Control of Pest Grasshoppers in North America.

Grasshoppers (Orthoptera: Acrididae) frequently inflict damage on millions of hectares of western rangelands and crops. The main method of controlling grasshopper outbreaks consists of covering their infestations with chemical insecticides. Although it is relatively cheap, fast, and efficient, chemical control bears serious risks to human health, non-target organisms, and the environment. To overcome this challenge, biological control is a less environmentally hazardous alternative to traditional, synthetic insecticides. This paper reviews strategies that could be used as effective ways to control such pests with a special focus on effective bait formulations that might provide a key model in developing biological control strategies for the grasshopper population.

Economic consequences of failure of initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infections.

BACKGROUND: Initial antibiotic therapy in hospitalized adults with complicated intra-abdominal infection (cIAI) usually is empiric. We explored the economic consequences of failure of such therapy in this patient population. METHODS: Using a large U.S. multi-institutional database, we identified all hospitalized adults admitted between April 1, 2003, and March 31, 2004; who had any cIAI; underwent laparotomy, laparoscopy, or percutaneous drainage of an intra-abdominal abscess ("surgery"); and received intravenous (IV) antibiotics. Initial therapy was characterized in terms of all IV antibiotics received, on the day of or one day before initial surgery. Antibiotic failure was designated on the basis of the need for reoperation or receipt of other IV antibiotics postoperatively. Switches to narrower spectrum agents and changes in regimen prior to discharge with no other evidence of clinical failure were not counted as antibiotic failures. Using multivariable linear regression, duration of IV antibiotic therapy, hospital length of stay, and total inpatient charges were compared between patients who did and did not fail initial therapy. Mortality was compared using multivariable logistic regression. RESULTS: Among 6,056 patients who met the study entrance criteria, 22.4% failed initial antibiotic therapy. Patients who failed received an additional 5.6 days of IV antibiotic therapy (10.4 total days [95% confidence interval 10.1, 10.8] days vs. 4.8 total days [4.8, 4.9] for those not failing), were hospitalized an additional 4.6 days (11.6 total days [11.3, 11.9] vs. 6.9 total days [6.8, 7.0], respectively), and incurred $6,368 in additional inpatient charges ($16,520 [$16,131, $16,919] vs. $10,152 [$10,027, $10,280]) (all, p < 0.01). They also were more likely to die in the hospital (9.5% vs. 1.3%; multivariable odds ratio 3.58 [95% confidence interval 2.53, 5.06]). CONCLUSIONS: Failure of initial IV antibiotic therapy in hospitalized adults with cIAIs is associated with longer hospitalization, higher hospital charges, and a higher mortality rate.

Intensity-modulated radiotherapy results in significant decrease in clinical toxicities compared with conventional wedge-based breast radiotherapy.

PURPOSE: We have previously demonstrated that intensity-modulated radiotherapy (IMRT) with a static multileaf collimator process results in a more homogenous dose distribution compared with conventional wedge-based whole breast irradiation (WBI). In the present analysis, we reviewed the acute and chronic toxicity of this IMRT approach compared with conventional wedge-based treatment. METHODS AND MATERIALS: A total of 172 patients with Stage 0-IIB breast cancer were treated with lumpectomy followed by WBI. All patients underwent treatment planning computed tomography and received WBI (median dose, 45 Gy) followed by a boost to 61 Gy. Of the 172 patients, 93 (54%) were treated with IMRT, and the 79 patients (46%) treated with wedge-based RT in a consecutive fashion immediately before this cohort served as the control group. The median follow-up was 4.7 years. RESULTS: A significant reduction in acute Grade 2 or worse dermatitis, edema, and hyperpigmentation was seen with IMRT compared with wedges. A trend was found toward reduced acute Grade 3 or greater dermatitis (6% vs. 1%, p = 0.09) in favor of IMRT. Chronic Grade 2 or worse breast edema was significantly reduced with IMRT compared with conventional wedges. No difference was found in cosmesis scores between the two groups. In patients with larger breasts (> or =1,600 cm(3), n = 64), IMRT resulted in reduced acute (Grade 2 or greater) breast edema (0% vs. 36%, p <0.001) and hyperpigmentation (3% vs. 41%, p = 0.001) and chronic (Grade 2 or greater) long-term edema (3% vs. 30%, p = 0.007). CONCLUSION: The use of IMRT in the treatment of the whole breast results in a significant decrease in acute dermatitis, edema, and hyperpigmentation and a reduction in the development of chronic breast edema compared with conventional wedge-based RT.

