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Article ; Online: Invited Commentary: Present on Admission and Present at Time of Surgery: Timestamping for Quality Assessment and Benchmarking.

Kaafarani, Haytham Ma / Itani, Kamal Mf

Journal of the American College of Surgeons

2022 Volume 236, Issue 1, Page(s) 15–17

MeSH term(s)	Humans ; Benchmarking ; Hospitalization
Language	English
Publishing date	2022-12-15
Publishing country	United States
Document type	Journal Article
ZDB-ID	1181115-8
ISSN	1879-1190 ; 1072-7515
ISSN (online)	1879-1190
ISSN	1072-7515
DOI	10.1097/XCS.0000000000000463
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Article ; Online: Nationwide, County-Level Analysis of the Patterns, Trends, and System-Level Predictors of Opioid Prescribing in Surgery in the US: Social Determinants and Access to Mental Health Services Matter.

Gaitanidis, Apostolos / Dorken Gallastegi, Ander / Van Erp, Inge / Gebran, Anthony / Velmahos, George C / Kaafarani, Haytham Ma

Journal of the American College of Surgeons

2024 Volume 238, Issue 3, Page(s) 280–288

Abstract: Background: The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, ...

Abstract	Background: The diversion of unused opioid prescription pills to the community at large contributes to the opioid epidemic in the US. In this county-level population-based study, we aimed to examine the US surgeons' opioid prescription patterns, trends, and system-level predictors in the peak years of the opioid epidemic. Study design: Using the Medicare Part D database (2013 to 2017), the mean number of opioid prescriptions per beneficiary (OPBs) was determined for each US county. Opioid-prescribing patterns were compared across counties. Multivariable linear regression was performed to determine relationships between county-level social determinants of health (demographic, eg median age and education level; socioeconomic, eg median income; population health status, eg percentage of current smokers; healthcare quality, eg rate of preventable hospital stays; and healthcare access, eg healthcare costs) and OPBs. Results: Opioid prescription data were available for 1,969 of 3,006 (65.5%) US counties, and opioid-related deaths were recorded in 1,384 of 3,006 counties (46%). Nationwide, the mean OPBs decreased from 1.08 ± 0.61 in 2013 to 0.87 ± 0.55 in 2017; 81.6% of the counties showed the decreasing trend. County-level multivariable analyses showed that lower median population age, higher percentages of bachelor's degree holders, higher percentages of adults reporting insufficient sleep, higher healthcare costs, fewer mental health providers, and higher percentages of uninsured adults are associated with higher OPBs. Conclusions: Opioid prescribing by surgeons decreased between 2013 and 2017. A county's suboptimal access to healthcare in general and mental health services in specific may be associated with more opioid prescribing after surgery.
MeSH term(s)	Adult ; Aged ; Humans ; Analgesics, Opioid/therapeutic use ; Medicare Part D ; Mental Health Services ; Practice Patterns, Physicians' ; Social Determinants of Health ; United States ; Health Services Accessibility ; Surgical Procedures, Operative
Chemical Substances	Analgesics, Opioid
Language	English
Publishing date	2024-01-16
Publishing country	United States
Document type	Journal Article
ZDB-ID	1181115-8
ISSN	1879-1190 ; 1072-7515
ISSN (online)	1879-1190
ISSN	1072-7515
DOI	10.1097/XCS.0000000000000920
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Article ; Online: Injury-related emergency department visits and unplanned readmissions are associated with worse long-term mental and physical health.

Orlas, Claudia P / Herrera-Escobar, Juan P / Moheb, Mohamad El / Velmahos, Andriana / Sanchez, Sabrina E / Kaafarani, Haytham Ma / Salim, Ali / Nehra, Deepika

Injury

2023 Volume 54, Issue 9, Page(s) 110881

Abstract: Background: The risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for ...

