Laparoscopic surgery for adrenocortical carcinoma: Estimating the risk of margin-positive resection.

BACKGROUND: Over recent years, there has been increasing adoption of minimally invasive surgery (MIS) in the treatment of adrenocortical carcinoma (ACC). However, MIS has been associated with noncurative resection and locoregional recurrence. We aimed to identify risk factors for margin-positivity among patients who undergo MIS resection for ACC. We hypothesized that a simple nomogram can accurately identify patients most suitable for curative MIS resection. METHODS: Curative-intent resections for ACC were identified through the National Cancer Database spanning 2010-2018. Trends in MIS utilization were reported using Pearson correlation coefficients. Factors associated with margin-positive resection were identified among preoperatively available variables using multivariable logistic regression, then incorporated into a predictive model. Model quality was cross validated using an 80% training data set and 20% test data set. RESULTS: Among 1260 ACC cases, 38.6% (486) underwent MIS resection. MIS utilization increased over time at nonacademic centers (R = 0.818, p = 0.007), but not at academic centers (R = 0.009, p = 0.982). Factors associated with margin-positive MIS resection were increasing age, nonacademic center (odds ratio [OR]: 1.8, p = 0.006), cT3 (OR: 4.7, p < 0.001) or cT4 tumors (OR: 14.6, p < 0.001), and right-sided tumors (OR: 2.0, p = 0.006). A predictive model incorporating these four factors produced favorable c-statistics of 0.75 in the training data set and 0.72 in the test data set. A pragmatic nomogram was created to enable bedside risk stratification. CONCLUSIONS: An increasing proportion of ACC are resected via minimally invasive operations, particularly at nonacademic centers. Patient selection based on a few key factors can minimize the risk of noncurative surgery.

Stereotactic radiosurgery before bilateral adrenalectomy is associated with lowered risk of Nelson's syndrome in refractory Cushing's disease patients.

BACKGROUND: Nelson's syndrome is a rare but challenging sequelae of Cushing's disease (CD) after bilateral adrenalectomy (BLA). We sought to determine if stereotactic radiosurgery (SRS) of residual pituitary adenoma performed before BLA can decrease the risk of Nelson's syndrome. METHODS: Consecutive patients with CD who underwent BLA after non-curative resection of ACTH secreting pituitary adenoma and had at least one follow-up visit after BLA were studied. Nelson's syndrome was diagnosed based on the combination of rising ACTH levels, increasing volume of the pituitary adenoma and/or hyperpigmentation. RESULTS: Fifty patients underwent BLA for refractory CD, and 43 patients (7 men and 36 women) had at least one follow-up visit after BAL. Median endocrine, imaging, and clinical follow-up were 66 months, 69 months, and 80 months, respectively. Nine patients (22%) were diagnosed with the Nelson's syndrome at median time after BLA at 24 months (range: 0.6-119.4 months). SRS before BLA was associated with reduced risk of the Nelson's syndrome (HR = 0.126; 95%CI [0.022-0.714], p=0.019), while elevated ACTH level within 6 months after BLA was associated with increased risk for the Nelson's syndrome (HR = 9.053; 95%CI [2.076-39.472], p=0.003). CONCLUSIONS: SRS before BLA can reduce the risk for the Nelson's syndrome in refractory CD patients requiring BLA and should be considered before proceeding to BLA. Elevated ACTH concentration within 6 months after BLA is associated with greater risk of the Nelsons' syndrome. When no prior SRS is administered, those with a high ACTH level shortly after BLA may benefit from early SRS.

Enhancing Medical Students' Interprofessional Teamwork Through Simulated Room of Errors Experience.

