Evaluation of Laparoscopy Virtual Reality Training on the Improvement of Trainees' Surgical Skills.

Background and objectives: The primary objective was to evaluate the benefit of training with virtual reality simulation. The secondary objective was to describe the short-term skill acquisition obtained by simulation training and to determine the factors affecting its magnitude. Materials and Methods: We prospectively performed a three-stage evaluation: face, constructive, and predictive to evaluate the training with a laparoscopic simulator with haptic feedback. The participants (n = 63) were divided according to their level of experience into three groups: 16% residents; 46% specialists and 38% were consultants. Results: Face evaluation demonstrates the acceptance of the design and realism of the tasks; it showed a median score of eight (IQR 3) on a Likert scale and 54% of participants (n = 34) gave the tissue feedback a moderate rating. Constructive evaluation demonstrates the improvement of the participants in the training session and the ability of the designed task to distinguish the experienced from the inexperienced surgeon based on the performance score, at task I (transfer of pegs) and II (laparoscopic salpingectomy). There was an improvement in both tasks with a significant increase in score and reduction in time. The study showed that those with a high score at the pre-test recorded a high score post-test, showing a significant pair-wise comparison (Z) and correlation (p) showing a significant statistical significance (p < 0.001). The predictive evaluation demonstrates the beneficiary effect of training four weeks afterward on the practice of surgeons addressed with five questions. It showed an improvement regarding implementation into daily routine, performance of procedure, suturing, shortening of the operative time, and complication management. Conclusions: Virtual reality simulation established high ratings for both realism and training capacity, including clinical relevance, critical relevance, and maintaining training enthusiasm.

Magnetism.

Quackery in medicine is as old as medicine itself. In times of crisis desperate patients often believe extraordinary claims. In the annals of pain killer quack medicine, elixirs, nostrums and liniments hold a special position. The College of Dentistry at NYU received a collection of 234 bottles of nostrums and liniments dating from approximately 1850 through 1940. In this paper, the FOURTH in a series of articles featuring "Elixirs of the Past" we bring to light four more samples claiming to have magnetic properties: Dr. J.R. Miller's Magnetic Balm, Havens' Electromagnetic Liniment, Headman's Magnetic Liniments, and Magnetic Cream. It goes without saying that none of these had any magnetic properties. In 1906, Congress enacted The Pure Food and Drug Act to prohibit exaggerated or unsubstantiated claims in the marketing and labeling of household products and to control the use of potentially harmful ingredients. The modern-day use of internet advertisements to make unsupported claims is in some ways even more brazen than the advertisements from a century ago.

Snake Oil and Indian Liniment.

Quackery in medicine is as old as medicine itself. In times of crisis, desperate patients often believe extraordinary claims. In the annals of pain-killer quack medicine, snake oil, elixirs, nostrums and Indian liniments hold a special position. NYU College of Dentistry (NYUCD) has a collection of 234 bottles of such medicines dating from the mid-1800s through 1940. This paper is the fifth in a series of articles featuring "Elixirs of the Past" in which we bring to light six more samples with claims to traditional Chinese or American Indian medicine using snake oil: Virex Compound, Rattlesnake Bill's Oil, Electric Indian Liniment, The King of All Indian Oils, Millerhaus Antiseptic Oil and Celebrated Indian Lotion. The six examples are just a few quack medications linked to fraud, overdose, addiction or death. In 1906, Congress enacted The Pure Food and Drug Act and reinforced it with the Federal Food, Drug and Cosmetic Act of 1938, to stop unsubstantiated medicinal claims and control the use of addictive and dangerous substances. The modern-day use of social media to advertise quack medicine is in some ways even more brazen than selling patent medicine a century ago.

Opium.

Quackery in medicine is as old as medicine itself. In times of crisis, desperate patients often believe extraordinary claims. In the annals of pain-killer quack medicine, elixirs, nostrums and liniments hold a prominent position. NYU College of Dentistry (NYUCD) has a collection of 234 bottles of such medicines dating from the mid-1800s through 1940. This paper is the second in a series of articles featuring "Elixirs of the Past" in which we bring to light five more samples containing opium: Dr. B.J. Kendall's Instant Relief for Pain, Dr. Munn's Elixir of Opium, Dill's Balm of Life, Foley's Pain Relief, and Brown's Instant Relief for Pain. These are just five examples out of countless syrups, nostrums, balm or liniments that contained narcotics and were linked to overdose, addiction and sometimes death. In 1906, Congress enacted The Pure Food and Drug Act to stop unsubstantiated medicinal claims and control the use of addictive substances. The modern-day use of internet advertisements to make unsupported claims is in some ways even more brazen than the advertisements from a century ago. Indeed, the recent widespread use of prescription painkillers, along with the resulting epidemic in opiate addiction that has caused upwards of 50,000 deaths is a case in point.

