Cost analysis of indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery.

BACKGROUND: Indocyanine green, near infrared, fluorescence angiography (ICG-FA) is increasingly adopted in colorectal surgery for intraoperative tissue perfusion assessment to reduce anastomotic leakage rates. However, the economic impact of this intervention has not been investigated. This study is a cost analysis of the routine use of ICG-FA in colorectal surgery from the hospital payer perspective. METHODS: A decision analysis model was developed for colorectal resections considering two scenarios: resection without using ICG-FA and resection with intraoperative ICG-FA for anastomotic perfusion assessment. Incorporated into the model were the costs of ICG agent, fluorescence angiography equipment, surgery, anastomotic leak, and the leak rates with and without ICG-FA. All input data were derived from recent publications. RESULTS: The routine use of ICG-FA for colorectal anastomosis is cost saving when cost analysis is performed using the following base case assumptions: 8.6% leak rate without ICG-FA, odds ratio of 0.46 for reduction of leakage with ICG-FA (4.8% leak rate relative to 8.6% base case), cost of ICG-FA of $250, and incremental cost of leak, not requiring reoperation, of $9,934.50. In one-way sensitivity analyses, routine use of ICG-FA was cost saving if the cost of an anastomotic leak is more than $5616.29, the cost of ICG-FA is less than $634.44, the leak rate (without ICG-FA) is higher than 4.9%, or the odds ratio for reduction of leak with ICG-FA is less than 0.69. There is a per-case saving of $192.22 with the use of ICG-FA. CONCLUSION: Using the best available evidence and most conservative base case values, routine use of ICG-FA in colorectal surgery was found to be cost saving. Since the evidence suggests there is a reduction in leak rate, the routine use of ICG-FA is a dominating strategy. However, the overall quality of evidence is low and there is a clear need for prospective, randomized controlled trials.

Impostorism and anxiety contribute to burnout among resident physicians.

PURPOSE: Physician burnout is an issue that has come to the forefront in the past decade. While many factors contribute to burnout the impact of impostorism and self-doubt has largely been ignored. We investigated the relationship of anxiety and impostorism to burnout in postgraduate medical learners. MATERIALS AND METHODS: Postgraduate learners in four diverse training programs: Family Medicine (FM), Paediatric Medicine (PM), Anesthesiology (AN), and General Surgery (GS) were surveyed to identify the incidence of impostorism (IP), anxiety, and burnout. IP, anxiety, and burnout were evaluated using the Clance Impostor Phenomenon Scale (CIPS), Maslach Burnout Inventory-Human Services Survey (MBI-HSS), and the General Anxiety Disorder-7 (GAD-7) questionnaires, respectively. Burnout was defined as meeting burnout criteria on all three domains. Relationships between IP, anxiety, and burnout were explored. RESULTS: Two hundred and sixty-nine residents responded to the survey (response rate 18.8%). Respondents were distributed evenly between specialties (FM = 24.9%, PM = 33.1%, AN = 20.4%, GS = 21.6%). IP was identified in 62.7% of all participants. The average score on the CIPS was 66.4 (SD = 14.4), corresponding to 'frequent feelings of impostorism.' Female learners were at higher risk for IP (RR = 1.27, 95% CI: 1.03-1.57). Burnout, as defined by meeting burnout criteria on all three subscales, was detected in 23.3% of respondents. Significant differences were seen in burnout between specialties (p = 0.02). GS residents were more likely to experience burnout (31.7%) than PM and AN residents (26.7 and 10.0%, respectively, p = 0.02). IP was an independent risk factor for both anxiety (RR = 3.64, 95% CI:1.96-6.76) and burnout (RR = 1.82, 95% CI: 1.07-3.08). CONCLUSIONS: Impostorism is commonly experienced by resident learners independent of specialty and contributes to learner anxiety and burnout. Supervisors and Program Directors must be aware of the prevalence of IP and the impact on burnout. Initiatives to mitigate IP may improve resident learner wellness and decrease burnout in postgraduate learners.

Pilot Evaluation of a Novel, Low-Cost, Simulation Model for Training and Assessment of Laparoscopic Intracorporeal Continuous Suturing.