BACKGROUND: Fostering medical students' appreciation for team members particularly those from other disciplines with varying levels of experience promotes a promising beginning to a health care career. METHODS: During surgical clerkship orientation, third-year medical students completed 30-item TeamSTEPPS Teamwork Attitudes Questionnaire preintervention and postintervention, spent 7 min identifying errors in a simulated operating room, followed by recorded physician-led 30-min discussions. RESULTS: Postintervention (67) compared with preintervention (141) mean TeamSTEPPS Teamwork Attitudes Questionnaire domain scores were statistically significantly higher for team structure (4.59, 4.70; P = 0.03) and higher but not significant for leadership (4.74, 4.75; P = 0.86), situation monitoring (4.62, 4.68; P = 0.32), communication (4.40, 4.50; P = 0.14), and decreased for mutual support (4.43, 4.36; P = 0.43). Medical students identified 2%-93% of 33 staged errors and 291 additional errors, which were placed into 14 categories. Soiled gloves in the operative field and urinary bag on the floor were the most frequently identified staged errors. Experienced nurses compared with medical students identified significantly more errors (mean, 17.7 versus 11.7, respectively; P < 0.001). Recognizing errors when lacking familiarity with the operative environment and appreciating teammates' perspectives were themes that emerged from discussions. CONCLUSIONS: This well-received teamwork exercise enabled medical students to appreciate team members' contributions and other disciplines' perspectives, in addition to the synergy that occurs with multidisciplinary teams.

Sarcopenia in emergency abdominal surgery.

BACKGROUND: Sarcopenia, a loss of skeletal muscle mass associated with aging, is a practical measure of frailty and has been previously identified as a predictor of outcomes in surgical cohorts including cancer resection and elderly patients. We hypothesized that sarcopenia, as measured by preoperative computerized tomography (CT) scan, predicts mortality and morbidity in emergent laparotomy. METHODS: Institutional American College of Surgeons National Surgical Quality Improvement Program data were queried for adult patients who underwent open emergency abdominal surgery between 2008 and 2013. Patients with abdominal CT scans within 30 d before surgery were included, and cross-sectional areas of the psoas muscles at vertebral level L4 were summed, normalized by patient height, and stratified by sex. The influence of this total psoas area (TPA) on postoperative morbidity and mortality was evaluated using univariate and multivariate analysis. RESULTS: Of 781 surgeries, 593 (75.9%) had appropriate preoperative CT scans. Median patient age was 61 years old, median TPA was 1719 mm2, and median body mass index was 26.7. Univariate analysis demonstrated a significant association between TPA and total postoperative morbidity (P = 0.0133), increased length of stay (<0.0001), and 90-d mortality (P = 0.0008) but not 30-d mortality (P = 0.26). In multivariate analysis, TPA lost its significance compared to more influential predictors of mortality, including American Society of Anesthesiologists classification. CONCLUSIONS: Sarcopenia, as measured by TPA, significantly predicted mortality in univariate analysis but lost significance in multivariate analysis when factors such as American Society of Anesthesiologists score were included. Because TPA is readily available at no additional risk or cost, it is a convenient additional tool for preoperative risk assessment and counseling.

Adoption of robotics in a general surgery residency program: at what cost?

BACKGROUND: Robotic technology is increasingly being utilized by general surgeons. However, the impact of introducing robotics to surgical residency has not been examined. This study aims to assess the financial costs and training impact of introducing robotics at an academic general surgery residency program. METHODS: All patients who underwent laparoscopic or robotic cholecystectomy, ventral hernia repair (VHR), and inguinal hernia repair (IHR) at our institution from 2011-2015 were identified. The effect of robotic surgery on laparoscopic case volume was assessed with linear regression analysis. Resident participation, operative time, hospital costs, and patient charges were also evaluated. RESULTS: We identified 2260 laparoscopic and 139 robotic operations. As the volume of robotic cases increased, the number of laparoscopic cases steadily decreased. Residents participated in all laparoscopic cases and 70% of robotic cases but operated from the robot console in only 21% of cases. Mean operative time was increased for robotic cholecystectomy (+22%), IHR (+55%), and VHR (+61%). Financial analysis revealed higher median hospital costs per case for robotic cholecystectomy (+$411), IHR (+$887), and VHR (+$1124) as well as substantial associated fixed costs. CONCLUSIONS: Introduction of robotic surgery had considerable negative impact on laparoscopic case volume and significantly decreased resident participation. Increased operative time and hospital costs are substantial. An institution must be cognizant of these effects when considering implementing robotics in departments with a general surgery residency program.

Ultraviolet (UV)-reflective paint with ultraviolet germicidal irradiation (UVGI) improves decontamination of nosocomial bacteria on hospital room surfaces.

