Patterns of Initial Opioid Prescribing to Opioid-Naive Patients
Objective: To determine the proportion of initial opioid prescriptions for opioid-naive patients prescribed by surgeons, dentists, and emergency physicians. We hypothesized that the percentage of such prescriptions grew as scrutiny of primary care and pain medicine opioid prescribing increased and guidelines were developed. Summary of Background Data: Data regarding the types of care for which opioid-naive patients are provided initial opioid prescriptions are limited. Methods: A retrospective cross-sectional study using a nationwide insurance claims dataset to study US adults aged 18 to 64 years. Our primary outco...
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Frailty as a Predictor of Death or New Disability After Surgery: A Prospective Cohort Study
Conclusions: Older people with frailty are significantly more likely to die or experience a new patient-reported disability after surgery. Clinicians performing frailty assessments before surgery should consider the CFS over the mFI as accuracy was similar, but ease of use and feasibility were higher. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Academic Advancement in Global Surgery: Appointment, Promotion, and Tenure: Recommendations From the American Surgical Association Working Group on Global Surgery
There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrativ...
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: REVIEW PAPERS Source Type: research

A Systematic Review of Behavioral Interventions to Decrease Opioid Prescribing After Surgery
Conclusions: We identified 6 types of behavioral strategies to decrease opioid prescription at discharge after surgery. Despite the risk of bias, almost all types of intervention seemed effective in reducing opioid prescriptions at discharge after surgery without negatively impacting pain control. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: REVIEW PAPERS Source Type: research

Does Sleeve Gastrectomy Expose the Distal Esophagus to Severe Reflux?: A Systematic Review and Meta-analysis
Conclusions: The postoperative prevalence of GERD, esophagitis, and BE following SG is significant. Symptoms do not always correlate with the presence of pathology. As the surgical uptake of SG continues to increase, there is a need to ensure that surgical decision-making and the consent process for this procedure consider these long-term complications while also ensuring their postoperative surveillance through endoscopic and physiological approaches. The long-term outcomes of this commonly performed bariatric procedure should be considered alongside its weight loss and metabolic effects. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: META-ANALYSES Source Type: research

Accuracy of Detecting Residual Disease After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: A Systematic Review and Meta-analysis
Conclusions: Current literature suggests insufficient accuracy of endoscopic biopsies, EUS, and 18F-FDG PET(-CT) as single modalities for detecting residual disease after nCRT for esophageal cancer. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: META-ANALYSES Source Type: research

Endovascular Aneurysm Repair With Inferior Mesenteric Artery Embolization for Preventing Type II Endoleak: A Prospective Randomized Controlled Trial
Conclusions: Our results demonstrated the effectiveness of IMA embolization during EVAR in high-risk patients for the prevention of T2EL, which is suggested for avoiding aneurysmal sac enlargement related to T2EL. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: RANDOMIZED CONTROLLED TRIALS Source Type: research

A Randomized Controlled Trial Evaluating the BREASTChoice Tool for Personalized Decision Support About Breast Reconstruction After Mastectomy
Objective: To evaluate a web-based breast reconstruction decision aid, BREASTChoice. Summary and Background Data: Although postmastectomy breast reconstruction can restore quality of life and body image, its morbidity remains substantial. Many patients lack adequate knowledge to make informed choices. Decisions are often discordant with patients’ preferences. Methods: Adult women with stages 0–III breast cancer considering postmastectomy breast reconstruction with no previous reconstruction were randomized to BREASTChoice or enhanced usual care (EUC). Results: Three hundred seventy-six patients were ...
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: RANDOMIZED CONTROLLED TRIALS Source Type: research

A Different Kind of Perioperative Surgical Home: Hospital at Home After Surgery
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Sacrificing the Future for the Sake of the Present
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Preserving an Academic Mission in the Face of Clinical Productivity Targets: Where Is the Academic Surgeon's Carrot?
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Harnessing the Power of Collaboration for Postmarket Surveillance of Hernia Mesh Devices
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Is There a Role for Liver Transplantation in the Treatment of Patients With Metastatic Colorectal Cancer?
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: FEATURES Source Type: research

Survival Following Liver Transplantation for Patients With Nonresectable Liver-only Colorectal Metastases
Conclusion: Liver transplantation provides the longest overall survival reported in colorectal cancer patient with nonresectable liver metastases. Improved selection criteria give patients with nonresectable colorectal liver metastases a 5-year overall survival comparable to other indications for liver transplantation. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: FEATURES Source Type: research

Bariatric Surgery Trends in the U.S.: 1% is the Loneliest Number
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: FEATURES Source Type: research