Interim cosmetic results and toxicity using 3D conformal external beam radiotherapy to deliver accelerated partial breast irradiation in patients with early-stage breast cancer treated with breast-conserving therapy.

PURPOSE: We present our ongoing clinical experience utilizing three-dimensional (3D)-conformal radiation therapy (3D-CRT) to deliver accelerated partial breast irradiation (APBI) in patients with early-stage breast cancer treated with breast-conserving therapy. METHODS AND MATERIALS: Ninety-one consecutive patients were treated with APBI using our previously reported 3D-CRT technique. The clinical target volume consisted of the lumpectomy cavity plus a 10- to 15 -mm margin. The prescribed dose was 34 or 38.5 Gy in 10 fractions given over 5 consecutive days. The median follow-up was 24 months. Twelve patients have been followed for > or =4 years, 20 for > or =3.5 years, 29 for >3.0 years, 33 for > or =2.5 years, and 46 for > or =2.0 years. RESULTS: No local recurrences developed. Cosmetic results were rated as good/excellent in 100% of evaluable patients at > or = 6 months (n = 47), 93% at 1 year (n = 43), 91% at 2 years (n = 21), and in 90% at > or =3 years (n = 10). Erythema, hyperpigmentation, breast edema, breast pain, telangiectasias, fibrosis, and fat necrosis were evaluated at 6, 24, and 36 months after treatment. All factors stabilized by 3 years posttreatment with grade I or II rates of 0%, 0%, 0%, 0%, 9%, 18%, and 9%, respectively. Only 2 patients (3%) developed grade III toxicity (breast pain), which resolved with time. CONCLUSIONS: Delivery of APBI with 3D-CRT resulted in minimal chronic (> or =6 months) toxicity to date with good/excellent cosmetic results. Additional follow-up is needed to assess the long-term efficacy of this form of APBI.

Predictors of efficacy and health resource utilization in treatment of complicated intra-abdominal infections: evidence for pooled clinical studies comparing tigecycline with imipenem-cilastatin.

BACKGROUND: Duration of intravenous (IV) treatment, surgical/radiologic interventions for infection control, and hospital length of stay (LOS) are important cost considerations in complicated intra-abdominal infections (cIAIs). METHODS: Data were pooled from two multinational, double-blind studies conducted in hospitalized adults with cIAIs who were randomized (1:1) to receive tigecycline (100 mg IV initial dose then 50 mg IV every 12 h) or imipenem-cilastatin (500 mg IV every 6 h) for 5 to 14 days in order to assess tigecycline safety and efficacy. This report focuses on developing predictors of cure and health care resource utilization, including the need for repeat surgical/radiologic interventions, duration of IV antibiotic therapy, and hospital LOS. Multiple regression models were applied for each of the above outcomes, incorporating both baseline and on-treatment potential covariates. Logistic modeling was used for categorical outcomes (cure; repeat surgical/radiologic interventions) and least squares modeling for continuous outcomes (duration of IV antibiotic therapy; LOS). Stepwise selection was used to retain only those predictors found to be significant (p < 0.05) independent risk factors. RESULTS: The most common causative pathogen was Escherichia coli (63.0%), with 63.3% of the patients exhibiting polymicrobial infections. The most common cIAI diagnosis was complicated appendicitis (51.9%). Lack of clinical cure (+ 6.1 days; p < 0.0001), perforation of the intestine (+3.7 days; p < 0.0001), an Acute Physiology and Chronic Health Evaluation (APACHE) score >15 (+3.1 days; p=0.039), abnormal plasma sodium concentration (+3.7 days; p=0.026), and repeat surgical/radiologic intervention (+2.2 days; p=0.0097) were identified as key risk factors for longer LOS. Inadequate source control was associated with reduced odds of cure, longer IV treatment duration (+1.5 days; p=0.007), and longer LOS. The treatment groups did not differ in terms of LOS, IV treatment duration, or clinical cure. CONCLUSION: Tigecycline was similar to imipenem-cilastatin in terms of both efficacy and health resource utilization. Risk factors identified in this study for both outcome measures are offered as support for guiding clinical practice.