An ultraviolet germicidal irradiation (UVGI) generator (the TORCH, ClorDiSys Solutions, Inc.) was used to compare the disinfection of surface coupons (plastic from a bedrail, stainless steel, and chrome-plated light switch cover) in a hospital room with walls coated with ultraviolet (UV)-reflective paint (Lumacept) or standard paint. Each surface coupon was inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE), placed at 6 different sites within a hospital room coated with UV-reflective paint or standard paint, and treated by 10 min UVC exposure (UVC dose of 0-688 mJ/cm2 between sites with standard paint and 0-553 mJ/cm2 with UV-reflective paint) in 8 total trials. Aggregated MRSA concentrations on plastic bedrail surface coupons were reduced on average by 3.0 log10 (1.8 log10 Geometric Standard Deviation [GSD]) with standard paint and 4.3 log10 (1.3 log10 GSD) with UV-reflective paint (p = 0.0005) with no significant reduction differences between paints on stainless steel and chrome. Average VRE concentrations were reduced by ≥4.9 log10 (<1.2 log10 GSD) on all surface types with UV-reflective paint and ≤4.1 log10 (<1.7 log10 GSD) with standard paint (p < 0.05). At 5 aggregated sites directly exposed to UVC light, MRSA concentrations on average were reduced by 5.2 log10 (1.4 log10 GSD) with standard paint and 5.1 log10 (1.2 log10 GSD) with UV-reflective paint (p = 0.017) and VRE by 4.4 log10 (1.4 log10 GSD) with standard paint and 5.3 log10 (1.1 log10 GSD) with UV-reflective paint (p < 0.0001). At one indirectly exposed site on the opposite side of the hospital bed from the UVGI generator, MRSA concentrations on average were reduced by 1.3 log10 (1.7 log10 GSD) with standard paint and 4.7 log10 (1.3 log10 GSD) with UV-reflective paint (p < 0.0001) and VRE by 1.2 log10 (1.5 log10 GSD) with standard paint and 4.6 log10 (1.1 log10 GSD) with UV-reflective paint (p < 0.0001). Coating hospital room walls with UV-reflective paint enhanced UVGI disinfection of nosocomial bacteria on various surfaces compared to standard paint, particularly at a surface placement site indirectly exposed to UVC light.

Containment Care Units for Managing Patients With Highly Hazardous Infectious Diseases: A Concept Whose Time Has Come.

The concept of containment care for patients with highly hazardous infectious diseases originated in conjunction with the development of sophisticated biosafety level 4 laboratories at the US Army Medical Research Institute of Infectious Diseases in the late 1960s. Over time, the original containment facility served as a model for the development of other facilities in the United States at government and academic centers. The Ebola outbreak of 2014-2015 brought the issue of containment care into the mainstream and led to the development of such capabilities at strategic points around the country. We describe the original concepts behind development of such facilities, how the concept and acceptance has evolved over time, and how the guidelines for managing patients infected with viral hemorrhagic fevers have evolved as new information has been learned about protecting medical care providers from highly hazardous infectious pathogens.

Kinetic Analysis of Biomarkers in a Cohort of US Patients With Ebola Virus Disease.

BACKGROUND: Ebola virus (EBOV) infection causes a severe and often fatal disease. Despite the fact that more than 30 000 individuals have acquired Ebola virus disease (EVD), the medical and scientific community still does not have a clear understanding of the mechanisms by which EBOV causes such severe disease. METHODS: In this study, 54 biomarkers in plasma samples serially collected from 7 patients with EVD were analyzed in an attempt to define the kinetics of inflammatory modulators. Two clinical disease groups were defined (moderate and severe) based on the need for clinical support. Biomarkers were evaluated for correlation with viremia and clinical disease in an effort to identify pathways that could be useful targets of therapeutic intervention. RESULTS: Patients with severe disease had higher viremia than those with moderate disease. Several biomarkers of immune activation and control were significantly elevated in patients with moderate disease. A series of pro-inflammatory cytokines and chemokines were significantly elevated in patients with severe disease. CONCLUSIONS: Biomarkers that were associated with severe EVD were proinflammatory and indicative of endothelial or coagulation cascade dysfunction, as has been seen historically in patients with fatal outcomes. In contrast, biomarkers that were associated with moderate EVD were suggestive of a strong interferon response and control of both innate and adaptive responses. Therefore, clinical interventions that modulate the phenotype and magnitude of immune activation may be beneficial in treating EVD.