Abstract	Background: The risk factors for unplanned emergency department (ED) visits and readmission after injury and the impact of these unplanned visits on long-term outcomes are not well understood. We aim to: 1) describe the incidence of and risk factors for injury-related ED visits and unplanned readmissions following injury and, 2) explore the relationship between these unplanned visits and mental and physical health outcomes 6-12 months post-injury. Methods: Trauma patients with moderate-to-severe injury admitted to one of three Level-I trauma centers were asked to complete a phone survey to assess mental and physical health outcomes at 6-12 months. Patient reported data on injury-related ED visits and readmissions was collected. Multivariable regression analyses were performed controlling for sociodemographic and clinical variables to compare subgroups. Results: Of 7,781 eligible patients, 4675 were contacted and 3,147 completed the survey and were included in the analysis. 194 (6.2%) reported an unplanned injury-related ED visit and 239 (7.6%) reported an injury-related readmission. Risk factors for injury-related ED visits included: younger age, Black race, a lower level of education, Medicaid insurance, baseline psychiatric or substance abuse disorder and penetrating mechanism. Risk factors for unplanned injury-related readmission included younger age, male sex, Medicaid insurance, substance abuse disorder, greater injury severity and penetrating mechanism of injury. Injury-related ED visits and readmissions were associated with significantly higher rates of PTSD, chronic pain and new injury-related functional limitations in addition to lower SF-12 mental and physical composite scores. Conclusions: Injury-related ED visits and unplanned readmissions are common after hospital discharge following treatment of moderate-severe injury and are associated with worse mental and physical health outcomes.
MeSH term(s)	United States/epidemiology ; Humans ; Male ; Patient Readmission ; Retrospective Studies ; Emergency Service, Hospital ; Hospitalization ; Trauma Centers
Language	English
Publishing date	2023-06-08
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	218778-4
ISSN	1879-0267 ; 0020-1383
ISSN (online)	1879-0267
ISSN	0020-1383
DOI	10.1016/j.injury.2023.110881
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Article ; Online: Intersection of Race, Ethnicity, and Sex in New Functional Limitations after Injury: Black and Hispanic Female Survivors at Greater Risk.

Orlas, Claudia P / Rentas, Courtney / Hau, Kaman / Ortega, Gezzer / Sanchez, Sabrina E / Kaafarani, Haytham Ma / Salim, Ali / Herrera-Escobar, Juan P

Journal of the American College of Surgeons

2022 Volume 236, Issue 1, Page(s) 47–56

Abstract: Background: The impact of disparities at the intersection of multiple marginalized social identities is poorly understood in trauma. We sought to evaluate the joint effect of race, ethnicity, and sex on new functional limitations 6 to 12 months ... ...

Abstract	Background: The impact of disparities at the intersection of multiple marginalized social identities is poorly understood in trauma. We sought to evaluate the joint effect of race, ethnicity, and sex on new functional limitations 6 to 12 months postinjury. Study design: Moderately to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing functional outcomes 6 to 12 months postinjury. Multivariate adjusted regression analyses were used to compare functional limitations by race and ethnicity alone, sex alone, and the interaction between both race and ethnicity and sex. The joint disparity and its composition were calculated across race and sex strata. Results: Included were 4,020 patients: 1,621 (40.3%) non-Hispanic White male patients, 1,566 (39%) non-Hispanic White female patients, 570 (14.2%) Black or Hispanic/Latinx male patients, and 263 (6.5%) Black or Hispanic/Latinx female patients (BHF). The risk-adjusted incidence of functional limitations was highest among BHF (50.6%) vs non-Hispanic White female patients (39.2%), non-Hispanic White male patients (35.8%), and Black or Hispanic male patients (34.6%; p < 0.001). In adjusted analysis, women (odds ratio 1.35 [95% CI 1.16 to 1.57]; p < 0.001) and Blacks or Hispanic patients (odds ratio 1.28 [95% CI 1.03 to 1.58]; p = 0.02) were more likely to have new functional limitations 6 to 12 months postinjury. When sex and race were analyzed together, BHF were more likely to have new functional limitations compared with non-Hispanic White male patients (odds ratio 2.12 [1.55 to 2.90]; p < 0.001), with 63.5% of this joint disparity being explained by the intersection of race and ethnicity and sex. Conclusion: More than half of the race and sex disparity in functional limitations experienced by BHF is explained by the unique experience of being both minority and a woman. Intermediate modifiable factors contributing to this intersectional disparity must be identified.
MeSH term(s)	Female ; Humans ; Male ; United States/epidemiology ; Ethnicity ; Hispanic or Latino ; Black People ; Minority Groups ; Survivors
Language	English
Publishing date	2022-12-15
Publishing country	United States
Document type	Journal Article
ZDB-ID	1181115-8
ISSN	1879-1190 ; 1072-7515
ISSN (online)	1879-1190
ISSN	1072-7515
DOI	10.1097/XCS.0000000000000428
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Article ; Online: Determinants of long-term physical and mental health outcomes after intensive care admission for trauma survivors.