Creation of clinical research databases in the 21st century: a practical algorithm for HIPAA Compliance.

BACKGROUND: Enforcement of the Health Insurance Portability and Accountability Act (HIPAA) began in April, 2003. Designed as a law mandating health insurance availability when coverage was lost, HIPAA imposed sweeping and broad-reaching protections of patient privacy. These changes dramatically altered clinical research by placing sizeable regulatory burdens upon investigators with threat of severe and costly federal and civil penalties. This report describes development of an algorithmic approach to clinical research database design based upon a central key-shared data (CK-SD) model allowing researchers to easily analyze, distribute, and publish clinical research without disclosure of HIPAA Protected Health Information (PHI). METHODS: Three clinical database formats (small clinical trial, operating room performance, and genetic microchip array datasets) were modeled using standard structured query language (SQL)-compliant databases. The CK database was created to contain PHI data, whereas a shareable SD database was generated in real-time containing relevant clinical outcome information while protecting PHI items. Small (< 100 records), medium (< 50,000 records), and large (> 10(8) records) model databases were created, and the resultant data models were evaluated in consultation with an HIPAA compliance officer. RESULTS: The SD database models complied fully with HIPAA regulations, and resulting "shared" data could be distributed freely. Unique patient identifiers were not required for treatment or outcome analysis. Age data were resolved to single-integer years, grouping patients aged > 89 years. Admission, discharge, treatment, and follow-up dates were replaced with enrollment year, and follow-up/outcome intervals calculated eliminating original data. Two additional data fields identified as PHI (treating physician and facility) were replaced with integer values, and the original data corresponding to these values were stored in the CK database. Use of the algorithm at the time of database design did not increase cost or design effort. CONCLUSIONS: The CK-SD model for clinical database design provides an algorithm for investigators to create, maintain, and share clinical research data compliant with HIPAA regulations. This model is applicable to new projects and large institutional datasets, and should decrease regulatory efforts required for conduct of clinical research. Application of the design algorithm early in the clinical research enterprise does not increase cost or the effort of data collection.

Clinical outcomes and fiscal consequences of bilateral neck exploration for primary idiopathic hyperparathyroidism without preoperative radionuclide imaging or minimally invasive techniques.