Background: Laparoscopic intracorporeal continuous suturing is being employed in a growing number of minimally invasive procedures. However, there is a lack of adequate bench models for gaining proficiency in this complex task. The purpose of this study was to assess a novel simulation model for running suture. Methods: Participants were grouped as novice (LSN) or expert (LSE) at laparoscopic suturing based on prior experience and training level. A novel low-cost bench model was developed to simulate laparoscopic intracorporeal continuous closure of a defect. The primary outcome measured was time taken to complete the task. Videos were scored by independent raters for Global Operative Assessment of Laparoscopic Skills (GOALS). Results: Sixteen subjects (7 LSE and 9 LSN) participated in this study. LSE completed the task significantly faster than LSN (430 ± 107 vs 637 ± 164 seconds, P ≤ .05). LSN scored higher on accuracy penalties than LSE (Median 30 vs 0, P ≤ .05). Mean GOALS score was significantly different between the 2 groups (LSE 20.64 ± 2.64 vs LSN 14.28 ± 1.94, P < .001) with good inter-rater reliability (ICC ≥ .823). An aggregate score using the formula: Performance Score = 1200-time(sec)-(accuracy penalties x 10) was significantly different between groups with a mean score of 741 ± 141 for LSE vs 285 ± 167 for LSN (P < .001). Conclusion A novel bench model for laparoscopic continuous suturing was able to significantly discriminate between laparoscopic experts and novices. This low-cost model may be useful for both training and assessment of laparoscopic continuous suturing proficiency.

Semaphorin 5B is a repellent cue for sensory afferents projecting into the developing spinal cord.

During vertebrate development, centrally projecting sensory axons of the dorsal root ganglia neurons first reach the embryonic spinal cord at the dorsolateral margin. Instead of immediately projecting into the grey matter, they bifurcate and extend rostrally and caudally to establish the longitudinal dorsal funiculus during a stereotyped waiting period of approximately 48 h. Collateral fibres then extend concurrently across multiple spinal segments and project to their appropriate targets within the grey matter. This rostrocaudal extension of sensory afferents is crucial for the intersegmental processing of information throughout the spinal cord. However, the precise cues that prevent premature entry during the waiting period remain to be identified. Here, we show that semaphorin 5B (Sema5B), a member of the semaphorin family of guidance molecules, is expressed in the chick spinal cord during this waiting period and dorsal funiculus formation. Sema5B expression is dynamic, with a reduction of expression apparent in the spinal cord concomitant with collateral extension. We show that Sema5B inhibits the growth of NGF-dependent sensory axons and that this effect is mediated in part through the cell adhesion molecule TAG-1. Knockdown of Sema5B in the spinal cord using RNA interference leads to the premature extension of cutaneous nociceptive axons into the dorsal horn grey matter. These premature projections predominantly occur at the site of dorsal root entry. Our results suggest that Sema5B contributes to a repulsive barrier for centrally projecting primary sensory axons, forcing them to turn and establish the dorsal funiculus.

Transmembrane semaphorin5B is proteolytically processed into a repulsive neural guidance cue.

Developing neuronal growth cones respond to a number of post-transcriptionally modified guidance cues to establish functional neural networks. The Semaphorin family has well-established roles as both secreted and transmembrane guidance cues. Here, we describe the first evidence that a transmembrane Semaphorin, Semaphorin 5B (Sema5B), is proteolytically processed from its transmembrane form and can function as a soluble growth cone collapsing guidance cue. Over-expression of A Disintegrin and Metalloprotease (ADAM)-17, results in an enhanced release of the Sema5B ectodomain, while removal of a predicted ADAM-17 cleavage site prevents its release. In contrast, knockdown of ADAM-17 does not significantly reduce Sema5B release, indicating there are additional unknown compensating proteases. This modulation of the transmembrane Sema5B to a diffusible cue represents a sophisticated method to regulate neuronal guidance in vivo.

Measurements using mammography and ultrasonography underestimate the size of high-volume ductal carcinoma in situ.

