U., Dzamic, Z., Kajmakovic, B., Prijovic, N., Zivkovic, M., Buta, M., Cvetkovic, A., Djurisic, I., Gacic, S., Goran, M., Inic, Z., Jeftic, N., Jevric, M., Jokic, V., Markovic, I., Milanovic, M., Nikolic, S., Pejnovic, L., Savkovic, N., Spurnic, I., Stevic, D., Stojiljkovic, D., Vucic, N., Zegarac, M., Karamarkovic, A., Kenic, M., Kovacevic, B., Krdzic, I., Milutinovic, V., Lieske, B., Galis, B., Simko, K., Almgla, N., Bernon, M., Boutall, A., Cairncross, L., Herman, A., Hilton, T., Jonas, E., Kloppers, C., Malherbe, F., Mugla, W., Nel, D., Rayamajhi, S., Van Wyngaard, T., Vogel, J., Castano-Leon, A. M., Delgado Fernandez, J., Eiriz Fernandez, C., Espino Segura-Illa, M., Esteban Sinovas, O., Garcia Perez, D., Gomez, P., Jimenez-Roldan, L., Lagares, A., Moreno-Gomez, L., Paredes, I., Perez Nunez, A., Sanchez Aniceto, G., Santas, M., Fernandez Rodriguez, P., Paniagua Garcia Senorans, M., Sanchez-Santos, R., Vigorita, V., Acrich, E., Baena Sanfeliu, E., Barrios, O., Golda, T., Santanach, C., Serrano-Navidad, M., Sorribas Grifell, M., Vives, R. V., Escola, D., Jimenez, A., Cayetano Paniagua, L., Gomez Fernandez, L., Artigues, E., Bernal-Sprekelsen, J. C., Catala Bauset, J. C., Collera, P., Diaz Del Gobbo, R., Farre Font, R., Flores Clotet, R., Gomez Diaz, C. J., Guardia, N., Guariglia, C. A., Osorio, A., Sanchez Jimenez, R., Sanchon, L., Soto Montesinos, C., Albi Martin, B., Garcia Villayzan, J. E., Alonso-Lamberti, L., Assaf, M., Baeza Pintado, N., Carabias, A., Garcia-Quijada, J., Huertas Fernandez, M. A., Jimenez Miramon, J., Jimenez, V., Jover, J. M., Landeo Aguero, S. A., Leon, R., Martin Salamanca, M. B., Perez Simon, V., Ponce, S., Rodriguez, J. L., Salazar, A., Valle Rubio, A., Aguado, H., Aldecoa Ansorregui, I., Bravo Infante, R., De Lacy, F. B., Di Somma, A., Diaz-Feijoo, B., Ensenat Nora, J., Fabregas, N., Ferres, A., Gil Ibanez, B., Gonzalez Sanchez, J. J., Gracia, I., Hoyos Castro, J. A., Lacy, A. M., Langdon, C., Momblan, D., Morales, X., Oleaga, L., Otero, A., Pedrosa, L., Poblete Carrizo, J., Reyes Figueroa, L. A., Roldan Ramos, P., Rumia-Arboix, J., Tercero-Uribe, A. I., Topczewski, T. E., Torales, J., Torne, A., Torne, R., Turrado-Rodriguez, V., Valero, R., Valverde, S., Anula, R., Cano-Valderrama, O., Del Campo Martin, M., Diez-Valladares, L., Dominguez, I., Dziakova, J., Garcia Alonso, M., Garcia Romero, E., Gomez Latorre, L., Muguerza, J. M., Pizarro, M. J., Saez Carlin, P., Sanchez Del Pueblo, C., Sanchez-Pernaute, A., Sanz Ortega, G., Sanz-Lopez, R., Torres, A., Garces-Albir, M., Lopez, F., Martin-Arevalo, J., Moro-Valdezate, D., Pla-Marti, V., Beltran De Heredia, J., De Andres Asenjo, B., Gomez Sanz, T., Jezieniecki, C., Nunez Del Barrio, H., Ortiz De Solorzano Aurusa, F. J., Romero De Diego, A., Ruiz Soriano, M., Trujillo Diaz, J., Vazquez Fernandez, A., Lora-Cumplido, P., Sosa, M. V., Gonzalez-Gonzalez, E., Minaya Bravo, A. M., Alonso de la Fuente, N., Cazador Labat, M., Cecchini, L., Espinosa, C. A., Jimenez Toscano, M., Lopez Campillo, A., Mancebo, G., Martorell, P., Munarriz, M., Grau-Talens, E. J., Martin-Perez, B., Benavides Buleje, J. A., Carrasco Prats, M., Fernandez, P. V., Fernandez-Lopez, A., Garcia Escudero, D., Garcia Porcel, V. J., Garcia Soria, V., Gimenez Frances, C., Gonzalez Valverde, F. M., Gurrea, E., Lopez-Morales, P., Marco Garrido, A., Martinez Alonso, J. A., Medina, E., Munoz Camarena, J. M., Parra Banos, P. A., Pena Ros, E., Ramirez Faraco, M., Ruiz-Marin, M., Sanchez Rodriguez, C., Valero Soriano, M., Estaire Gomez, M., Fernandez Camunas, A., Garcia Santos, E. P., Jimenez Higuera, E., Martinez-Pinedo, C., Munoz-Atienza, V., Padilla-Valverde, D., Picon Rodriguez, R., Redondo Calvo, F. J., Sanchez-Garcia, S., Sanchez-Pelaez, D., Colombari, R. C., Del