Herrera-Escobar, Juan P / Lamarre, Taylor / Rosen, Jordan / Ilkhani, Saba / Haynes, Ashley N / Hau, Kaman / Jenkins, Kendall / Ruske, Jack / Wang, Joyce Y / Serventi-Gleeson, Jessica / Sanchez, Sabrina E / Kaafarani, Haytham Ma / Velmahos, George / Salim, Ali / Levy-Carrick, Nomi C / Anderson, Geoffrey A

American journal of surgery

2024

Abstract: Introduction: Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical ... ...

Abstract	Introduction: Collectively, studies from medical and surgical intensive care units (ICU) suggest that long-term outcomes are poor for patients who have spent significant time in an ICU. We sought to identify determinants of post-intensive care physical and mental health outcomes 6-12 months after injury. Methods: Adult trauma patients [ISS ≥9] admitted to one of three Level-1 trauma centers were interviewed 6-12 months post-injury to evaluate patient-reported outcomes. Patients requiring ICU admission ≥ 3 days ("ICU patients") were compared with those who did not require ICU admission ("non-ICU patients"). Multivariable regression models were built to identify factors associated with poor outcomes among ICU survivors. Results: 2407 patients were followed [598 (25%) ICU and 1809 (75%) non-ICU patients]. Among ICU patients, 506 (85%) reported physical or mental health symptoms. Of them, 265 (52%) had physical symptoms only, 15 (3%) had mental symptoms only, and 226 (45%) had both physical and mental symptoms. In adjusted analyses, compared to non-ICU patients, ICU patients were more likely to have new limitations for ADLs (OR = 1.57; 95% CI = 1.21, 2.03), and worse SF-12 mental (mean Δ = -1.43; 95% CI = -2.79, -0.09) and physical scores (mean Δ = -2.61; 95% CI = -3.93, -1.28). Age, female sex, Black race, lower education level, polytrauma, ventilator use, history of psychiatric illness, and delirium during ICU stay were associated with poor outcomes in the ICU-admitted group. Conclusions: Physical impairment and mental health symptoms following ICU stay are highly prevalent among injury survivors. Modifiable ICU-specific factors such as early liberation from ventilator support and prevention of delirium are potential targets for intervention.
Language	English
Publishing date	2024-02-14
Publishing country	United States
Document type	Journal Article
ZDB-ID	2953-1
ISSN	1879-1883 ; 0002-9610
ISSN (online)	1879-1883
ISSN	0002-9610
DOI	10.1016/j.amjsurg.2024.02.013
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Article ; Online: Appraising the Quality of Reporting of American College of Surgeons NSQIP Emergency General Surgery Studies.

El Moheb, Mohamad / Sabbagh, Hadi / Badin, Daniel / Mahmoud, Tala / Karam, Basil / El Hechi, Majed W / Kaafarani, Haytham Ma

Journal of the American College of Surgeons

2021 Volume 232, Issue 5, Page(s) 671–680

Abstract: Background: The quality of emergency general surgery (EGS) studies that use the American College of Surgeons-National Quality Improvement Program (ACS-NSQIP) database is variable. We aimed to critically appraise the methodologic reporting of EGS ACS- ... ...