Use of Postexposure Prophylaxis After Occupational Exposure to Zaire ebolavirus.

From September 2014 to April 2015, 6 persons who had occupational exposures to Zaire ebolavirus in West Africa received investigational agent rVSV-ZEBOV or TKM-100802 for postexposure prophylaxis and were monitored in the United States. All patients experienced self-limited symptoms after postexposure prophylaxis; none developed Ebola virus disease.

U.S. Ebola Treatment Center Clinical Laboratory Support.

Fifty-five hospitals in the United States have been designated Ebola treatment centers (ETCs) by their state and local health authorities. Designated ETCs must have appropriate plans to manage a patient with confirmed Ebola virus disease (EVD) for the full duration of illness and must have these plans assessed through a CDC site visit conducted by an interdisciplinary team of subject matter experts. This study determined the clinical laboratory capabilities of these ETCs. ETCs were electronically surveyed on clinical laboratory characteristics. Survey responses were returned from 47 ETCs (85%). Forty-one (87%) of the ETCs planned to provide some laboratory support (e.g., point-of-care [POC] testing) within the room of the isolated patient. Forty-four (94%) ETCs indicated that their hospital would also provide clinical laboratory support for patient care. Twenty-two (50%) of these ETC clinical laboratories had biosafety level 3 (BSL-3) containment. Of all respondents, 34 (72%) were supported by their jurisdictional public health laboratory (PHL), all of which had available BSL-3 laboratories. Overall, 40 of 44 (91%) ETCs reported BSL-3 laboratory support via their clinical laboratory and/or PHL. This survey provided a snapshot of the laboratory support for designated U.S. ETCs. ETCs have approached high-level isolation critical care with laboratory support in close proximity to the patient room and by distributing laboratory support among laboratory resources. Experts might review safety considerations for these laboratory testing/diagnostic activities that are novel in the context of biocontainment care.

Evaluating Isolation Behaviors by Nurses Using Mobile Computer Workstations at the Bedside.

This secondary analysis from a larger mixed methods study with a sequential explanatory design investigates the clinical challenges for nurses providing patient care, in an airborne and contact isolation room, while using a computer on wheels for medication administration in a simulated setting. Registered nurses, who regularly work in clinical care at the patient bedside, were recruited as study participants in the simulation and debriefing experience. A live volunteer acted as the standardized patient who needed assessment and intravenous pain medication. The simulation was video recorded in a typical hospital room to observe participating nurses conducting patient care in an airborne and contact isolation situation. Participants then reviewed their performance with study personnel in a formal, audio-recorded debriefing. Isolation behaviors were scored by an expert panel, and the debriefing sessions were analyzed. Considerable variation was found in behaviors related to using a computer on wheels while caring for a patient in isolation. Currently, no nursing care guidelines exist on the use of computers on wheels in an airborne and contact isolation room. Specific education is needed on nursing care processes for the proper disinfection of computers on wheels and the reduction of the potential for disease transmission from environmental contamination.

Comparison of hospital room surface disinfection using a novel ultraviolet germicidal irradiation (UVGI) generator.

The estimated 721,800 hospital acquired infections per year in the United States have necessitated development of novel environmental decontamination technologies such as ultraviolet germicidal irradiation (UVGI). This study evaluated the efficacy of a novel, portable UVGI generator (the TORCH, ChlorDiSys Solutions, Inc., Lebanon, NJ) to disinfect surface coupons composed of plastic from a bedrail, stainless steel, chrome-plated light switch cover, and a porcelain tile that were inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE). Each surface type was placed at 6 different sites within a hospital room and treated by 10-min ultraviolet-C (UVC) exposures using the TORCH with doses ranging from 0-688 mJ/cm(2) between sites. Organism reductions were compared with untreated surface coupons as controls. Overall, UVGI significantly reduced MRSA by an average of 4.6 log10 (GSD: 1.7 log10, 77% inactivation, p < 0.0001) and VRE by an average of 3.9 log10 (GSD: 1.7 log10, 65% inactivation, p < 0.0001). MRSA on bedrail was reduced significantly (p < 0.0001) less than on other surfaces, while VRE was reduced significantly less on chrome (p = 0.0004) and stainless steel (p = 0.0012) than porcelain tile. Organisms out of direct line of sight of the UVC generator were reduced significantly less (p < 0.0001) than those directly in line of sight. UVGI was found an effective method to inactivate nosocomial pathogens on surfaces evaluated within the hospital environment in direct line of sight of UVGI treatment with variation between organism and surface types.