Changes in Utilization of Bariatric Surgery in the United States From 1993 to 2016
Conclusions: Perioperative safety of bariatric surgery improved over the last quarter-century. Despite growth in number of surgeries, utilization has only marginally increased. Addressing barriers for utilization may allow for greater access to surgical therapy. (Source: Annals of Surgery)
Source: Annals of Surgery - January 10, 2020 Category: Surgery Tags: FEATURES Source Type: research

Virtual and Augmented Reality in Liver Surgery
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: BRIEF CLINICAL REPORTS Source Type: research

Intraoperative 3D Hologram Support With Mixed Reality Techniques in Liver Surgery
Conclusions: This initial experience suggested that an intraoperative hologram with mixed reality techniques contributed to “last-minute simulation,” not for “navigation.” The intraoperative hologram might be a new next-generation operation-supportive tool in terms of spatial awareness, sharing, and simplicity. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: BRIEF CLINICAL REPORTS Source Type: research

Strictureplasty: Still an Important and Evolving Technique for Small Bowel Crohn's Disease
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: BRIEF CLINICAL REPORTS Source Type: research

Michelassi II Strictureplasty for Crohn's Disease: A New Side-to-Side Isoperistaltic Strictureplasty With Discontinuous Bowel Loops
Conclusions: The Michelassi II, or the end-to-side-to-side-to-end strictureplasty, is a variant of the original SSIS technique to address severe and extensive small bowel Crohn's disease presenting with 3 severely fibrotic and deformed bowel loops separated by 2 diseased segments with sequential strictures. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: BRIEF CLINICAL REPORTS Source Type: research

Leveraging the Incidence, Burden, and Fiscal Implications of Unplanned Hospital Revisits for the Prioritization of Prevention Efforts in Pediatric Surgery
Conclusions and Relevance: A small number of procedures account for a disproportionate burden of revisit-associated resource utilization in pediatric surgery. Gastrostomy, fundoplication, and appendectomy should be considered high-priority targets for prevention efforts within pediatric surgery. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Hospital Volume Matters: The Volume–Outcome Relationship in Open Juxtarenal AAA Repair
Objective: We studied whether the volume–outcome relationship would persist in more complex aortic operations. Background: Despite the added complexity of the involvement of the renal arteries in open juxtarenal abdominal aortic aneurysm (AAA) repair, the volume effect in these difficult operations has yet to be defined. Methods: We identified all patients in the Vascular Quality Initiative (VQI) who underwent open AAA repair from 2003 to 2016. We calculated each hospital's average annual volume for total open AAA repairs, and total open juxtarenal AAA repairs. We compared adjusted perioperative and long-term...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Redefining the Influence of Ethnicity on Simultaneous Kidney and Pancreas Transplantation Outcomes: A 15-year Single-center Experience
Objective: To examine the largest single-center experience of simultaneous kidney/pancreas transplantation (SPK) transplantation among African-Americans (AAs). Background: Current dogma suggests that AAs have worse survival following SPK than white recipients. We hypothesize that this national trend may not be ubiquitous. Methods: From August 30, 1999, through October 1, 2014, 188 SPK transplants were performed at the University of Alabama at Birmingham (UAB) and 5523 were performed at other US centers. Using Kaplan-Meier survival estimates and Cox proportional hazards regression, we examined the influence of recip...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Implications for Breast Cancer Restaging Based on the 8th Edition AJCC Staging Manual
Objective: We assessed the changes that have resulted from the latest breast cancer staging guidelines and the potential impact on prognosis. Background: Contemporary data suggest that combining anatomic staging and tumor biology yields a predictive synergy for determining breast cancer prognosis. This forms the basis for the American Joint Committee on Cancer's (AJCC) Staging Manual, 8th edition. We assessed the changes that have resulted from the new staging guidelines and the potential impact on prognosis. Methods: Women with stages I to III breast cancer from 2010 to 2014 in the National Cancer Data Base were p...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Surgical Transgastric Necrosectomy for Necrotizing Pancreatitis: A Single-stage Procedure for Walled-off Pancreatic Necrosis
Objective: The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients. Background: WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention. Methods: A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing interventio...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Textbook Outcome: Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery
Conclusions: TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Is Hepatectomy Justified for BRAF Mutant Colorectal Liver Metastases?: A Multi-institutional Analysis of 1497 Patients
Objective: To analyze clinical outcomes and prognostic variables of patients undergoing hepatic resection for BRAF mutant (BRAF-mut) colorectal liver metastases (CRLM). Background: Outcomes following hepatectomy for BRAF-mut CRLM have not been well studied. Methods: All patients who underwent hepatectomy for CRLM with complete resection and known BRAF status during 2001 to 2016 at 3 high-volume centers were analyzed. Results: Of 4124 patients who underwent hepatectomy for CRLM, 1497 had complete resection and known BRAF status. Thirty-five (2%) patients were BRAF-mut, with 71% of V600E mutation. Compared with BR...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

