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This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies.From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted.Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being.Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.

Objective Headache disorders are exceedingly common in children and adolescents. The association between headaches, emotional stress, and disruptions in daily routines are well established. The goal of this study is to compare the experiences of patients with a preexisting diagnosis of a primary headache disorder in terms of headache frequency and severity, lifestyle techniques for headache prevention, screen use, and mood from before and after the onset of the COVID-19 pandemic. Methods Patients evaluated by the Headache Clinic at Children’s National Hospital between Summer 2020 and Winter 2021 were enrolled in a patient registry. Patients completed a questionnaire examining changes in headache characteristics and lifestyle factors since the onset of the COVID-19 pandemic. Results A total of 107 patients completed the survey. Since the pandemic’s onset, patients reported decreased physical activity (n = 59, 55%), increased frequency of chronic headaches from 40% (N = 42) to 50% (N = 54), and increased constant daily headaches from 22% (n = 24) to 36% (n = 38). Patients reported worsened anxiety (n = 58, 54%), mood (n = 50, 47%), and workload (n = 49, 46%). Sixty-one percent (n = 65) of patients reported using screens for school for more than 6 hours per day. The majority (n = 67, 63%) of patients indicated that they would prefer attending in-person school, with 14% (n = 15) responding that they preferred online school. Conclusion Since the COVID-19 pandemic’s onset, pediatric headache patients have experienced increasing headache frequency, worsening anxiety and mood, decreased physical activity, and increased screen usage. Although this study is limited by sample size and observational design, future population-based studies will further elucidate the impact of this pandemic on pediatric headache.

Background and Objectives Prolonged screen exposure is often cited as a trigger for pediatric headache. We present initial findings evaluating the association between adolescent screen use type, duration, and school disability. Methods New patients aged 12–17 years presenting to a headache clinic were screened and surveyed regarding headache characteristics, behavioral habits, school attendance, and screen utilization. Results 99 adolescents (29 M, 70 F) with average age 14.8 years and average headache frequency of 17 days per month completed the survey. Patients missed an average of five full days and three partial days of school due to headaches over the 90 days prior to survey completion. No statistically significant correlation was found between type or duration of screen exposure and monthly headache frequency, school attendance, or school functioning. A small positive association was seen between increasing duration of computer use, total hours screen use, and school absenteeism. While most adolescents reported prolonged screen use (58.6%) and luminosity (64.6%) worsened headaches, no statistical difference was seen in average number of headache days per month. Conclusions Average monthly headache frequency in an adolescent population was not significantly correlated with type or duration of screen exposure. Further studies are needed to elucidate how screen utilization impacts school related headache disability.

Background Approximately 38% of patients with colorectal cancer will develop isolated liver metastases. Sidedness of colon tumor is identified in non-metastatic and unresected metastatic cancers as predictive of survival, yet its dedicated analysis in resected liver metastases is minimal. Our primary aim was to assess whether left-sided primary tumors improve prognosis in stage IV cancer patients undergoing curative-intent liver metastasectomy; it was hypothesized that it would. Methods This is a retrospective, observational cohort study from 1996 to 2016 in a single tertiary-care facility. Survival from diagnosis was calculated via Kaplan–Meier method and compared between the right and left sides via log-rank analysis. Results Median survival differs significantly between colorectal tumors of the right and left origins after hepatic metastasectomy in 612 patients. In patients with right-sided tumors, median survival from diagnosis was 4.5 years (IQR 4.1–5.3), and 6.3 years (IQR 5.6–6.9) in those with left tumors (HR 1.5, 95% CI 1.38–1.60, p Conclusion As in studies on earlier-stage or unresected metastatic disease, tumor sidedness is an important prognostic factor in patient survival with liver metastasectomy. Clinical risk scores should include side of primary tumor. Further work is needed to determine the molecular basis for this difference.