valle, E., Fernandez, M., Lozano Lominchar, P., Rey Valcarcel, C., Steiner, M. A., Tudela, M., Zorrilla Ortuzar, J., Alcaide Matas, F., Garcia Perez, J. M., Troncoso Pereira, P., Mora-Guzman, I., Abellan, M., Achalandabaso Boira, M., Jorba, R., Memba Ikuga, R., Olona, C., Sales Mallafre, R., Cavalle Busquets, P., Gavalda Pellice, M. G. P., Salinas Pena, J., Aragon Achig, E. J., Barbier, L., Caja Vivancos, P., Gainza, A., Garcia Gutierrez, J. J., Mallabiabarrena Ormaechea, G., Marin, H., Martin Playa, P., Melchor Corcostegui, I., Prieto Calvo, M., Rodriguez Fraga, A., Villalabeitia Ateca, I., De Andres Olabarria, U., Duran Ballesteros, M., Fernandez Pablos, F. J., Ibanez-Aguirre, F. J., Sanz Larrainzar, A., Ugarte-Sierra, B., De La Hoz Rodriguez, A., Di Martino, M., Garcia Septiem, J., Martin-Perez, E., Munoz De Nova, J. L., Calvo Espino, P., Guillamot Ruano, P., Colao Garcia, L., Diaz Perez, D., Esteban Agusti, E., Galindo Jara, P., Gutierrez Samaniego, M., Hernandez Bartolome, M. A., Serrano Gonzalez, J., Alonso Poza, A., Dieguez, B., Garcia-Conde, M., Hernandez-Garcia, M., Losada, M., Chiesa-Estomba, C. M., Gonzalez Garcia, J. A., Larruscain, E., Sistiaga-Suarez, J. A., Alvarez, E., Chavarrias, N., Frias, L., Garcia Pineda, V., Gegundez Simon, A., Gortazar, S., Gracia, M., Guevara, J., Hernandez Gutierrez, A., Loayza, A., Maria Dolores, D. T., Marti, C., Melendez, M., Moreno-Palacios, E., Perez, Y., Prieto Nieto, M. I., Ramos-Martin, P., Rubio-Perez, I., Saavedra, J., Sanchez-Mendez, J. I., Siegrist Ridruejo, J., Urbieta, A., Zapardiel, I., Cantalejo diaz, M., De Miguel Ardevines, M. D. C., Duque-Mallen, V., Gascon Ferrer, I., Gonzalez-Nicolas Trebol, M. T., Gracia-Roche, C., Herrero Lopez, M., Jariod Ferrer, U. M., Lanzon, A., Martinez German, A., Matute, M., Redondo, C., Sanchez Fuentes, N., Sanchez-Rubio, M., Santero-Ramirez, M. S., Saudi, S., Simon Sanz, M. V., Uson-Bouthelier, T., Blazquez Martin, A., Diez Alonso, M., Garcia Rico, E., Garcia-Loarte Gomez, E., Garcia-Moreno Nisa, F., Gutierrez Calvo, A., Hernandez, P., Lasa, I., Mendoza-Moreno, F., Morales Palacios, N., Ovejero Merino, E., Vera Mansilla, C., Acebes Garcia, F., Bailon, M., Bueno Canones, A. D., Choolani Bhojwani, E., Marcos-Santos, P., Miguel, T., Pacheco Sanchez, D., Perez-Saborido, B., Sanchez Gonzalez, J., Tejero-Pintor, F. J., Alconchel, F., Conesa, A., Gil Martinez, J., Gutierrez Fernandez, A. I., Lopez Abad, A., Nicolas-Lopez, T., Ramirez Romero, P., Roca Calvo, M. J., Rodrigues, K., Ruiz Manzanera, J. J., Soriano, A. I., Cano, A., Capitan-Morales, L., Cintas Catena, J., Gomez-Rosado, J., Oliva Mompean, F., Perez Sanchez, M. A., Rio Lafuente, F. D., Torres Arcos, C., Valdes-Hernandez, J., Cholewa, H., Domingo, S., Frasson, M., Lago, V., Marina Martin, T., Martinez Chicote, C., Sancho-Muriel, J., Landaluce-Olavarria, A., Lecumberri, D., Abad Gurumeta, A., Abad-Motos, A., Martinez-Hurtado, E., Ripolles-Melchor, J., Ruiz Escobar, A., Cuadrado-Garcia, A., Garcia-Sancho Tellez, L., Heras Aznar, J., Mate, P., Ortega Vazquez, I., Picardo, A. L., Rojo Lopez, J. A., Sanchez Cabezudo Noguera, F., Serralta De Colsa, D., Anchuelo Latorre, J., Cagigas Fernandez, C., Caina Ruiz, R., Gomez Ruiz, M., Hernanz, F., Jimeno Fraile, J., Martinez-Perez, P., Poch, C., Santarrufina Martinez, S., Valbuena Jabares, V., Moliner-Sanchez, C., Pingarron-Martin, L., Rey-Biel, J., Ruiz Martin, I., Blas Laina, J. L., Cros, B., Escartin, J., Garcia Egea, J., Nogues, A., Talal El-Abur, I., Yanez, C., Cagigal Ortega, E. P., Cervera, I., Diaz Pena, P., Elena, G. D. C. R., Enjuto, D., Fernandez Bernabe, P., Garces Garcia, R., Gonzalez, J., Hernandez, I., Herrera-Merino, N., Marqueta De