Abstract	Background: The quality of emergency general surgery (EGS) studies that use the American College of Surgeons-National Quality Improvement Program (ACS-NSQIP) database is variable. We aimed to critically appraise the methodologic reporting of EGS ACS-NSQIP studies. Study design: We searched the PubMed ACS-NSQIP bibliography for EGS studies published from 2004 to 2019. The quality of reporting of each study was assessed according to the number of criteria fulfilled with respect to the 13-item RECORD statement and the 10-item JAMA Surgery checklist. Three criteria in each checklist were not applicable and were therefore excluded. An analysis was conducted comparing studies published in high and low impact factor (IF) journals. Results: We identified a total of 99 eligible studies. Twenty-six percent of studies were published in high IF journals, and 73% of the journals had a policy requiring adherence to reporting statements. The median number of criteria fulfilled for the RECORD statement (out of 10 items) and the JAMA Surgery checklist (out of 7 items) were both equal to 4 (interquartile range [IQR] 3, 5). Sixty-three percent of studies did not explain the methodology for data cleaning, 81% of studies did not describe the population selection process, and 55% did not discuss the implications of missing variables. There were no differences in overall scores between studies published in high and low IF journals. Conclusions: The methodologic reporting of EGS studies using ACS-NSQIP remains suboptimal. Future efforts should focus on improving adherence to the policies to mitigate potential sources of bias and improve the credibility of large database studies.
MeSH term(s)	Bibliographies as Topic ; Databases, Factual/standards ; Databases, Factual/statistics & numerical data ; Emergency Treatment/methods ; General Surgery/methods ; General Surgery/organization & administration ; General Surgery/standards ; General Surgery/statistics & numerical data ; Humans ; Quality Improvement ; Research Design/standards ; Treatment Outcome ; United States
Language	English
Publishing date	2021-02-15
Publishing country	United States
Document type	Journal Article
ZDB-ID	1181115-8
ISSN	1879-1190 ; 1072-7515
ISSN (online)	1879-1190
ISSN	1072-7515
DOI	10.1016/j.jamcollsurg.2021.01.012
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Article ; Online: Circulating cellular clusters are associated with thrombotic complications and clinical outcomes in COVID-19.

Dorken-Gallastegi, Ander / Lee, Yao / Li, Guansheng / Li, He / Naar, Leon / Li, Xuejin / Ye, Ting / Van Cott, Elizabeth / Rosovsky, Rachel / Gregory, David / Tompkins, Ronald / Karniadakis, George / Kaafarani, Haytham Ma / Velmahos, George C / Lee, Jarone / Frydman, Galit H

iScience

2023 Volume 26, Issue 7, Page(s) 107202

Abstract: We sought to study the role of circulating cellular clusters (CCC) -such as circulating leukocyte clusters (CLCs), platelet-leukocyte aggregates (PLA), and platelet-erythrocyte aggregates (PEA)- in the immunothrombotic state induced by COVID-19. Forty- ... ...

Abstract	We sought to study the role of circulating cellular clusters (CCC) -such as circulating leukocyte clusters (CLCs), platelet-leukocyte aggregates (PLA), and platelet-erythrocyte aggregates (PEA)- in the immunothrombotic state induced by COVID-19. Forty-six blood samples from 37 COVID-19 patients and 12 samples from healthy controls were analyzed with imaging flow cytometry. Patients with COVID-19 had significantly higher levels of PEAs (p value<0.001) and PLAs (p value = 0.015) compared to healthy controls. Among COVID-19 patients, CLCs were correlated with thrombotic complications (p value = 0.016), vasopressor need (p value = 0.033), acute kidney injury (p value = 0.027), and pneumonia (p value = 0.036), whereas PEAs were associated with positive bacterial cultures (p value = 0.033). In predictive
Language	English
Publishing date	2023-06-25
Publishing country	United States
Document type	Journal Article
ISSN	2589-0042
ISSN (online)	2589-0042
DOI	10.1016/j.isci.2023.107202
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Article ; Online: Severity Grading Systems for Intraoperative Adverse Events. A Systematic Review of the Literature and Citation Analysis.

Sayegh, Aref S / Eppler, Michael / Sholklapper, Tamir / Goldenberg, Mitchell G / Perez, Laura C / La Riva, Anibal / Medina, Luis G / Sotelo, Rene / Desai, Mihir M / Gill, Inderbir / Jung, James J / Kazaryan, Airazat M / Edwin, Bjørn / Biyani, Chandra Shekhar / Francis, Nader / Kaafarani, Haytham Ma / Cacciamani, Giovanni E

Annals of surgery

2023 Volume 278, Issue 5, Page(s) e973–e980

Abstract: Introduction: The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true ... ...