BACKGROUND: Radionuclide imaging-directed, minimally invasive parathyroid operation is promoted in the surgical literature and public domain as the fastest, most successful, and cheapest means of treating primary idiopathic hyperparathyroidism. The validity of these claims is unproven. This study reviews the treatment outcome results of a large series of patients treated with standard parathyroid operation without preoperative localization studies. Cost comparisons are made between this series and previous reports of selected patients in whom preoperative radionuclide imaging preceded minimally invasive parathyroid operation. METHODS: Diagnosis, treatment, and outcome data for 688 consecutive patients undergoing first neck exploration for primary idiopathic hyperparathyroidism were prospectively collected. All patients in our series underwent standard bilateral neck exploration without preoperative localization studies. Intraoperative methylene blue was used to aid identification of all parathyroid glands. Surgical findings, pathological diagnosis, operative time, length-of-stay, and treatment success data were collected. Cost data were calculated for our series using the identical calculations used in previous reports. Our outcome and calculated cost data were compared with previous reports by centers advocating scan-directed, minimally invasive parathyroid operation. RESULTS: Of 2,752 predicted total glands, 2,520 (91.6%) were identified using standard neck exploration without radionuclide localization studies. Single adenoma, with at least 1 normal gland, was found in 542 patients (78.8%), with 8 in a fifth gland. Multiple-gland hyperplasia was identified in 98 patients (14.2%) and of these 22 (3.2%) were double adenomas. Ten patients had parathyroid carcinoma (1.5%), and all received definitive surgical treatment during the primary operation. Cure rates were assessed by measurement of normal serum calcium and parathyroid hormone levels at 3 and 12 months after operation, and were 97.7% in our series. Mean operating time for the entire series was 65 minutes, decreased to 35 minutes in patients with single adenomas, and mean recovery room time was 30 minutes. Mean total costs for patients undergoing standard exploration for single adenoma was US dollars 1,107, and increased to US dollars 1,243 when patients with multigland disease, hyperplasia, or malignancy were included. CONCLUSIONS: Our series demonstrates operative times and treatment outcomes with costs that are approximately one-third less than those for scan-directed, minimally invasive operation for primary idiopathic hyperparathyroidism. Thus, claims that scan-directed parathyroid operation is the cheapest, fastest, and most successful means of treatment are not supported by these data.

Pro- and antiinflammatory cytokine production after radiofrequency ablation of unresectable hepatic tumors.

BACKGROUND: Experience using radiofrequency ablation (RFA) for treating unresectable hepatic malignancies is expanding, with promising outcomes and fewer complications compared with cryotherapy. STUDY DESIGN: This study examined systemic inflammatory responses after RFA as measured by the appearance of postoperative symptoms and cytokine production. Seventeen patients (11 men, 6 women) aged 40 to 85 years (mean 64.2 years) with unresectable primary and metastatic hepatic tumors underwent RFA. Mean liver volume treated with RFA was 35.3% +/- 3.6% (SEM) (median 36.8%). Plasma cytokines (tumor necrosis factor-alpha, interleukin [IL]-1beta, IL-1ra, IL-6, IL-8, IL-10, p55, and p75) were measured from anesthesia induction through 48 hours after RFA. Ex vivo whole-blood cytokine production was measured at baseline, 24 hours, and 48 hours after RFA. RESULTS: Cytokine and cytokine-receptor production were not notably altered by RFA. Ex vivo whole-blood endotoxin stimulation indicated that intrinsic cellular immune function remained intact after treatment, although modest decreases in stimulated tumor necrosis factor alpha production were observed 24 to 48 hours after RFA. Variceal bleeding, hepatic failure, and death occurred in one patient 30 days after RFA. None of the remaining patients exhibited tachycardia or hypotension. Fevers (> or = 38.5 degrees C) developed in three patients during the first 48 hours postoperatively. There was no association between plasma cytokines and postoperative complications. CONCLUSIONS: In contrast to previous reports using cryotherapy, systemic inflammatory responses as measured by increased cytokines were not observed after RFA. The cryotherapy-induced "cryoshock" phenomenon was not observed in patients undergoing RFA in our study. We conclude that RFA ablation is fundamentally different than cryotherapy and apparently does not stimulate Kupffer and other hepatic macrophages to produce proinflammatory cytokines.

Transanal excision of locally advanced rectal cancers downstaged using neoadjuvant chemoradiotherapy.