Administration of Brincidofovir and Convalescent Plasma in a Patient With Ebola Virus Disease.

From 2014 to May 2015, >26 000 Ebola virus disease (EVD) cases were reported from West Africa. We present a patient with EVD who received brincidofovir and convalescent plasma. The relative contributions of supportive care, investigational therapies, and patient's immune-response on survival could not be determined. Randomized trials are needed.

The Use of TKM-100802 and Convalescent Plasma in 2 Patients With Ebola Virus Disease in the United States.

BACKGROUND: The current West Africa Ebola virus disease (EVD) outbreak has resulted in multiple individuals being medically evacuated to other countries for clinical management. METHODS: We report two patients who were transported from West Africa to the United States for treatment of EVD. Both patients received aggressive supportive care measures, as well as an investigational therapeutic (TKM-100802) and convalescent plasma. RESULTS: While one patient experienced critical illness with multi-organ failure requiring mechanical ventilation and renal replacement therapy, both patients recovered without serious long-term sequelae to date. CONCLUSIONS: It is unclear what role the experimental drug and convalescent plasma had in the recovery of these patients. Prospective clinical trials are needed to delineate the role of investigational therapies in the care of patients with EVD.

Smallpox Vaccination of Laboratory Workers at US Variola Testing Sites.

To evaluate the need to revaccinate laboratory workers against smallpox, we assessed regular revaccination at the US Laboratory Response Network's variola testing sites by examining barriers to revaccination and the potential for persistence of immunity. Our data do not provide evidence to suggest prolonging the recommended interval for revaccination.

Ebola virus disease: preparedness and infection control lessons learned from two biocontainment units.

PURPOSE OF REVIEW: This review details infection control issues encountered in the management of patients with Ebola virus disease (EVD), with emphasis on how these issues were confronted in two biocontainment patient care units in the United States. RECENT FINDINGS: There is a notable paucity of medical literature to guide infection control policies and procedures when caring for patients with EVD. Thus, the experience of the Serious Communicable Diseases Unit at Emory University Hospital and the Nebraska Biocontainment Unit at the University of Nebraska Medical Center serves as the basis for this review. Facility issues, staffing, transportation logistics, and appropriate use of personal protective equipment are detailed. Other topics addressed include the evaluation of patients under investigation and ethical issues concerning the safe utilization of advanced life support. SUMMARY: This review intends to serve as a reference for facilities that are in the process of creating protocols for managing patients with EVD. Given the lack of literature to support many of the recommendations discussed, it is important to utilize the available referenced guidelines, along with the practical experiences of biocontainment units, to optimize the care provided to patients with EVD while strictly adhering to infection control principles.

Lessons learned: critical care management of patients with Ebola in the United States.

OBJECTIVE: This report will describe the preparations for and the provision of care of two patients with Ebola virus disease in the biocontainment unit at the University of Nebraska Medical Center. DATA SOURCES: Patient medical records. STUDY SELECTION: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Not applicable. CONCLUSIONS: Safe and effective care of patients with Ebola virus disease requires significant communication and planning. Adherence to a predetermined isolation protocol is essential, including proper donning and doffing of personal protective equipment. Location of the patient care area and the logistics of laboratory testing, diagnostic imaging, and the removal of waste must be considered. Patients with Ebola virus disease are often dehydrated and need adequate vascular access for fluid resuscitation, nutrition, and phlebotomy for laboratory sampling. Advanced planning for acute life-threatening events and code status must be considered. Intensivist scheduling should account for the significant amount of time required for the care of patients with Ebola virus disease. With appropriate precautions and resources, designated hospitals in the United States can safely provide care for patients with Ebola virus disease.