Salas, M., Martinez Pascual, P., Perez Gonzalez, M., Ramos Bonilla, A., Rodriguez Gomez, L., Bescos, C., Blanco-Colino, R., Brana, I., Caimari, B., De Pablo Garcia-Cuenca, A., Duran-Valles, F., Espin-Basany, E., Giralt Lopez De Sagredo, J., Pamias, J., Pellino, G., Prat, N., Pujol Pina, R., Saez Barba, M., Arulanantham, A., Bandara, G. B. K., Jayarajah, U., Ravindrakumar, S., Rodrigo, V. S., Srishankar, S., Ali Karar, A. A., Elbe, P., Lindqvist, E. K., Taflin, H., Alga, A., Heinius, G., Nordberg, M., Pieniowski, E., Gkekas, I., Lofgren, N., Rutegard, M., Sund, M., Arigoni, M., Bernasconi, M., Christoforidis, D., Di Giuseppe, M., La Regina, D., Mongelli, F., Chevallay, M., Dwidar, O., Gialamas, E., Sauvain, M., Klenke, F., Kollar, A., Kurze, C., Adamina, M., Bachler, T., Crugnale, A. S., Giardini, M., Guglielmetti, L., Peros, G., Solimene, F., Aghayeva, A., Hamzaoglu, I., Sahin, I., Akaydin, E., Aliyeva, Z., Aytac, E., Baca, B., Dulgeroglu, O., Ozben, V., Ozmen, B. B., Uras, C., Arikan, A. E., Bilgin, I. A., Bozkirli, B., Ceyhan, G. O., Kara, H., Karahasanoglu, T., Celik, H., Meydanli, M. M., Akilli, H., Ayhan, A., Kuscu, E., Onan, M. A., Akgor, U., Dincer, H. A., Erol, T., Gultekin, M., Orhan, N., Ozgul, N., Salman, M. C., Soyak, B., Alhamed, A., Ergun, S., Ozcelik, M. F., Sanli, A. N., Uludag, S. S., Velidedeoglu, M., Zengin, A. K., Bozkurt, M. A., Kara, Y., Kocatas, A., Cimenoglu, B., Demirhan, R., Saracoglu, K., Azamat, I. F., Balik, E., Bugra, D., Giray, B., Kulle, C. B., Taskiran, C., Vatansever, D., Gozal, K., Guler, S. A., Koken, H., Tatar, O. C., Utkan, N. Z., Yildirim, A., Yuksel, E., Akin, E., Altintoprak, F., Bayhan, Z., Cakmak, G., Capoglu, R., Celebi, F., Demir, H., Dikicier, E., Firat, N., Gonullu, E., Kamburoglu, M. B., Kocer, B., Kucuk, I. F., Mantoglu, B., Colak, E., Kucuk, G. O., Uyanik, M. S., Goksoy, B., Bozkurt, E., Citgez, B., Mihmanli, M., Tanal, M., Yetkin, G., Akalin, M., Arican, C., Avci, E. K., Aydin, C., Demirli Atici, S., Emiroglu, M., Kaya, T., Kebabci, E., Kilinc, G., Kirmizi, Y., Ogucu, H., Salimoglu, S., Sert, I., Tugmen, C., Tuncer, K., Uslu, G., Yesilyurt, D., Karaman, E., Kolusari, A., Yildiz, A., Benson, O., Lule, H., Agilinko, J., Ahmeidat, A., Barabasz, M., Bekheit, M., Cheung, L. K., Colloc, T., Cymes, W., Elhusseini, M., Gradinariu, G., Hannah, A., Kamera, B. S., Mignot, G., Shaikh, S., Sharma, P., Abu-Nayla, I., Agrawal, A., Al-Mohammad, A., Ali, S., Ashcroft, J., Azizi, A., Baker, O., Balakrishnan, A., Byrne, M., Colquhoun, A., Cotter, A., Coughlin, P., Davies, R. J., Durrani, A., Elshaer, M., Fordington, S., Forouhi, P., Georgiades, F., Grimes, H., Habeeb, A., Hudson, V., Hutchinson, P., Irune, E., Jah, A., Khan, D. Z., Kyriacou, H., Lamb, B., Liau, S., Luke, L., Mahmoud, R., Mannion, R., Masterson, L., Mitrofan, C. G., Mohan, M., Morris, A., Murphy, S., O'Neill, R., Price, S., Pushpa-Rajah, J., Raby-Smith, W., Ramzi, J., Rooney, S., Santarius, T., Singh, A., Tan, X. S., Townson, A., Tweedle, E., Walker, C., Waseem, S., Yordanov, S., Jones, T., Kattakayam, A., Loh, C., Lunevicius, R., Pringle, S., Schache, A., Sheel, A., Rossborough, C., Angelou, D., Choynowski, M., Mcaree, B., Mccanny, A., Neely, D., Tutoveanu, G., Ahad, S., De La Cruz Monroy, M. F. I., Mosley, F., Oktseloglou, V., Alanbuki, A., Patel, M., Shabana, A., Perera, E., Raveendran, D., Ravi-Shankar, K., Thiruchelvam, J., Arrowsmith, L., Campbell, W., Grove, T., Kontovounisios, C., Warren, O., Rolland, P., Aggarwal, A., Brown, S., Jelley, C., Neal, N., Clifford, R., Eardley, N., Krishnan, E., Manu, N., Martin, E., Roy Mahapatra, S., Serevina, O. L., Smith, C., Vimalachandran, D., Bordenave, M., Houston, R., Putnam, G., Robson, A., Tustin, H., Emslie, K., Labib, P. L., Marchbank, A., Miller, D., Minto, G., Natale, J., Nwinee, H., Panahi, P., Rogers, L., Abubakar, A., Akhter