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.

A Novel Thyroid Ultrasound Proficiency Metric Designed Through a Multidisciplinary Delphi Approach.

BACKGROUND: Thyroid ultrasounds extend surgeons' outpatient capabilities and are essential for operative planning. However, most residents are not formally trained in thyroid ultrasound. The purpose of this study was to create a novel thyroid ultrasound proficiency metric through a collaborative Delphi approach. METHODS: Clinical faculty experienced in thyroid ultrasound participated on a Delphi panel to design the thyroid Ultrasound Proficiency Scale (UPS-Thyroid). Participants proposed items under the categories of Positioning, Technique, Image Capture, Measurement, and Interpretation. In subsequent rounds, participants voted to retain, revise, or exclude each item. The process continued until all items had greater than 70% consensus for retention. The UPS-Thyroid was pilot tested across 5 surgery residents with moderate ultrasound experience. Learning curves were assessed with cumulative sum. RESULTS: Three surgeons and 4 radiologists participated on the Delphi panel. Following 3 iterative Delphi rounds, the panel arrived at >70% consensus to retain 14 items without further revisions or additions. The metric included the following items on a 3-point scale for a maximum of 42 points: Positioning (1 item), Technique (4 items), Image Capture (2 items), Measurement (2 items), and Interpretation (5 items). A pilot group of 5 residents was scored against a proficiency threshold of 36 points. Learning curve inflection points were noted at between 4 to 7 repetitions. CONCLUSIONS: A multidisciplinary Delphi approach generated consensus for a thyroid ultrasound proficiency metric (UPS-Thyroid). Among surgery residents with moderate ultrasound experience, basic proficiency at thyroid ultrasound is feasible within 10 repetitions.

American Association of Endocrine Surgeons Guidelines for Adrenalectomy: Executive Summary.

Importance: Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications. Objective: To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy. Evidence Review: A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included. Findings: Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics. Conclusions and Relevance: Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.

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.

New endocrine fellowship programs do not decrease the endocrine surgery experience of residents in co-located general surgery programs.

BACKGROUND: New pediatric and vascular surgical fellowship programs decrease resident operative experience in those subspecialties in co-located general surgery programs.After 2 decades of increases, the mean number of endocrine surgery cases performed by general surgery residents nationally has decreased since 2010 to 2011. We hypothesized that new endocrine surgery fellowship programs lead to a decrease in the number of endocrine surgery cases performed by co-located general surgery residents and may be a contributing factor in the recent national decline in endocrine surgery cases performed by general surgery residents. METHODS: Endocrine surgery fellowship programs associated with a single, Accreditation Council of Graduate Medical Education-accredited general surgery program that have completed training of 1 fellow by the 2014-2015 academic year were identified. Endocrine surgery cases performed by general surgery residents who completed co-located general surgery programs from 2002 to 2003 through 2017 to 2018 were recorded. Descriptive statistics are shown as mean ± standard deviation. Statistical significance was calculated using the Mann-Whitney U Test. RESULTS: In the 13 general surgery programs with 5 years of case log data after the matriculation of the first fellow, the mean number of total endocrine surgery cases/resident increased from 47 ± 23 in year 0 to 57 ± 25 in year 5 (z-score = 2.53; P < .05). CONCLUSION: New endocrine surgery fellowship programs do not decrease the endocrine surgery cases performed by general surgery residents and have not contributed to the national decline in endocrine surgery cases by general surgery residents.

The ups and downs of general surgery resident experience in endocrine surgery: Analysis of 30 years of ACGME graduate case logs.

BACKGROUND: The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases. METHODS: American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level. RESULTS: The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P < .001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P < .001) but has declined since its peak at 36.9 in 2010 to 2011 (P = .014). Thyroid operations increased from 11.4 to 19.8 (P < .001) but peaked at 23.5 in 2010 to 2011 and have since declined (P < .001). Parathyroid operations more than doubled from 4.2 to 9.7 (P < .001). Adrenal operations increased from 1 to 2.2 (P < .001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P < .001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P < .001). Surgeon Junior endocrine surgery cases increased overall (P < .001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P < .001). CONCLUSION: After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.

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.

Compliance with the Accreditation Council for Graduate Medical Education duty hours in a general surgery residency program: Challenges and solutions in a teaching hospital.