Vessel ligation training via an adaptive simulation curriculum.

BACKGROUND: A cost-effective model for open vessel ligation is currently lacking. We hypothesized that a novel, inexpensive vessel ligation simulator can efficiently impart transferrable surgical skills to novice trainees. MATERIALS AND METHODS: VesselBox was designed to simulate vessel ligation using surgical gloves as surrogate vessels. Fourth-year medical students performed ligations using VesselBox and were evaluated by surgical faculty using the Objective Structured Assessments of Technical Skills global rating scale and a task-specific checklist. Subsequently, each student was trained using VesselBox in an adaptive practice session guided by cumulative sum. Posttesting was performed on fresh human cadavers by evaluators blinded to pretest results. RESULTS: Sixteen students completed the study. VesselBox practice sessions averaged 21.8 min per participant (interquartile range 19.5-27.7). Blinded posttests demonstrated increased proficiency, as measured by both Objective Structured Assessments of Technical Skills (3.23 versus 2.29, P < 0.001) and checklist metrics (7.33 versus 4.83, P < 0.001). Median speed improved from 128.2 s to 97.5 s per vessel ligated (P = 0.001). After this adaptive training protocol, practice volume was not associated with posttest performance. CONCLUSIONS: VesselBox is a cost-effective, low-fidelity vessel ligation model suitable for graduating medical students and junior residents. Cumulative sum can facilitate an adaptive, individualized curriculum for simulation training.

Considerations for safe EMS transport of patients infected with Ebola virus.

The Nebraska Biocontainment Unit through the Nebraska Medical Center in Omaha, Nebraska, recently received patients with confirmed Ebola virus from West Africa. The Nebraska Biocontainment Unit and Omaha Fire Department's emergency medical services (EMS) coordinated patient transportation from airport to the high-level isolation unit. Transportation of these highly infectious patients capitalized on over 8 years of meticulous planning and rigorous infection control training to ensure the safety of transport personnel as well as the community during transport. Although these transports occurred with advanced notice and after confirmed Ebola virus disease (EVD) diagnosis, approaches and key lessons acquired through this effort will advance the ability of any EMS provider to safely transport a confirmed or suspected patient with EVD. Three critical areas have been identified from our experience: ambulance preparation, appropriate selection and use of personal protective equipment, and environmental decontamination.

Surrogate testing suggests that chlorine dioxide gas exposure would not inactivate Ebola virus contained in environmental blood contamination.

The ability to decontaminate a room potentially containing the Ebola virus is important to healthcare facilities in the United States. Ebola virus remains viable in body fluids, a room that has housed a patient with Ebola virus disease must have all surfaces manually wiped with an approved disinfectant, which increases occupational exposure risk. This study evaluated the efficacy of gaseous chlorine dioxide inactivation of bacterial organisms in blood as Ebola virus surrogates and as the organisms used by the Nebraska Biocontainment Unit to provide the margin of safety for decontamination. Bacillus anthracis, Escherichia coli, Enterococcus faecalis, and Mycobacterium smegmatis blood suspensions that were exposed to ClO2 gas concentrations and exposure limits. The log reduction in Colony Forming Units (CFU) was determined for each bacterial blood suspension. Exposure parameters approximating industry practices for ClO2 environmental decontamination (360ppm concentration to 780 ppm-hrs exposure, 65% relative humidity) as well as parameters exceeding current practice (1116 ppm concentration to 1400 ppm-hrs exposure; 1342ppm concentration to 1487 ppm-hrs exposure) were evaluated. Complete inactivation was not achieved for any of the bacterial blood suspensions tested. Reductions were observed in concentrations of B. anthracis spores (1.3 -3.76 log) and E. faecalis vegetative cells (1.3 log) whereas significant reductions in vegetative cell concentrations for E. coli and M. smegmatis blood suspensions were not achieved. Our results showed that bacteria in the presence of blood were not inactivated using gaseous ClO2 decontamination. ClO2 decontamination alone should not be used for Ebola virus, but decontamination processes should first include manual wiping of potentially contaminated blood; especially for microorganisms as infectious as the Ebola virus.