Rahman, M. M., Ko, K. Y. K., O'Brien, H., Sasapu, K., Woodun, H., Inglis, R., Ng, H. J., De Gea Rico, A., Ghazali, N., Lambert, J., Markose, G., Math, S., Sarantitis, I., Shrestha, D., Sultana, A., Taggarsi, M., Timbrell, S., Vaz, O. P., Vitone, L., Day, A., Dent, H., Fahim, M., Waheed, S., Hunt, A., Laskar, N., Gupta, A., Steinke, J., Thrumurthy, S., Massie, E., Mcgivern, K., Rutherford, D., Wilson, M., Hardie, J., Kazzaz, S., Handa, S., Kaushal, M., Kler, A., Patel, P., Redfern, J., Tezas, S., Aawsaj, Y., Amonkar, S., Blackwell, L., Blake, D., Carter, J., Emerson, H., Fisher, A., Katory, M., Korompelis, P., Mccormick, W., Mustafa, A., Pearce, L., Ratnavelu, N., Reehal, R., Kretzmer, L., Lalou, L., Manku, B., Parwaiz, I., Stafford, J., Abdelkarim, M., Asqalan, A., Gala, T., Ibrahim, S., Maw, A., Mithany, R., Morgan, R., Sundaram Venkatesan, G., Ang, K., Caruana, E. J., Chowdhry, M. F., Mohammad, A., Nakas, A., Rathinam, S., Boal, M., Brown, O., Dwerryhouse, S., Higgs, S., Vallance, A., Boyd, E., Irvine, V., Kirk, A., Bakolas, G., Boulton, A., Chandock, A., Khan, T., Kumar, M., Agoston, P., Bille, A., Challacombe, B., Fraser, S., Harrison-Phipps, K., King, J., Mehra, G., Mills, L., Najdy, M., Nath, R., Okiror, L., Pilling, J., Rizzo, V., Routledge, T., Sayasneh, A., Stroman, L., Wali, A., Fehervari, M., Fotopoulou, C., Habib, N., Hamrang-Yousefi, S., Jawad, Z., Jiao, L., Pai, M., Ploski, J., Rajagopal, P., Saso, S., Sodergren, M., Spalding, D., Laws, S., Hardie, C., Mcnaught, C., Alam, R., Budacan, A., Cahill, J., Kalkat, M., Karandikar, S., Kenyon, L., Naumann, D., Patel, A., Ayorinde, J., Chase, T., Cuming, T., Ghanbari, A., Humphreys, L., Tayeh, S., Aboelkassem Ibrahim, A., Bichoo, R., Cao, H., Chai, A. K. W., Choudhury, J., Evans, C., Fitzjohn, H., Ikram, H., Langstroth, M., Loubani, M., Mcmillan, A., Nazir, S., Qadri, S. S. A., Robinson, A., Ross, E., Sehgal, T., Wilkins, A., Dixon, J., Dunning, J., Freystaetter, K., Jha, M., Lester, S., Madhavan, A., Thulasiraman, S. V., Viswanath, Y., Curl-Roper, T., Delimpalta, C., Liao, C. C. L., Velchuru, V., Westwood, E., Belcher, E., Bond-Smith, G., Chidambaram, S., Di Chiara, F., Fasanmade, K., Fraser, L., Fu, H., Ganau, M., Gore, S., Graystone, J., Jeyaretna, D., Khatkar, H., Lami, M., Maher, M., Mastoridis, S., Mihai, R., Piper, R., Prabhu, S., Risk, O. B. F., Selbong, U., Shah, K., Smillie, R., Soleymani majd, H., Sravanam, S., Stavroulias, D., Tebala, G. D., Vatish, M., Verberne, C., Wallwork, K., Winter, S., Bhatti, M. I., Boyd-Carson, H., Elsey, E., Gemmill, E., Herrod, P., Jibreel, M., Lenzi, E., Saafan, T., Sapre, D., Sian, T., Watson, N., Athanasiou, A., Bourke, G., Bradshaw, L., Brunelli, A., Burke, J., Coe, P., Costigan, F., Elkadi, H., Johnstone, J., Kanatas, A., Kantola, V., Kaufmann, A., Laios, A., Lam, S., Macinnes, E., Munot, S., Nahm, C., Otify, M., Pompili, C., Smith, I., Theophilou, G., Toogood, G., Wade, R., Ward, D., West, C., Annamalai, S., Ashmore, C., Boddy, A., Hossain, T., Kourdouli, A., Gvaramadze, A., Jibril, A., Prusty, L., Thekkinkattil, D., Harky, A., Shackcloth, M., Askari, A., Cirocchi, N., Kudchadkar, S., Patel, K., Sagar, J., Shaw, S., Talwar, R., Abdalla, M., Edmondson, R., Ismail, O., Jones, D., Newton, K., Stylianides, N., Aderombi, A., Andaleeb, U., Bajomo, O., Beatson, K., Garrett, W., Mehmood, M., Ng, V., Al-Habsi, R., Divya, G. S., Keeler, B., Al-Sarireh, B., Egan, R., Harries, R., Henry, A., Kittur, M., Li, Z., Parkins, K., Soliman, F., Spencer, N., Thompson, D., Burgess, C., Gemmell, C., Grieco, C., Hollyman, M., Hunt, L., Morrison, J., Ojha, S., Ryan, N., Abbadessa, F., Barnard, S., Dawe, N., Hammond, J., Mahmoud