β-Blockade in Rectal Cancer Surgery: A Simple Measure of Improving Outcomes
Objective: To ascertain whether regular β-blocker exposure can improve short- and long-term outcomes after rectal cancer surgery. Background: Surgery for rectal cancer is associated with substantial morbidity and mortality. There is increasing evidence to suggest that there is a survival benefit in patients exposed to β-blockers undergoing non-cardiac surgery. Studies investigating the effects on outcomes in patients subjected to surgery for rectal cancer are lacking. Methods: All adult patients undergoing elective abdominal resection for rectal cancer over a 10-year period were recruited from the prospec...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Incidence and Efficacy of Stent Placement in Leak Management After Bariatric Surgery: An MBSAQIP Analysis
Conclusion: Placement of stents for management of leaks after bariatric surgery is common throughout the United States. The use of stents can be effective; however, it does not prevent reoperation and is associated with an increased likelihood of readmission. Both technique and resource utilization should be considered when choosing a management pathway for leaks. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Propensity Score–Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy
Introduction: Totally minimally invasive esophagectomy (TMIE) is increasingly used in treatment of patients with esophageal carcinoma. However, it is currently unknown if McKeown TMIE or Ivor Lewis TMIE should be preferred for patients in whom both procedures are oncologically feasible. Methods: The study was performed in 4 high-volume Dutch esophageal cancer centers between November 2009 and April 2017. Prospectively collected data from consecutive patients with esophageal cancer localized in the distal esophagus or gastroesophageal junction undergoing McKeown TMIE or Ivor Lewis TMIE were included. Patients were prop...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

First-year Analysis of the Operating Room Black Box Study
Conclusions: During elective laparoscopic operations, frequent intraoperative errors and events, variation in surgeons’ technical skills, and a high amount of environmental distractions were identified using the OR Black Box. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Increased Healthcare Utilization for Medical Comorbidities Prior to Surgery Improves Postoperative Outcomes
Objective: The purpose of this study was to evaluate the impact of optimization of preoperative comorbidities by nonsurgical clinicians on short-term postoperative outcomes. Summary background data: Preoperative comorbidities can have substantial effects on operative risk and outcomes. The modifiability of these comorbidity-associated surgical risks remains poorly understood. Methods: We identified patients with a major comorbidity (eg, diabetes, heart failure) undergoing an elective colectomy in a multipayer national administrative database (2010–2014). Patients were included if they could be matched to a pr...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Robotic Surgery Is Less Physically Demanding Than Laparoscopic Surgery: Paired Cross Sectional Study
Objective: To study musculoskeletal workload in experienced surgeons during laparoscopic surgery (LS) compared with robotic assisted laparoscopy (RALS). Background: 70–90% of surgeons who regularly perform LS report musculoskeletal symptoms, mainly in neck and shoulders. Data regarding the potential ergonomic benefits of RALS in a clinical setting is very limited. Methods: Twelve surgeons with advanced experience in both LS and RALS each performed 2 hysterectomies on the same day. LS was performed standing, RALS sitting, the latter allowing forearm and head support. Bipolar surface electromyogram (EMG) was re...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Detection of Deteriorating Patients on Surgical Wards Outside the ICU by an Automated MEWS-Based Early Warning System With Paging Functionality
Background: The establishment of early warning systems in hospitals was strongly recommended in recent guidelines to detect deteriorating patients early and direct them to adequate care. Upon reaching predefined trigger criteria, Medical Emergency Teams (MET) should be notified and directed to these patients. The present study analyses the effect of introducing an automated multiparameter early warning score (MEWS)-based early warning system with paging functionality on 2 wards hosting patients recovering from highly complex surgical interventions. Methods: The deployment of the system was accompanied by retrospective...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

Postoperative Surgical Site Infections: Understanding the Discordance Between Surveillance Systems
Conclusion: There is significant discordance in the determination of SSIs reported by the NHSN, NSQIP, and administrative data. The differences and limitations of each of these systems have to be recognized, especially when using these data for quality reports and pay for performance. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: ORIGINAL ARTICLES Source Type: research

A Pathway for Developing Postoperative Opioid Prescribing Best Practices
Conclusion: A pathway for creating evidence-based opioid-prescribing recommendations can be utilized in diverse practice environments and can lead to significantly decreased opioid prescribing without adversely affecting patient outcomes. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: REVIEW PAPERS Source Type: research

