The use of modified four-dimensional computed tomography in patients with primary hyperparathyroidism: an argument for the abandonment of routine sestamibi single-positron emission computed tomography (SPECT).

BACKGROUND: Four-dimensional computed tomography (4D CT) has emerged as an extremely sensitive preoperative imaging modality for primary hyperparathyroidism compared with the historical use of sestamibi and ultrasound (US). Specialized volume rendering and technical modifications further enhance this technique for operative guidance while reducing radiation exposure. METHODS: Patients undergoing parathyroidectomy for primary hyperparathyroidism from December 2010 to September 2013, carried out by two surgeons at a tertiary cancer center, were evaluated. Comparison was made between the three imaging modalities (4D CT, sestamibi, and US) for preoperative localization rate and accuracy. Biochemical parameters and radiation exposure were also analyzed. RESULTS: A total of 202 patients were identified from the database and 200 patients were included in the analysis. All patients underwent 4D CT (100 %), 185 sestamibi (92.5 %) and 186 US (93 %). In patients with single-gland disease (n = 153), 4D CT, sestamibi, and US were positive in 96 %, 65.4 % and 57.7 % of patients, respectively and, when positive, were accurately localized in 97.2 %, 93.4 % and 96.3 % of patients, respectively. In patients with multigland disease (MGD) [n = 47], 4D CT, sestamibi, and US predicted MGD in 32 %, 0 %, and 13.6 % of patients, respectively. With our technique modification, radiation exposure from 4D CT approached that of sestamibi. CONCLUSIONS: Low-dose, modified 4D CT with volume rendering when compared with sestamibi has a statistically significant higher positivity rate, improved accuracy rate, provides excellent images, superior surgical planning, and has a comparable radiation exposure risk profile. Consideration should be made for the abandonment of routine sestamibi single-positron emission computed tomography (SPECT), with 4D CT as the preoperative imaging modality of choice.

Duodenal penetration of an inferior vena cava filter: case report and literature review.

The insertion of inferior vena cava filters (IVCF) is a well-known therapy used in the prevention of pulmonary embolism (PE). The incidence of IVCF-related complications is low and complete caval penetration of a filter with adjacent organ injury has a reported incidence of 0­1%. We report the case of an 18-year-old male who sustained a spinal cord injury after a motor vehicle crash. The patient received a prophylactic IVCF and subsequently presented with right flank pain, postprandial nausea, and vomiting. His exam was benign and a computed tomography scan revealed extra-caval penetration of the filter with struts within the duodenal lumen and psoas muscle. The patient underwent an exploratory laparotomy with extraction of the filter, inferior vena cava venorrhaphy, and repair of the duodenal injury. This complication illustrates the potential morbidity of a common procedure and emphasizes the importance of investigating the IVCF as a possible source of abdominal pain.

Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines.

INTRODUCTION: Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. MATERIALS AND METHODS: This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. RESULTS: This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). CONCLUSIONS: Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.

Attrition Rate in Military General Surgery GME and Effect on Quality of Military Programs.

INTRODUCTION: The attrition rate in civilian general surgery Graduate Medical Education (GME) is estimated at 20%, while estimates of attrition in military general surgery (MGS) GME programs using the same methodology are nearly twice that. We sought to identify the true attrition rate in MGS GME, identify factors influencing attrition, and examine the relationship between attrition and quality of MGS GME. METHODS: Deidentified data were collected on categorical general surgery residents matriculating from 2010 to 2013 from all 12 MGS residency programs. Information gathered included gender, medical degree, marital status, location of program, presence of a military-related interruption in training, and age at start of the categorical contract. For those who did not graduate, data on postgraduate year at time of attrition, reasons for attrition, and deficiencies in core competencies were solicited. To assess the effect of true attrition rate on graduate performance, we compared the published 5-year American Board of Surgery qualifying exam/certifying exam first time pass rates between military and civilian programs. RESULTS: One hundred eighty-four categorical residents matriculated from 2010 to 2013. Fifty six (31.5 %) were women, 151 (62.1%) were MD's, 103 (56%) were married, 172 (93.5%) were less than 35 years old, and 33 (17.9%) had a military-related interruption in training. Nineteen individuals left residency prior to graduation (15 resigned, 2 resigned in lieu of termination, 2 terminated) for an overall attrition rate of 10.3%. The most common year for attrition was PGY-3 (31.6%) and most common reason for resignation was changing to a different subspecialty (73.3%). Men and women had equal attrition rates (10.3%), and there was no meaningful difference between MD's and DO's (9.9% vs 12.1%, p = 0.71) or region of training (10.6% East vs 9.1% West, p = 0.73). However, those who were not married, had a militarily mandated interruption in training and started their categorical training over the age of 35 had higher attrition rates (married 5.6%, not married 15%, p = 0.04, interruption 16% vs no interruption 9%, p = 0.1; Age ≥ 35 33.3% vs age < 35 6.7%, p < 0.01). Comparison of American Board of Surgery (ABS) first time pass rates over a similar time period showed that military programs performed statistically discernibly better than civilian programs (82% ± 12 vs 75% ± 13, p = 0.047). CONCLUSIONS: Previous used methodology over estimates the attrition rate in MGS GME. The lower rate in MGS programs results in a high level of graduate performance as measured by ABS pass rates. Interruption in training and especially marital status and age ≥ 35 appear to be potential predictors of attrition. Components of MGS GME training and selection processes might inform efforts to reduce attrition and improve performance in civilian surgical GME.