Ali, F., Mcpherson, I., Mellor, C., Moir, J., Pandanaboyana, S., Powell, J., Rai, B., Roy, C., Sachdeva, A., Saleh, C., Tingle, S., Williams, T., Manickavasagam, J., Mcdonald, C., Mcgrath, N., Mcsorley, N., Ragupathy, K., Ramsay, L., Solth, A., Kakisi, O., Seebah, K., Shaikh, I., Sreedharan, L., Youssef, M., Shah, J., Ameerally, P., Mclarty, N., Mills, S., Shenfine, A., Sahnan, K., Abu, J., Addae-Boateng, E., Bratt, D., Brock, L., Burnside, N., Cadwell-Sneath, S., Gajjar, K., Gan, C., Grundy, C., Hallam, K., Hassell, K., Hawari, M., Joshi, A., Khout, H., Konstantinidi, K., Lee, R. X. N., Nunns, D., Schiemer, R., Walton, T., Weaver, H., Whisker, L., Williamson, K., Mcveigh, J., Myatt, R., Williams, M. A., Kaur, R., Leung, E., Michel, M., Patil, S., Ravindran, S., Sarveswaran, J., Scott, L., Edmond, M., King, E., Almond, M., Breik, O., Cato, L. D., Idle, M., Kamal, M., Kisiel, A., Kulkarni, R., Mak, J. K. C., Martin, T., Nankivell, P., Parente, A., Parmar, S., Pathanki, A. M., Phelan, L., Praveen, P., Saeed, S., Sharma, N., Singh, J., Tirotta, F., Vijayan, D., Geddes, A., Mccaul, J., Mcmahon, J., Khan, A. H., Khan, F., Mansuri, A., Mukherjee, S., Sarigul, M., Singh, S., Tan, K. 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Macdonald, M, Narice, B, Rominiyi, O, Thompson, A, Varley, I, Drake, T, Harrison, E, Linder, G, Mayes, J, Mcgregor, R, Skipworth, R, Zamvar, V, Hawkin, P, Raymond, T, Ryska, O, Baron, R, Dunne, D, Gahunia, S, Halloran, C, Howes, N, Mckinney, R, Mcnicol, F, Russ, J, Szatmary, P, R Tan, J, Thomas, A, Whelan, P, Anzak, A, Banerjee, A, Fuwa, O, Hughes, F, D Jayasinghe, J, Knowles, C, Kocher, H, Leal Silva, I, S Ledesma, F, Minicozzi, A, Navaratne, L, Rahman, R, Ramamoorthy, R, Sohrabi, C, Thaha, M, Thakur, B, Venn, M, Yip, V, Baumber, R, Parry, J, Evans, S, Jeys, L, Morris, G, Parry, M, Ahmadi, N, Aresu, G, M Barrett-Brown, Z, S Coonar, A, Durio Yates, H, Gearon, D, Hogan, J, King, M, Peryt, A, S Pradeep, I, Adishesh, M, Atherton, R, Baxter, K, Brocklehurst, M, Chaudhury, M, Krishnamohan, N, Mcaleer, J, Owens, G, Parkin, E, Patkar, P, Phang, I, Aladeojebi, A, Ali, M, Barmayehvar, B, Gaunt, A, Gowda, M, Halliday, E, Kitchen, M, Mansour, F, Thomas, M, Zakai, D, Abbassi-Ghadi, N, Assalaarachchi, H, Currie, A, Flavin, M, Frampton, A, Hague, M, Hammer, C, Hopper, J, Horsnell, J, Humphries, S, Kamocka, A, K Madhuri, T, Preston, S, Singh, P, Stebbing, J, Tailor, A, Walker, D, Aljanadi, F, Jones, M, Mhandu, P, O'Donnell, C, Turkington, R, Al-Ishaq, Z, Bhasin, S, S Bodla, A, Burahee, A, Crichton, A, Fossett, R, Pigadas, N, Pickford, S, Rahman, E, Snee, D, Vidya, R, Yassin, N, Fountain, D, T Hasan, M, Karabatsou, K, Laurente, R, Pathmanaban, O, Al-Mukhtar, A, Edwards, J, Giblin, A, Kelty, C, Lee, M, Lye, G, Newman, T, Sharkey, A, Steele, C, Sureshkumar Shah, N, Whitehall, E, Athwal, R, Baker, A, Jones, L, Konstantinou, C, Ramcharan, S, Vatish, J, Wilkin, R, Ethunandan, M, K Sekhon, G, Shields, H, Singh, R, Wensley, F, Lawday, S, Lyons, A, Abbott, T, Anwar, S, Ghufoor, K, Chung, E, Hagger, R, Hainsworth, A, Karim, A, Owen, H, Ramwell, A, Williams, K, Baker, C, Davies, A, Gossage, J, Kelly, M, Knight, W, Hall, J, Harris, G, James, G, Kang, C, J Lin, D, D Rajgor, A, Royle, T, Scurrah, R, Steel, B, J Watson, L, Choi, D, Hutchison, R, Jain, A, Luoma, V, Marcus, H, May, R, Menon, A, Pramodana, B, Webber, L, A Aneke, I, Asaad, P, Brown, B, Collis, J, Duff, S, Khan, A, Moura, F, Wadham, B, Warburton, H, Elmoslemany, T, Jenkinson, M, Millward, C, Zakaria, R, Mccluney, S, Parmar, C, Shah, S, Allison, J, S