Background Pancreaticoduodenectomy (PD) incurs a surgical site infection rate of up to 18%. Published rates after minimally invasive PD are comparable or superior to open, but data are limited to high-volume, single-institution series. This study aimed to determine national outcomes. We hypothesized nationwide infections would be reduced with a minimally invasive approach. Materials and methods Using the newly available pancreatectomy-specific outcomes in National Surgical Quality Improvement Project, data on surgical site infection in PD were extracted from the procedure-targeted participant user file from 2014 to 2015. χ2 test determined correlation of infection with approach. Linear regression determined correlation of known parameters with infection rate. Results Overall infection rate was 24%. Compared with open, laparoscopic rates were lower (P = 0.001), but robotic rates were comparable with open. Stenting, longer operative times, and soft gland texture were associated with increased infection rates, whereas larger duct size and drains were associated with decreased rates (all P Conclusions Laparoscopic PD is associated with decreased surgical site infection on a national level. This represents the first procedure-targeted National Surgical Quality Improvement Project report on this endpoint. Despite greater infection rates than previously reported, these data support previous institutional reports of decreased infection rates with laparoscopic approach.

The current popularity of metabolic surgery has led to increasing attention to long-term nutritional complications.The purpose of this retrospective study is to accurately define the long-term incidence of clinically significant anemia after Roux-en-Y gastric bypass (RYGB) and to identify factors that contribute to increased risk.The study cohort consisted of 2116 patients who underwent RYGB with necessary laboratory information available, and with longitudinal follow-up available (mean 5.3 ± 3.3 yr). A concurrent cohort of nonoperated patients matched for age, sex, body mass index, and baseline hemoglobin was identified (N = 1126). The RYGB and control cohorts were followed longitudinally to estimate the percent that develop mild, moderate, or severe anemia using Kaplan-Meier analysis. Predictors of severe anemia within the RYGB cohort were identified using Cox regression.The percent developing postRYGB mild, moderate, and severe anemia was 27%, 9%, and 2% at 1 year postRYGB and increased to 68%, 33%, and 11% at 5 years postRYGB. As compared with the nonoperated control cohort, the RYGB cohort was more likely to develop mild anemia (hazard ratio [HR] = 1.36, P.001), moderate anemia (HR = 1.75, P.001), and severe anemia (HR = 1.87, P.001). Severity of anemia was associated with an increasing percentage of microcytosis (P.0001). Clinical factors independently associated with an increased risk of severe anemia within the RYGB cohort included females and males40 years of age (HR = 2.97, 95% confidence interval [CI] = 1.14, 7.75, P = .026), preoperative anemia (HR = 1.65, 95% CI = 1.19, 2.29, P = .0029), preoperative low ferritin level (HR = 2.28, 95% CI = 1.39, 3.74, P = .0029), and a rapid 6-month weight loss trajectory (HR = 1.71, 95% CI = 1.22, 2.38, P = .0018).The long-term incidence of clinically significant anemia after RYGB is alarmingly high and warrants more detailed study.

Background: Celiac artery stenosis and occlusion have been described rarely in patients undergoing pancreaticoduodenectomy (PD), although it occurs relatively frequently in this group. An arterial connection between the celiac and superior mesenteric arteries, known as the Arc of Buhler, provides alternative flow to the celiac distribution once the gastroduodenal artery (GDA) is ligated in PD. Case Presentation: A 69-year-old man, in whom pre- and intraoperative efforts to stent an occluded celiac artery failed, had sufficient retrograde flow from an unrecognized Arc of Buhler to maintain adequate hepatic arterial perfusion after ligation of the GDA during a PD. Conclusions: Although there are several case reports and case series regarding the management of celiac stenosis in PD, the impact of an Arc of Buhler variant in this setting has been rarely reported. This case report demonstrates the ability of an intact Arc of Buhler to maintain adequate hepatic perfusion after ligation of the GDA and avoid the potential morbidity of a hepatic artery bypass procedure.

A pilot study is underway to quantifyin vivothe uptake and distribution of Tc-99m Sestamibi in subjects without previous history of breast cancer using a dedicated SPECT-CT breast imaging system. Subjects undergoing diagnostic parathyroid imaging studies were consented and imaged as part of this IRB-approved breast imaging study. For each of the seven subjects, one randomly selected breast was imaged prone-pendant using the dedicated, compact breast SPECT-CT system underneath the shielded patient support. Iteratively reconstructed and attenuation and/or scatter corrected images were coregistered; CT images were segmented into glandular and fatty tissue by three different methods; the average concentration of Sestamibi was determined from the SPECT data using the CT-based segmentation and previously established quantification techniques. Very minor differences between the segmentation methods were observed, and the results indicate an average image-basedin vivoSestamibi concentration of0.10±0.16 μCi/mL with no preferential uptake by glandular or fatty tissues.