The beneficial effects of dichloroacetate in acute limb ischemia.

OBJECTIVE: The purpose of this study was to determine the effects of dichloroacetate (DCA) in acute limb ischemia. METHODS: Anterior tibialis muscle samples of DCA-treated and control animals (Sprague Dawley rats) were collected and assayed for pyruvate dehydrogenase activity, lactate, adenosine triphosphate, and creatine phosphate using spectrophotometry. A physiograph was used to measure fatigability. In an ischemia/reperfusion model using New Zealand rabbits, serum lactate and end-tidal CO2 were compared. Skeletal muscle was evaluated microscopically for muscle necrosis. RESULTS: DCA administration resulted in a 50% increase in pyruvate dehydrogenase activity (p = 0.025), reversal of the increase in lactate levels seen during acute limb ischemia (p = 0.41), a significant increase in the time to skeletal muscle fatigue (p = 0.05), a trend toward increased adenosine triphosphate (p = 0.07), and a significant increase in creatine phosphate (p < 0.02). DCA treatment resulted in a decrease in serum lactate (p < 0.01) and end-tidal CO2 (p < 0.001). CONCLUSION: In acute limb ischemia and reperfusion, DCA administration provides metabolic protection to skeletal muscle.

Role of Repeat 18F-Fluorodeoxyglucose Positron Emission Tomography Examination in Predicting Pathologic Response Following Neoadjuvant Chemoradiotherapy for Esophageal Adenocarcinoma.

IMPORTANCE: Predicting complete pathologic response (CPR) preoperatively can significantly affect surgical decision making. There are conflicting data regarding positron emission tomography computed tomography (PET CT) characteristics and the ability of PET CT to predict pathologic response following neoadjuvant chemoradiotherapy in esophageal adenocarcinoma because most existing studies that include squamous histology have limited numbers and use nonstandardized PET CT imaging. OBJECTIVE: To determine if PET CT characteristics are associated with CPR in patients undergoing trimodality treatment for esophageal adenocarcinoma. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical record review was conducted at a large tertiary cancer center from a prospectively maintained database from January 1, 2005, to December 31, 2012. Inclusion criteria were patients undergoing esophagectomy for locally advanced esophageal adenocarcinoma post-neoadjuvant chemoradiotherapy with 2 standardized PET CT studies done at our institution (pre-neoadjuvant chemoradiotherapy and post-neoadjuvant chemoradiotherapy) for review. Data collected included clinical, pathologic, imaging, and treatment characteristics. MAIN OUTCOME AND MEASURE: The primary study outcome was the association of PET CT characteristics with histologic confirmed pathologic response. RESULTS: Of the total participants, 77 patients met the inclusion criteria. Twenty-two patients (28.6%) had CPR vs 55 patients (71.4%) who had incomplete pathologic response. The 2 groups were similar in age, sex, race/ethnicity, comorbid conditions, Eastern Cooperative Oncology Group status, tumor grade, chemotherapy, and radiation regimen and days between the 2 PET CTs. The mean prestandardized uptake variable (SUV; 14.5 vs 11.2; P = .05), δ SUV (10.3 vs 5.4; P = .02), and relative δ SUV (0.6 vs 0.4; P = .02) were significantly higher in those with CPR vs incomplete pathologic response. Using the Youden Index, a δ SUV value less than 45% was predictive of residual disease with a positive predictive value of 91.7% (95% CI, 73-99; P < .05). CONCLUSIONS AND RELEVANCE: To our knowledge, this is the largest study examining the role of PET CT characteristics in esophageal adenocarcinoma for patients undergoing neoadjuvant chemoradiotherapy that demonstrates that δ SUV of less than 45% is associated with patients with residual disease but not CPR. Based on the findings from our study, the current recommendation is still surgical resection regardless of the posttherapy PET SUV in the primary tumor. However, our study highlights the ability to detect patients with residual disease and the need to critically evaluate these patients for consideration of additional therapies.