Babar, M, Collard, B, Goodrum, S, Lau, K, Scott, R, Thomas, E, Whitmore, H, Balasubramaniam, D, Jayasankar, B, Kapoor, S, Ramachandran, A, Elhamshary, A, Imam, Smb, Kapriniotis, K, Kasivisvanathan, V, Lindsay, J, Rakhshani-Moghadam, S, Beech, N, Chand, M, Green, L, Kalavrezos, N, Kiconco, H, Mcewen, R, Schilling, C, Sinha, D, Pereca, J, Chopra, S, Egbeare, D, Thomas, R, Combellack, T, Jones, Sef, Kornaszewska, M, Mohammed, M, Sharma, A, Tahhan, G, Valtzoglou, V, Williams, J, Eskander, P, Gash, K, Gourbault, L, Hanna, M, Maccabe, T, Newton, C, Olivier, J, Rozwadowski, S, Teh, E, West, D, Al-Omishy, H, Baig, M, Bates, H, Di Taranto, G, Dickson, K, Dunne, N, Gill, C, Howe, D, Jeevan, D, Khajuria, A, Martin-Ucar AMcEvoy, K, Naredla, P, Robertson, S, Sait, M, R Sarma, D, Shanbhag, S, Shortland, T, Simmonds, S, Skillman, J, Tewari, N, Walton, G, A Akhtar, M, Brunt, A, Mcintyre, J, Milne, K, M Rashid, M, Sgro, A, E Stewart, K, Turnbull, A, Aguilar Gonzalez, M, Talukder, S, Boyle, C, Fernando, D, Gallagher, K, Laird, A, Tham, D, Bath, M, Patki, P, Tanabalan, C, Arif, T, Magee, C, Nambirajan, T, Powell, S, Vinayagam, R, Flindall, I, Hanson, A, Mahendran, V, Green, S, Lim, M, Macdonald, L, Miu, V, Onos, L, Sheridan, K, Young, R, Alam, F, Griffiths, O, Houlden, C, Jones, R, S Kolli, V, K Lala, A, Leeson, S, Peevor, R, Seymour, Z, Chen, L, Henderson, E, Loehrer, A, Brown, K, Fleming, D, Heron, C, Hill, C, Kay, H, Leede, E, Mcelhinney, K, Olson, K, C Osterberg, E, Riley, C, Srikanth, P, Thornhill, M, Blazer, D, Dilalla, G, S Hwang, E, Lee, W, Lidsky, M, Plichta, J, Rosenberger, L, Scheri, R, Turnage, K, Visgauss, J, Zani, S, Farma, J, Clark, J, Kwon, D, Etchill, E, E Gabre-Kidan AJenny, H, Kent, A, Ladd, M, Long, C, Malapati, H, Margalit, A, Rapaport, S, Rose, J, Stevens, K, Tsai, L, Vervoort, D, Yesantharao, P, Dehal, A, Klaristenfeld, D, Huynh, K, Brown, L, Ganly, I, Mullinax, J, Gusani, N, Hazelton, J, Maines, J, S Oh, J, Ssentongo, A, Ssentongo, P, Azam, M, Choudhry, A, Marx, W, Fleming, J, Fuson, A, Gigliotti, J, Ovaitt, A, Ying, Y, K Abel, M, Andaya, V, Bigay, K, A Boeck, M, Chern, H, Corvera, C, El-Sayed, I, Glencer, A, Ha, P, Hamilton, Bc, Heaton, C, Hirose, K, M Jablons, D, Kirkwood, K, Z Kornblith, L, R Kratz, J, Lee, R, N Miller, P, Nakakura, E, Nunez-Garcia, B, O'Donnell, R, Ozgediz, D, Park, P, Robinson, B, Sarin, A, Sheu, B, Varma, M, Wai, K, Wustrack, R, J Xu, M, Beswick, D, Goddard, J, Manor, J, Song, J, Fullmer, T, Gaskill, C, Gross, N, Kiong, K, L Roland, C, N Zafar, S, Abdallah, M, Abouassi, A, Almasri, M, Kulkarni, G, Marwan, H, Mehdi, M, Aoun, S, S Ban, V, H Batjer, H, Caruso, J, Abbott, D, Acher, A, Aiken, T, Barrett, J, Foley, E, Schwartz, P, Hawkins, A, Maiga, A, Laufer, J, Scasso, S, Surgery, Graduate School, Glasbey, J, Nepogodiev, D, Simoes, J, Omar, O, Li, E, Abou Chaar, M, Chaudhry, D, Videria, J, Gujjuri, R, Kaafarani, H, Minaya-Bravo, A, Mckay, S, Roberts, K, Miguel-Mendez, C, Smart, N, Stewart, G, Institut de Recherche sur les Maladies Virales et Hépatiques (IVH), Université de Strasbourg (UNISTRA)-Institut National de la Santé et de la Recherche Médicale (INSERM), Laboratoire des sciences de l'ingénieur, de l'informatique et de l'imagerie (ICube), École Nationale du Génie de l'Eau et de l'Environnement de Strasbourg (ENGEES)-Université de Strasbourg (UNISTRA)-Institut National des Sciences Appliquées - Strasbourg (INSA Strasbourg), Institut National des Sciences Appliquées (INSA)-Institut National des Sciences Appliquées (INSA)-Institut National de Recherche en Informatique et en Automatique (Inria)-Les Hôpitaux Universitaires de Strasbourg (HUS)-Centre National de la Recherche Scientifique (CNRS)-Matériaux et Nanosciences Grand-Est (MNGE), Université de Strasbourg (UNISTRA)-Université de Haute-Alsace (UHA) Mulhouse - Colmar (Université de Haute-Alsace (UHA))-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS)-Université de Strasbourg (UNISTRA)-Université de Haute-Alsace (UHA) Mulhouse - Colmar (Université de Haute-Alsace (UHA))-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS)-Réseau nanophotonique et optique, Université de Strasbourg (UNISTRA)-Université de Haute-Alsace (UHA) Mulhouse - Colmar (Université de Haute-Alsace (UHA))-Centre National de la Recherche Scientifique (CNRS)-Université de Strasbourg (UNISTRA)-Centre National de la Recherche Scientifique (CNRS), COVIDSurg Collaborative, Kolias, Angelos [0000-0003-3992-0587], Stewart, Grant [0000-0003-3188-9140], Apollo - University of Cambridge Repository, Glasbey JC, Nepogodiev D, Simoes JFF, Omar O, Li E, Venn ML, Pgdme, Abou Chaar MK, Capizzi V, Chaudhry D, Desai A, Edwards JG, Evans JP, Fiore M, Videria JF, Ford SJ, Ganly I, Griffiths EA, Gujjuri RR, Kolias AG, Kaafarani HMA, Minaya-Bravo A, McKay SC, Mohan HM, Roberts KJ, San Miguel-Méndez C, Pockney P, Shaw R, Smart NJ, Stewart GD, Sundar Mrcog S, Vidya R, Bhangu AA, COVIDSurg Collaborative, Palmerini Emanuela, Frisoni Tommaso, Donati Davide, A Belvedere, P Bernante, P Bertoglio, S Boussedra, E Brunocilla, R Cipriani, G Cisternino, E De Crescenzo, P De Iaco, G Dondi, F Frio, E Jovine, F Mineo Bianchi, J Neri, D Parlanti, A M Perrone, A P Pezzuto, M Pignatti, V Pinto, G Poggioli, M Ravaioli, M Rottoli, R Schiavina, M Serenari, M Serra, P Solli, M Taffurelli, M Tanzanu, M Tesei, T Violante, S Zanotti, V Tonini, M Cervellera, A Gori, L Sartarelli, Glasbey, James C, Simoes, Joana F F, Venn, Mary L, Pgdme, null, Abou Chaar, Mohammad K, Edwards, Jonathan G, Evans, Jonathan P, Videria, Jose Flavio, Ford, Samuel J, Griffiths, Ewen A, Gujjuri, Rohan R, Kolias, Angelos G, Kaafarani, Haytham M A, McKay, Siobhan C, Mohan, Helen M, Roberts, Keith J, Smart, Neil J, Stewart, Grant D, Sundar Mrcog, Sudha, and Bhangu, Aneel A, Toia, F

Subjects
Male, Cancer Research, Outcome Assessment, International Cooperation, Settore MED/18 - CHIRURGIA GENERALE, Settore MED/19 - Chirurgia Plastica, 030230 surgery, Aged, Aged, 80 and over, COVID-19, Cohort Studies, Critical Care, Elective Surgical Procedures, Epidemics, Female, Humans, Logistic Models, Middle Aged, Neoplasms, Outcome Assessment, Health Care, Postoperative Complications, SARS-CoV-2, 0302 clinical medicine, Operating theater, cohort studies, Health care, middle aged, 80 and over, Medicine, Lung, Cancer, COVID-19/epidemiology, OUTCOMES, Manchester Cancer Research Centre, Pulmonary Complication, ORIGINAL REPORTS, aged, Oncology, 030220 oncology & carcinogenesis, Pneumonia & Influenza, Patient Safety, Elective Surgical Procedure, Life Sciences & Biomedicine, 6.4 Surgery, Cohort study, Human, medicine.medical_specialty, elective surgical procedures/methods, Logistic Model, Health Care, Clinical Sciences, Oncology and Carcinogenesis, Epidemic, [SDV.CAN]Life Sciences [q-bio]/Cancer, cancer surgery, SARS-CoV-2 pandemic, epidemics, COVIDSurg Collaborative, NO, outcome assessment, health care/methods, 03 medical and health sciences, male, Settore MED/28 - Malattie Odontostomatologiche, Clinical Research, 1112 Oncology and Carcinogenesis, Oncology & Carcinogenesis, Elective surgery, Elective Cancer Surgery in SARS-CoV-2, Elective Cancer Surgery in COVID-19, covid 19, sars-cov-2, Science & Technology, business.industry, Prevention, ResearchInstitutes_Networks_Beacons/mcrc, Evaluation of treatments and therapeutic interventions, 1103 Clinical Sciences, Pneumonia, Odds ratio, medicine.disease, Good Health and Well Being, neoplasms/surgery, critical care/methods, Emergency medicine, postoperative complications/prevention & control, Neoplasm, Postoperative Complication, Cohort Studie, business, aged, 80 and over, SARS-CoV-2/physiology, logistic models