Nivolumab-induced hypophysitis leading to hypopituitarism and secondary empty sella syndrome in a patient with non-small cell lung cancer.

We describe the clinical course of a 64-year-old woman with stage IVa lung adenocarcinoma who presented with over 1 month of fatigue, unintentional weight loss and emesis. She initiated treatment with nivolumab immunotherapy 1 year prior and had been tolerating the treatment well. A comprehensive workup revealed multiple endocrinological abnormalities consistent with hypophysitis leading to hypopituitarism in the form of central adrenal insufficiency and hypogonadism as well as a partially empty sella on imaging. This case demonstrates that while receiving novel forms of treatment such as immunotherapy, patients should be monitored closely for a wide range of adverse effects.

Clinical utility of routine postoperative morning cortisol monitoring in detecting new hypothalamic-pituitary-adrenal axis insufficiency following endoscopic transsphenoidal surgery for sellar lesions.

OBJECTIVE: Hypothalamic-pituitary-adrenal (HPA) axis dysfunction is a well-documented complication of transsphenoidal craniotomy (TSC) for sellar lesions. The authors aimed to assess their multidisciplinary approach to the diagnosis and treatment of postoperative hypocortisolemia utilizing conservative screening methods. METHODS: The authors performed a retrospective review of 257 patients who underwent TSC for pituitary adenoma (PA) or Rathke cleft cyst (RCC) at the University of Southern California between 2012 and 2017. Patients with preoperative adrenal insufficiency, Cushing's disease, or < 3 months of postoperative follow-up were excluded. Patient demographics, pathology, tumor characteristics, and complications were recorded. Postoperative day 1 (POD1) morning serum cortisol was assessed in all patients. Hypocortisolemia on POD1 (serum cortisol < 5 µg/dl) prompted a 7 am cortisol level measurement on POD 2 (POD2). Clinical signs and symptoms of hypocortisolemia were consistently monitored. After two serum cortisol levels < 5 µg/dl, or one serum level < 5 µg/dl plus a high clinical suspicion for HPA dysfunction, high-risk patients received glucocorticoid supplementation. RESULTS: Data on 165 patients were included in the analysis; there were 101 women (61.2%) and 64 men (38.7%). Preoperative diagnoses included nonfunctional adenoma (n = 97, 58.7%), growth hormone-secreting adenoma (n = 37, 22.4%), RCC (n = 18, 10.9%), prolactinoma (n = 8, 4.8%), and other (n = 5, 3.0%). One hundred thirty-eight patients (63.0%) had either suprasellar extension or cavernous sinus invasion. POD1 hypocortisolemia was diagnosed in 8 patients (4.8%). Of these patients, 2 (1.2%) were clinically asymptomatic and had normalized POD2 cortisol levels. Six patients (3.6%) had clinical symptoms and POD2 cortisol levels confirming HPA axis deficiency. Of these 6 patients treated with early glucocorticoid replacement, 2 patients recovered HPA axis function during follow-up, making the incidence of new, permanent HPA axis deficiency 2.5%. CONCLUSIONS: In the authors' institutional review, all patients warranting postoperative glucocorticoid replacement had both complicated surgical courses and associated clinical symptoms of hypocortisolemia. The authors' algorithm of withholding steroids until patients demonstrate clear evidence of postoperative hypocortisolemia is safe and clinically efficacious. Their data further suggest that routine postoperative cortisol screening may not be necessary following an uncomplicated operative resection, with gland preservation and the absence of clinical symptoms indicative of HPA dysfunction.

An unusual presentation of post gastric bypass hypoglycemia with both postprandial and fasting hypoglycemia

There has been an increasing awareness of post gastric bypass hypoglycemia (PGBH). Histopathologic findings from such patients who underwent partial/total pancreatomy, however, can vary widely from minimal changes to classic nesidioblastosis, making the pathologic diagnosis challenging. PGBH typically presents as postprandial hypoglycemia, as opposed to insulinoma, which presents as fasting hypoglycemia. Herein, we describe an unusual case of a patient with PGBH who initially presented with postprandial hypoglycemia three years after surgery, but later developed fasting hyperinsulinemic hypoglycemia as the disease progressed. Our hypothesis for this phenomenon is that this disease is progressive, and later in its course, the insulin release becomes dissociated from food stimulation and is increased at baseline. Future studies are needed to investigate the prevalence as well as etiology of this progression from postprandial to fasting hypoglycemia. Learning points: •• There has been an increasing awareness of post gastric bypass hypoglycemia (PGBH). •• Histopathologically, PGBH can vary from minimal changes to nesidioblastosis. •• Although uncommon, patients with PGBH after Roux-en-Y gastric bypass may present with both postprandial and fasting hyperinsulinemic hypoglycemia as disease progresses. •• Our hypothesis for this phenomenon is that the insulin release becomes dissociated from food stimulation and is increased at baseline with disease progression.