Low dose four-dimensional computerized tomography with volume rendering reconstruction for primary hyperparathyroidism: How I do it?

Modification of 4-dimensional computed tomography (4D-CT) technique with volume rendering reconstructions and significant dose reduction is a safe and accurate method of pre-operative localization for primary hyperparathyroidism. Modified low dose 4D-CT with volume rendering reconstructions provides precise preoperative localization and is associated with a significant reduction in radiation exposure compared to classic preoperative localizing techniques. It should be considered the preoperative localization study of choice for primary hyperparathyroidism.

Neoadjuvant chemoradiotherapy for esophageal/gastroesophageal carcinoma.

BACKGROUND: Esophageal/gastroesophageal junction (GEJ) adenocarcinoma is increasingly treated with trimodality therapy. We present our experience using carboplatin/paclitaxel and radiotherapy followed by surgery. METHODS: Consecutive patients with distal esophageal/GEJ adenocarcinoma (≥T2 or N+) treated from July 2010 to October 2011 were identified. Treatment included neoadjuvant carboplatin/paclitaxel with concurrent radiotherapy (CRT) to 50.4 Gy using an IMRT technique and then Ivor Lewis esophagogastrectomy (ILE). PET/CT was performed prior to and after CRT. Patient/treatment characteristics and tumor response were analyzed. RESULTS: Over this timeframe, 16 patients completed trimodality therapy. All were male, median age of 60 years (45-72 years). All tumors were grade 2-3 with mean tumor length of 4.4 cm (1-9 cm). A median of 6 cycles (5-9 cycles) neoadjuvant carboplatin/paclitaxel were administered. Average time from diagnosis to CRT completion was 76 days (44-141 days) and 60 days (35-92 days) from CRT end to surgery. Neoadjuvant CRT was well tolerated with mean weight loss of 3.9 kg. All pts had R0 resections. No anastomotic leaks or perioperative mortality occurred. Mean hospital stay was 13 days (8-28 days). Pathologic complete response (pCR) was seen in 38% of patients, microscopic residual disease (isolated tumor cells or <2 mm) in 31%, and macroscopic residual disease remained in 31%. Mean SUV reduction was 41% (0-100%). Of 11 patients with ≥35% SUV decrease, 45% had pCR and 27% had microscopic residual disease. Three patients had signet ring features. Of these, 2 had no SUV reduction and all had gross residual disease, including the only patient with positive nodal disease. CONCLUSIONS: Trimodality therapy utilizing concurrent carboplatin/paclitaxel and radiotherapy to 50.4 Gy followed by surgery was well tolerated and resulted in significant pathologic complete response or minimal residual disease. Further investigation of predictive factors for response is needed to best tailor therapy in the management of esophageal/GEJ adenocarcinoma.

Iatrogenic venous pseudoaneurysm: case report and review of the literature.

Iatrogenic venous pseudoaneurysm following venipuncture is an extremely rare complication of a very common medical procedure. A review of the vascular surgical literature revealed that only two cases of venous pseudoaneurysm secondary to venipuncture have been reported in the past half-century. We report the case of a 64-year-old anticoagulated male with a 7-month history of right arm swelling after venipuncture. The patient, on warfarin therapy for chronic atrial fibrillation, described progressive swelling at a previous venipuncture site. He eventually underwent limited two-dimensional ultrasonography, performed for a suspected hematoma, revealing a 4.3 x 3.3 x 2.0 cm pseudoaneurysm of the right basilic vein. These findings were later confirmed by a formal venous duplex sonogram. Similar to other forms of aneurysm and focal vascular dilation, the risks of venous psuedoaneurysm include embolism, thrombosis, and the compression of adjacent structures. Although both thrombin injection and coil embolization have been described as nonsurgical treatment options for arterial pseudoaneurysms, surgical resection may be the most appropriate approach for those with a venous equivalent. The segment of basilic vein containing the pseudoaneurysm was resected. This case demonstrates the need for physicians to consider venous pseudoaneurysm as a possible complication of venipuncture in individuals undergoing anticoagulation therapy.