Abstract	Introduction: The accurate assessment and grading of adverse events (AE) is essential to ensure comparisons between surgical procedures and outcomes. The current lack of a standardized severity grading system may limit our understanding of the true morbidity attributed to AEs in surgery. The aim of this study is to review the prevalence in which intraoperative adverse event (iAE) severity grading systems are used in the literature, evaluate the strengths and limitations of these systems, and appraise their applicability in clinical studies. Methods: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. PubMed, Web of Science, and Scopus were queried to yield all clinical studies reporting the proposal and/or the validation of iAE severity grading systems. Google Scholar, Web of Science, and Scopus were searched separately to identify the articles citing the systems to grade iAEs identified in the first search. Results: Our search yielded 2957 studies, with 7 studies considered for the qualitative synthesis. Five studies considered only surgical/interventional iAEs, while 2 considered both surgical/interventional and anesthesiologic iAEs. Two included studies validated the iAE severity grading system prospectively. A total of 357 citations were retrieved, with an overall self/nonself-citation ratio of 0.17 (53/304). The majority of citing articles were clinical studies (44.1%). The average number of citations per year was 6.7 citations for each classification/severity system, with only 2.05 citations/year for clinical studies. Of the 158 clinical studies citing the severity grading systems, only 90 (56.9%) used them to grade the iAEs. The appraisal of applicability (mean%/median%) was below the 70% threshold in 3 domains: stakeholder involvement (46/47), clarity of presentation (65/67), and applicability (57/56). Conclusion: Seven severity grading systems for iAEs have been published in the last decade. Despite the importance of collecting and grading the iAEs, these systems are poorly adopted, with only a few studies per year using them. A uniform globally implemented severity grading system is needed to produce comparable data across studies and develop strategies to decrease iAEs, further improving patient safety.
MeSH term(s)	Humans ; Intraoperative Complications/diagnosis ; Intraoperative Complications/epidemiology ; Bibliometrics
Language	English
Publishing date	2023-04-27
Publishing country	United States
Document type	Systematic Review ; Journal Article
ZDB-ID	340-2
ISSN	1528-1140 ; 0003-4932
ISSN (online)	1528-1140
ISSN	0003-4932
DOI	10.1097/SLA.0000000000005883
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Article ; Online: Critically Appraising the Quality of Reporting of American College of Surgeons TQIP Studies in the Era of Large Data Research.

Gebran, Anthony / Bejjani, Antoine / Badin, Daniel / Sabbagh, Hadi / Mahmoud, Tala / El Moheb, Mohamad / Nederpelt, Charlie J / Joseph, Bellal / Nathens, Avery / Kaafarani, Haytham Ma

Journal of the American College of Surgeons

2022 Volume 234, Issue 6, Page(s) 989–998

Abstract: Background: The American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database is one of the most widely used databases for trauma research. We aimed to critically appraise the quality of the methodological reporting of ACS-TQIP ... ...

Abstract	Background: The American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database is one of the most widely used databases for trauma research. We aimed to critically appraise the quality of the methodological reporting of ACS-TQIP studies. Study design: The ACS-TQIP bibliography was queried for all studies published between January 2018 and January 2021. The quality of data reporting was assessed using the Strengthening the Reporting of Observational studies in Epidemiology-Reporting of Studies Conducted Using Observational Routinely Collected Health Data (STROBE-RECORD) statement and the JAMA Surgery checklist. Three items from each tool were not applicable and thus excluded. The quality of reporting was compared between high- and low-impact factor (IF) journals (cutoff for high IF is >90th percentile of all surgical journals). Results: A total of 118 eligible studies were included; 12 (10%) were published in high-IF journals. The median (interquartile range) number of criteria fulfilled was 5 (4-6) for the STROBE-RECORD statement (of 10 items) and 5 (5-6) for the JAMA Surgery checklist (of 7 items). Specifically, 73% of studies did not describe the patient population selection process, 61% did not address data cleaning or the implications of missing values, and 76% did not properly state inclusion/exclusion criteria and/or outcome variables. Studies published in high-IF journals had remarkably higher quality of reporting than those in low-IF journals. Conclusion: The methodological reporting quality of ACS-TQIP studies remains suboptimal. Future efforts should focus on improving adherence to standard reporting guidelines to mitigate potential bias and improve the reproducibility of published studies.
MeSH term(s)	Checklist ; Humans ; Quality Improvement ; Reproducibility of Results ; Research Design ; Surgeons
Language	English
Publishing date	2022-03-22
Publishing country	United States
Document type	Journal Article
ZDB-ID	1181115-8
ISSN	1879-1190 ; 1072-7515
ISSN (online)	1879-1190
ISSN	1072-7515
DOI	10.1097/XCS.0000000000000182
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Article ; Online: Role of Transfusion Volume and Transfusion Rate as Markers of Futility During Ultramassive Blood Transfusion in Trauma.