Heparin-induced thrombocytopenia (HIT) is a life-threatening, thrombotic disorder associated with development of anti–platelet factor 4 (anti-PF4)/heparin autoantibodies. Little is known about the antigenic and cellular requirements that initiate the immune response to these complexes. To begin to delineate mechanisms of autoantibody formation in HIT, we studied the immunizing effects of murine PF4 (mPF4)/heparin in mice with and without thymic function. Euthymic mice were injected with mPF4/heparin complexes, mPF4, heparin, or buffer. Mice injected with mPF4/heparin, but not mPF4 or heparin alone, developed heparin-dependent autoantibodies that shared serologic and functional characteristics of human HIT antibodies, including preferential binding to mPF4/heparin complexes and causing heparin- and FcRγIIA-dependent platelet activation. In contrast, athymic mice did not develop HIT-like antibodies. Taken together, these studies establish that PF4/heparin complexes are highly immunogenic and elicit self-reacting anti-PF4/heparin antibodies in a T cell–dependent manner.

The use of Tc-99m-Sestamibi in molecular breast imaging is common due to its preferential uptake in malignant tissue. However, quantification of the baseline uptake in normal, healthy breast tissue is not possible using planar-imaging devices. Using our dedicated breast SPECT-CT system, an IRB approved pilot study is underway to quantify mean activity in normal breast tissue, and to differentiate uptake between adipose and glandular tissues. A cohort of patients at normal breast cancer risk undergoing another diagnostic Sestamibi study was imaged using the breast SPECT-CT system. SPECT images were corrected and quantitatively reconstructed using previously developed methods, and registered with the CT images. The CT images were segmented, and the average activity concentration was measured for glandular, adipose, and total breast tissue. Results indicate no preferential uptake between tissues and low average uptake, which may be used to determine a universal threshold for cancer detection.

Background: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions. Objectives: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care. Design setting: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will. Results: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent (95% confidence interval [CI] 84.6–95.4%) of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% (95% CI 86.5–96.6%) defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% [95% CI 71.2–85.6%] vs. 22% [95% CI 14.4–28.8%], respectively; Case B 67% [95% CI 58.4–74.9%] vs. 33% [95% CI 25.1–1.6%], respectively; Case C 63% [95% CI 55.1–71.9%] vs. 37% [95% CI 28.1–44.9%]), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p < 0.0001); Case B, defibrillation increased from 40% to 59% (p < 0.0001); and Case C, defibrillation increased from 36% to 65% (p < 0.0001). Conclusions: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.

Patients undergoing cardiopulmonary bypass (CPB) represent a high-risk population for developing life-threatening complications of Heparin-Induced Thrombocytopenia and Thrombosis (HITT). Approximately 30-70% of patients undergoing CPB develop heparin dependent autoantibodies to PF4/heparin, which can provoke disease in susceptible individuals. To address the clinical relevance of bypass associated anti-PF4/heparin, we have created a rat model of autoimmune PF4/heparin in the setting of CPB. Sprague-Dawley rats were prepared for CPB using cannulae in the right external jugular vein for venous return to the CPB circuit and the ventral tail artery for arterial inflow. Rats were administered 0.3–0.4U/g heparin i.v. after cannulation, and were then connected to a miniaturized CPB system complete with a membrane oxygenator primed with 40 ml of blood from 2 syngeneic donors (each receiving 0.3U/g i.v. heparin). CPB was maintained for 75 minutes with a flow between 160–180 mls/kg/min (normal cardiac output in the rat) after which animals were decannulated and sacrificed for study over the ensuing 6 weeks. Control rats were subjected to a sham operation for which they received the same dose of heparin, as well as arterial and venous catheterization, but were not placed on CPB. Blood was collected from control animals or rats after CPB and tested for autoantibodies to rat PF4/heparin (rP+H) by ELISA. Rats were studied either after sham operation (n=6) or after CPB at the following time points: 15 minutes (n=15), 3 days (n=6), 16 days (n=25), and at 6 weeks (n=8). Rats undergoing CPB had markedly elevated anti-rP+H levels (as gauged by mean A450 nm ± SEM) 16 days after the procedure as compared to rats receiving sham operation (0.211 ± 04, 16 day CPB vs. 0.01 ± 0.01sham; P = 0