BACKGROUND: The inception of work hour restrictions for resident physicians in 2003 created controversial changes within surgery training programs. On a recent Accreditation Council for Graduate Medical Education survey at our institution, we noted a discrepancy between low recorded violations of the duty hour restrictions and the surgery resident's perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and to encourage accurate reporting among surgery trainees. METHODS: The A3/Lean methodology, an industry-derived, systematic, problem-solving approach, was used to investigate barriers to accurate reporting of duty hours by residents within the Department of Surgery at our academic institution. In partnership with our office of Graduate Medical Education, we encouraged a 6-month period where residents were asked to record duty hour accurately and to provide honest, descriptive explanations of violations without punitive effects on residents or the program. We performed a 6-month before-and-after analysis of duty hours violations after the A3/Lean implementation. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by key thematic areas revealed resident attitudes and opinions about duty hour violations. RESULTS: Residents reported concern for personal and programmatic, punitive measures, desire to retain control of their education, and frustration with the administrative burden after violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior with 10 total violations prior to A3 meeting and 179 violations afterward (P = .003). This change was driven largely from an increase in short break violations (4 vs 134, P = .021). Analysis of violations revealed trends by post-graduate year, rotation, and weekend cross-coverage. Key findings including less than anticipated violations of the 80-hour work week despite high rates of short break violations. The ability to participate in procedures voluntarily and a sense of professional responsibility emerged as the prevailing themes among surgery residents describing violations. CONCLUSION: Systematic evaluation of duty hour reporting within a surgery training program can identify structural and cultural barriers to accurate reporting of duty hours. Accurate reporting can identify program-specific trends in duty hour violations that can be addressed though programmatic intervention.

Defining the competencies for laparoscopic transabdominal adrenalectomy: An investigation of intraoperative behaviors and decisions of experts.

BACKGROUND: Safe performance of laparoscopic transabdominal adrenalectomy requires the application of a complex body of knowledge and skills, which are difficult to define, teach, and measure. This qualitative study aims to characterize expert behaviors, decisions, and other cognitive processes required to perform laparoscopic transabdominal adrenalectomy. METHOD: Hierarchical and cognitive task analyses for right and left laparoscopic transabdominal adrenalectomy were performed using semi-structured interviews and field observations of experts. Verbal data was supplemented with published literature, coded and thematically analyzed using constructivist grounded-theory by 2 independent reviewers. RESULTS: A conceptual framework was synthesized. Sixty-eight tasks, 46 cognitive behaviors, and 52 potential errors were identified and categorized into 8 procedural steps and 8 fundamental principles: anticipation, exposure, teamwork or communication, physiology, dissection techniques, oncologic margins, tactical modification, and error recovery. Experts emphasized the importance of creating a 3-dimensional mental model of the anatomy or pathology (eg, aberrant vessels, tumor location) that is consistently fine-tuned throughout the operation, with conscious awareness of danger zones (eg, medial arc). Despite variations in dissection techniques, experts highlighted 2 themes: macrodissection and microdissection, with emphasis on nonlinear motions and effective transitions between the 2 when appropriate. CONCLUSION: This study defines behaviors and competencies that are essential to performing laparoscopic transabdominal adrenalectomy effectively and safely.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity.

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

Preoperative Molecular Markers in Thyroid Nodules.

The need for distinguishing benign from malignant thyroid nodules has led to the pursuit of differentiating molecular markers. The most common molecular tests in clinical use are Afirma® Gene Expression Classifier (GEC) and Thyroseq® V2. Despite the rapidly developing field of molecular markers, several limitations exist. These challenges include the recent introduction of the histopathological diagnosis "Non-Invasive Follicular Thyroid neoplasm with Papillary-like nuclear features", the correlation of genetic mutations within both benign and malignant pathologic diagnoses, the lack of follow-up of molecular marker negative nodules, and the cost-effectiveness of molecular markers. In this manuscript, we review the current published literature surrounding the diagnostic value of Afirma® GEC and Thyroseq® V2. Among Afirma® GEC studies, sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) ranged from 75 to 100%, 5 to 53%, 13 to 100%, and 20 to 100%, respectively. Among Thyroseq® V2 studies, Se, Sp, PPV, and NPV ranged from 40 to 100%, 56 to 93%, 13 to 90%, and 48 to 97%, respectively. We also discuss current challenges to Afirma® GEC and Thyroseq® V2 utility and clinical application, and preview the future directions of these rapidly developing technologies.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program.

BACKGROUND: The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement. STUDY DESIGN: A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention. RESULTS: Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12. CONCLUSION: Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Vessel Ligation Fundamentals: A Comparison of Technical Evaluations by Crowdsourced Nonclinical Personnel and Surgical Faculty.

BACKGROUND: Evaluation of fundamental surgical skills is invaluable to the training of medical students and junior residents. This study assessed the effectiveness of crowdsourcing nonmedical personnel to evaluate technical proficiency at simulated vessel ligation. STUDY DESIGN: Fifteen videos were captured of participants performing vessel ligation using a low-fidelity model (5 attending surgeons and 5 medical students before and after training). These videos were evaluated by nonmedical personnel recruited through Amazon Mechanical Turk, as well as by 3 experienced surgical faculty. Evaluation criteria were based on Objective Structured Assessment of Technical Skills (scale: 5-25). Results were compared using Wilcoxon signed rank-sum and Cronbach's alpha (α). RESULTS: Thirty-two crowd workers evaluated all 15 videos. Crowd workers scored attending surgeon videos significantly higher than pretraining medical student videos (20.5 vs 14.9, p < 0.001), demonstrating construct validity. Across all videos, crowd evaluations were more lenient than expert evaluations (19.1 vs 14.5, p < 0.001). However, average volunteer evaluations correlated more strongly with average expert evaluations (α = 0.95) than the strength of correlation between any 2 individual expert evaluators (α = 0.72-0.88). Combined reimbursement for all workers was $80.00. CONCLUSION: After adjustments for score inflation, crowdsourced can evaluate surgical fundamentals with excellent validity. This resource is considerably less costly and potentially more reliable than individual expert evaluations.