Abstract

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks. Copyright © 2020 American Society of Clinical Oncology. All rights reserved. Bowel and Cancer Research; Sarcoma UK; Yorkshire Cancer Research; European Society of Coloproctology; National Institute for Health Research: 16.136.79; Bowel Disease Research Foundation; Urology Foundation Supported by a National Institute for Health Research (NIHR) Global Health Research Unit grant (NIHR 16.136.79) using UK aid from the UK government to support global health research, Association of Coloproctology of Great Britain and Ireland, Bowel & Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research. The funders had no role in the study design; data collection, analysis, and interpretation; or writing of this report. The views expressed are those of the authors and not necessarily those of the National Health Service, NIHR, or UK Department of Health and Social Care.

Published
2021

50. Are Mechanical Prostheses Valid Alternatives To Ross Procedure In Young Children Under 6 Years Old?

Author

Lazaros Kochilas, Jessica H. Knight, James D. St. Louis, Geetha Raghuveer, and Bahaaldin Alsoufi

Subjects
Pulmonary and Respiratory Medicine, medicine.medical_specialty, business.industry, Ross procedure, medicine.medical_treatment, Operative mortality, Hazard ratio, medicine.disease, Confidence interval, Article, Surgery, Aortic valve replacement, Aortic valve surgery, Medicine, Cumulative incidence, Congenital disease, Cardiology and Cardiovascular Medicine, business
Abstract

Background Aortic valve replacement in young children is associated with technical difficulties and potential morbidity. In contrast to the versatile Ross operation, mechanical prostheses (MP) are uncommonly used. Methods We examined transplant-free survival and cardiac reoperation among 124 young children (aged 1-6 years) who underwent the Ross operation (n = 84) or MP (n = 40) for congenital disease (1982-2003) using the Pediatric Cardiac Care Consortium database. We explored variables influencing outcomes. Results Children who received MP were operated in an earlier era and were more likely to have aortic regurgitation, conotruncal abnormalities, prior aortic valve surgery, and to need Konno annular enlargement. Although no significant differences were found in hospital mortality (1.2% vs 5.0%, P = .24) or 15-year transplant-free survival (94.1% vs 87.5%, P = .16) between Ross and MP recipients, survival diverged with later follow-up (91.3% vs 68.9%, respectively, at 25 years; P = .01). On multivariable regression analysis the association of MP use and transplant-free survival changed over time (hazard ratios, 0.8 [95% confidence interval, 0.1-4.4; P = .78] vs 6.0 [95% confidence interval, 0.6-63.1; P = .13], respectively) before and after 17 years. Cumulative incidence of cardiac reoperation at 10 years was 37.7% and 53.6% after the Ross procedure and MP, respectively (P = .05). The most common reoperation after the Ross procedure was conduit replacement and pacemaker ± automated internal cardiac defibrillator and after MP was pacemaker ± automated internal cardiac defibrillator and redo aortic valve replacement. Conclusions Over the study period there was a trend for increased Ross utilization. Interestingly MP use was associated with comparable operative mortality and survival up to 17 years, albeit with higher need for redo aortic valve replacement. On longer follow-up survival diverged with increased attrition in the MP group, likely because of late valve– and reoperation-related complications.

Published
2020

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