Driver Gene Mutations and Epigenetics in Colorectal Cancer
Objective: The majority of patients with colorectal cancer are diagnosed with locally advanced and/or disseminated disease, and treatment options include surgery in combination with cytotoxic chemotherapy regimens, biologics, and/or radiotherapy. Thus, colorectal cancer remains a heavy burden on society and health care systems. Mounting evidence show that driver gene mutations play only part of the role in carcinogenesis. Epigenetics are strongly implicated in initiation and progression of colorectal cancer along with major players such as intestinal microbiotic dysbiosis and chronic mucosal inflammation. To assess phe...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: REVIEW PAPERS Source Type: research

Prophylactic Negative Pressure Wound Therapy for Closed Laparotomy Incisions: A Meta-analysis of Randomized Controlled Trials
Conclusion: The adoption of NPWT for routine SSI prophylaxis following laparotomy is currently not supported and should be used primarily in the context of a clinical trial. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: META-ANALYSES Source Type: research

Laparoscopic Versus Open Pancreaticoduodenectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials
Conclusions: At current level of evidence, LPD shows no advantage over OPD. Limitations include high risk of bias and moderate to very low certainty of evidence. Further studies should focus on patient safety during LPD learning curves and the potential role of robotic surgery. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: META-ANALYSES Source Type: research

Inguinal Vascular Surgical Wound Protection by Incisional Negative Pressure Wound Therapy: A Randomized Controlled Trial—INVIPS Trial
Conclusion: NPWT on closed inguinal vascular surgical incisions in elective patients reduces the incidence of SSI. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: RANDOMIZED CONTROLLED TRIALS Source Type: research

Direct Oral Feeding Following Minimally Invasive Esophagectomy (NUTRIENT II trial): An International, Multicenter, Open-label Randomized Controlled Trial
Conclusion: Direct oral feeding after an esophagectomy does not affect functional recovery and did not increase incidence or severity of postoperative complications. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: RANDOMIZED CONTROLLED TRIALS Source Type: research

Understanding Our Own Biases as Surgeons: A Departmental Effort
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Anchoring to Zero Exposure: Opioid-free Minimally Invasive Surgery
Surgeons universally overprescribe opioids even in surgeries that are minimally invasive. Despite some drops in opioid prescribing nationally, surgeons and dentists have not changed their prescribing habits. Opioid guidelines are inherently flawed by the anchoring heuristic and efforts should center on decreasing exposures to opioids through a physician-lead response. No-opioid minimally invasive surgery should be the goal rather than the exception. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Should Zero Harm Be Our Goal?
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: SURGICAL PERSPECTIVES Source Type: research

Annals Editorial “Toward Understanding Healthcare Value”
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: FEATURES Source Type: research

Understanding the Costs Associated With Surgical Care Delivery in the Medicare Population
Background: Surgical care has been largely untargeted by Medicare payment reforms because episode costs associated with its delivery are not currently well understood. Objective: To quantify the costs of inpatient and outpatient surgery in the Medicare population. Methods: We analyzed claims data from a 20% national sample of Medicare beneficiaries (2008–2014). For a given study year, we identified all inpatient and outpatient procedures and constructed claims windows around them to define surgical episodes. After summing payments for services rendered during each episode, we totaled all inpatient and outpati...
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: FEATURES Source Type: research

Medicare Reimbursement for General Surgery Procedures: 2000 to 2018
Conclusion: After adjusting for inflation, Medicare reimbursement rates in general surgery have steadily decreased from 2000 to 2018. It is important that these trends are understood and considered by surgeons, healthcare administrators, and policy-makers in order to develop and implement agreeable models of reimbursement while ensuring access to quality general surgery care in the United States. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: FEATURES Source Type: research

Do We Know When to Use Minimally Invasive Approaches for Pancreas Resection?
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: FEATURES Source Type: research

The Miami International Evidence-based Guidelines on Minimally Invasive Pancreas Resection
Conclusion: The IG-MIPR using SIGN methodology give guidance to surgeons, hospital administrators, patients, and medical societies on the use and outcome of MIPR as well as the approach to be taken regarding this challenging type of surgery. (Source: Annals of Surgery)
Source: Annals of Surgery - December 21, 2019 Category: Surgery Tags: FEATURES Source Type: research

Comment on “Robotic Versus Video-assisted Lobectomy/Segmentectomy for Lung Cancers—A Meta-analysis”
No abstract available (Source: Annals of Surgery)
Source: Annals of Surgery - November 12, 2019 Category: Surgery Tags: LETTERS AND REPLIES Source Type: research