Gestational Primary Hyperparathyroidism Due to Ectopic Parathyroid Adenoma: Case Report and Literature Review.

Gestational primary hyperparathyroidism (GPHPT) is a rare condition with fewer than 200 cases reported. We present the case of a 21-year-old woman who presented at 10 weeks' gestation with severe hypercalcemia. Laboratory investigation was consistent with primary hyperparathyroidism. Neck ultrasound did not reveal any parathyroid enlargement. Due to the persistence of severe hypercalcemia, she was treated with 4 weeks of cinacalcet therapy, which was poorly tolerated due to nausea and vomiting. At 14 weeks' gestation, she underwent neck exploration with right lower, left upper, and partial right upper parathyroid gland excision. Intra- and postoperative parathyroid hormone (PTH) and calcium levels remained elevated. After a thorough discussion of risks/benefits, the patient requested further treatment. A parathyroid sestamibi scan (PSS) revealed an ectopic adenoma in the left mediastinum. The adenoma was removed via video-assisted thorascopic parathyroidectomy with intraoperative PTH declining to nearly undetectable levels. She ultimately delivered a physically and developmentally normal infant at 37 weeks' gestation. Appropriate treatment of severe GPHPT may prevent the maternal and fetal complications of hypercalcemia. This case, in which cinacalcet therapy and PSS were used, adds to the body of literature regarding treatment of severe GPHPT.

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.

An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections.

BACKGROUND: Total abdominal colectomy (TAC) is the standard surgical treatment of Clostridium difficile infection (CDI). An alternative therapy, loop ileostomy and colonic lavage (IL), was described in 2011, but the results have never been validated. METHODS: Patients treated surgically for CDI between April 2011 and June 2015 were included. Bivariable analysis was used to compare 30-day mortality, 1-year mortality, CDI recurrence, colon preservation and ileostomy reversal. RESULTS: Ten IL patients and thirteen TAC patients were identified. 30-day mortality (30% vs 23%, p = 1.0) and 1-year mortality (40% vs 46%, p = 1.0) were similar. Four IL and three TAC patients (57% vs 30%, p = 0.35) experienced recurrent CDI. All six surviving IL patients had successful colon preservation; five underwent ileostomy reversal compared to three in the TAC group (83% vs 43%, p = 0.27). CONCLUSIONS: Although IL allowed colon preservation and return of intestinal continuity in most patients, IL did not decrease mortality or recurrent CDI when compared to TAC.

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.

Characterization of nuclear foci-targeting of Luman/CREB3 recruitment factor (LRF/CREBRF) and its potential role in inhibition of herpes simplex virus-1 replication.

The recently identified Luman/CREB3-binding partner LRF (Luman/CREB3 recruitment factor) was shown to localize to discrete sub-nuclear foci. Luman is implicated in herpes simplex virus-1 (HSV-1) latency/reactivation and the unfolded protein response (UPR) pathway; therefore, we sought to characterize the formation of the LRF nuclear foci in the context of cellular signaling and HSV-1 replication. Here, we mapped the nuclear foci-targeting sequence to the central region containing the first leucine zipper (a.a.415-519), and found that the integrity of the whole region appears essential for LRF foci formation. LRF foci integrity was unaffected by inhibition of cellular DNA replication and translation, however, disruption of transcription resulted in altered LRF localization. When compared to other cellular and viral foci LRF co-localized with the nuclear receptor co-activator GRIP1, while the HSV-1 gene products ICP4, ICP27 and VP13/14 disrupted foci formation to varying degrees. Interestingly, cells over-expressing LRF were resistant to productive HSV-1 infection and this resistance was dependent upon protein targeting and an N-terminal transactivation domain. When LRF knockdown cells were subjected to primary infection, HSV-1 gene expression and progeny virus yield were enhanced by ∼3 fold compared to wildtype cells. Taken together, these results indicate that LRF is a key regulator that may act direct or indirectly as a repressor of essential genes required for productive viral infection.

Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism.

BACKGROUND: Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes. METHODS: A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings. RESULTS: Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14 mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240 g compared with 1,300 g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6 months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol. CONCLUSION: With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be considered to avoid unnecessary radiation exposure.