BACKGROUND: Surgical decisions for ductal carcinoma in situ (DCIS) are based on lesion sizes. This study aims to determine the accuracy of pre-operative imaging in estimating the size of DCIS. METHODS: This was a retrospective review of clinicopathologic data of patients treated for DCIS with breast conserving surgery (BCS) between 2012 and 2018. Mammographic and sonographic lesion sizes were compared with final pathology sizes. RESULTS: For the 152 lesions visible on mammography, mean size on imaging was significantly smaller when compared to final pathology (2.3 vs. 3.6 cm, p < 0.001). The mean difference of 1.3 cm was a significant underestimation with a correlation coefficient of 0.367 (p < 0.001). For 48 sonographically visible lesions, the radiologic size was significantly smaller than pathologic size (1.7 vs. 4.1 cm, p < 0.001), but the degree of underestimation was not significantly correlated (p = 0.379). CONCLUSION: DCIS size was significantly underestimated by imaging. This must be taken into consideration during surgical planning.

Upstage rate of radial scar/complex sclerosing lesion identified on core needle biopsy.

BACKGROUND: We assessed the cancer upstage rate of Radial Scars (RS), and Complex Sclerosing Lesions (CSL), and risk-stratified lesions based on radiological and pathological features. METHODS: Characteristics of RS/CSL treated from 2013 to 2018 were examined for features associated with cancer. RESULTS: 78 RS/CSL were found on core needle biopsy (CNB) and surgically excised. 9 (11.5%) lesions were upstaged. Upstaged patients were older (66 vs 51, p = 0.033). More upstaged lesions were accompanied by a mass on both mammography (87.5% vs. 30.0%, p = 0.005) and ultrasound (100.0% vs. 62.8%, p = 0.043). 20.5% of lesions biopsied under ultrasound guidance with small needles (14-18G) were upstaged, but no lesions biopsied under stereotactic guidance with large needles (9-12 G) with vacuum assistance were upstaged (p = 0.009). CONCLUSIONS: Excision of RS/CSL seen on CNB is warranted, especially if the patient is older, the CNB is performed under ultrasound guidance with small needles, or if a mass is present on imaging.

Assays to Examine Transmembrane Semaphorin Function In Vitro.

The semaphorins are a large family of secreted and membrane associated proteins that play numerous key roles in the development and function of the nervous system and other tissues. They have been primarily associated with their function as guidance cues in the developing nervous system. In general, semaphorins have been shown to function as inhibitory guidance cues; however there are also numerous examples where they can function as attractive or permissive cues. Thus it is important to employ a variety of assays to test for semaphorin function. While numerous assays have been established for secreted semaphorins, testing the function of transmembrane semaphorins has been challenging. In this chapter we outline two assays that we have used extensively to test their function. In one assay we examine the effect of a constant source of a transmembrane semaphorin on neurite outgrowth and in a second assay we examine whether neurons will actively avoid growing across islands of cells expressing a transmembrane semaphorin. We have found both assays to be relatively easy to perform and useful to test semaphorin function and signaling.

Quality indicators for thyroid cancer surgery: current perspective.

INTRODUCTION: While the disease specific mortality of differentiated thyroid cancer has remained low with current treatments, its incidence has been steadily rising over the past several decades, and cancer related recurrence and morbidity have remained a significant problem. Quality indicators currently employed are relevant to the surgical intervention, but do not necessarily reflect oncological outcomes. Therefore, thyroid cancer specific surgical quality indicators, that offer insight into risk of cancer related morbidity and mortality are needed. AREAS COVERED: This review aims to discuss the role of measuring quality in thyroid surgical oncology and carry out a comprehensive review of potential quality indicators for thyroid cancer operations. The three quality indicators reviewed here are the postoperative radioactive iodine update by remnant thyroid tissue, the proportion of resected lymph nodes with evidence of metastases, and the post-operative serum thyroglobulin level. Expert commentary: Together, these quality indicators may be utilized to guide improvement of the quality of surgical care for this unique patient population. A critical future step in establishing the role of quality indicators for thyroid cancer surgery is the determination of cutoff values of each indicator in an evidence-based manner.