Dorken Gallastegi, Ander / Secor, Jordan D / Maurer, Lydia R / Dzik, Walter S / Saillant, Noelle N / Hwabejire, John O / Fawley, Jason / Parks, Jonathan / Kaafarani, Haytham Ma / Velmahos, George C

Journal of the American College of Surgeons

2022 Volume 235, Issue 3, Page(s) 468–480

Abstract: Background: Using a large national database, we evaluated the relationship between RBC transfusion volume, RBC transfusion rate, and in-hospital mortality to explore the presence of a futility threshold in trauma patients receiving ultramassive blood ... ...

Abstract	Background: Using a large national database, we evaluated the relationship between RBC transfusion volume, RBC transfusion rate, and in-hospital mortality to explore the presence of a futility threshold in trauma patients receiving ultramassive blood transfusion. Study design: The ACS-TQIP 2013 to 2018 database was analyzed. Adult patients who received ultramassive blood transfusion (≥20 units of RBC/24 hours) were included. RBC transfusion volume and rate were captured at the only 2 time points available in TQIP (4 hours and 24 hours), or time of death, whichever came first. Results: Among 5,135 patients analyzed, in-hospital mortality rate was 62.1% (n = 3,190), and 4-hour and 24-hour mortality rates were 17.53% (n = 900) and 42.41% (n = 2,178), respectively. RBC transfusion volumes at 4 hours (area under the receiver operating characteristic curve [AUROC] 0.59 [95% CI 0.57 to 0.60]) and 24 hours (AUROC 0.59 [95% CI 0.57 to 0.60]) had low discriminatory ability for mortality and were inconclusive for futility. Mean RBC transfusion rates calculated within 4 hours (AUROC 0.65 [95% CI 0.63 to 0.66]) and 24 hours (AUROC 0.85 [95% CI 0.84 to 0.86]) had higher discriminatory ability than RBC transfusion volume. A futility threshold was not found for the mean RBC transfusion rate calculated within 4 hours. All patients with a final mean RBC transfusion rate of ≥7 U/h calculated within 24 hours of arrival experienced in-hospital death (n = 1,326); the observed maximum length of survival for these patients during the first 24 hours ranged from 24 hours for a rate of 7 U/h to 4.5 hours for rates ≥21 U/h. Conclusion: RBC transfusion volume within 4 or 24 hours and mean RBC transfusion rate within 4 hours were not markers of futility. The observed maximum length of survival per mean RBC transfusion rate could inform resuscitation efforts in trauma patients receiving ongoing transfusion between 4 and 24 hours.
MeSH term(s)	Adult ; Blood Transfusion ; Hospital Mortality ; Humans ; Medical Futility ; ROC Curve ; Resuscitation ; Retrospective Studies ; Wounds and Injuries/complications ; Wounds and Injuries/therapy
Language	English
Publishing date	2022-08-10
Publishing country	United States
Document type	Journal Article
ZDB-ID	1181115-8
ISSN	1879-1190 ; 1072-7515
ISSN (online)	1879-1190
ISSN	1072-7515
DOI	10.1097/XCS.0000000000000268
Database	MEDical Literature Analysis and Retrieval System OnLINE

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