BACKGROUND: Our institution has previously demonstrated a survival advantage conferred by preoperative neoadjuvant therapy for locally advanced rectal cancers. We now report our results using transanal excision as definitive surgical therapy in a selected group of patients who experienced significant downstaging of T3 rectal cancers after neoadjuvant therapy. STUDY DESIGN: Seventy-four patients diagnosed with locally advanced (T3) rectal cancers were treated with neoadjuvant chemoradiotherapy. After neoadjuvant therapy, 11 (14.9%) patients who had significant downstaging of their tumors were selected to undergo transanal excision of their residual rectal cancers. Intraoperative cryostat evaluation was used to confirm negative margin status, and all patients were subsequently followed with routine endoscopy, transrectal ultrasonography, and digital rectal examinations. RESULTS: Tumors were located between 1 cm and 7 cm from the anal verge (mean 4.3 +/- 0.6 cm), and were located in lateral, anterior, and posterior positions. Mean followup was 55.2 +/- 8.9 months (median 47.9 months). Imaging studies using CT, MRI, transrectal ultrasonography, or combination demonstrated suspicious lymph nodes in three patients. After neoadjuvant therapy, these lymph nodes were no longer demonstrated in two patients. There were no local recurrences, nodal metastases, or operative mortalities. One patient (9%) developed distant metastases (pulmonary nodules), and remains alive 30 months after transanal excision. One patient (9%) experienced sphincter laxity, which was successfully repaired, and is now asymptomatic. One patient (9%) developed postoperative urgency that resolved spontaneously. CONCLUSIONS: In patients who have initial bulky (T3) lesions, and experience significant downstaging after neoadjuvant chemoradiotherapy, transanal excision appears to be a safe and effective treatment, preserving sphincter function and avoiding laparotomy.

Hepatic artery embolization for control of symptoms, octreotide requirements, and tumor progression in metastatic carcinoid tumors.

Hepatic artery embolization (HAE) has been utilized for treatment of advanced hepatic carcinoid metastases, with promising symptom palliation and tumor control. Our institution employs transcatheter HAE using Lipiodol/Gelfoam for treatment of carcinoid hepatic metastases, and this report presents our experience with twenty-four patients, examining symptom control, quality-of-life, octreotide dependence, and tumor progression. Twenty-four (11 male, 13 female, mean age = 59.4 +/- 2.5 yr) patients with carcinoid and unresectable hepatic metastases, confirmed by urinary 5-hydroxyindole acetic acid (5-HIAA) measurement and biopsy, were treated with Lipiodol/Gelfoam HAE from 1993-2001. Median follow-up was 35.0 months. Before HAE, 14 patients (58.3%) had malignant carcinoid syndrome, with symptoms quantified using our previously reported Carcinoid Symptom Severity Score, and 13 patients (54.2%) required octreotide for symptom palliation. Following treatment, symptom severity, octreotide dose, and tumor response were measured. Asymptomatic patients did not develop symptoms or require following treatment. Hepatic metastases remained stable (n = 4) or decreased (n = 19) in 23 patients (95.8%). Mean pretreatment Symptom Severity Scores (3.8 +/- 0.2), decreased to 1.4 +/- 0.1 post-treatment (P < 0.00001), with 64.3% of patients becoming asymptomatic. Mean pretreatment octreotide dosages (679.6 +/- 73.0 microg/d), decreased to 262.9 +/- 92.7 microg/d (P = 0.0024) post-treatment, with 46.2% of patients discontinuing octreotide. There were no treatment-related serious complications or deaths. This study demonstrates that Lipiodol/Gelfoam HAE produces excellent control of malignant carcinoid syndrome, allowing patients to decrease or eliminate use of octreotide, while controlling hepatic tumor burden.

An Internet-based tool for evaluating third-year medical student performance.

BACKGROUND: Shortened non-primary care medical school clerkships have increased time pressures for accurate assessment of student knowledge, skills, and attitudes. Paper-based student evaluations suffer from low response rates, inefficient data acquisition and analysis, and difficulty obtaining input from multiple evaluators. This project describes the development of a Web-based model for evaluating third-year medical student performance, improving evaluation response rates, and including multiple evaluators' input. METHODS: A secure Web-based system was designed to maintain evaluation data (11-item competency-based evaluations, oral examinations, National Board of Medical Examiners surgery test, and objective structured clinical examination) for the third-year surgery clerkship. Historical response rate, completion time, and administrative effort data were compared with data obtained using the Web-based model. RESULTS: Faculty response rates improved from 71.3% to 89.9%, with response times decreased from 28.0 +/- 3.0 to 9.0 +/- 0.7 days using the Web-based model. Administrative time requirements decreased from 5 days to 2 hours per rotation, and manual data entry, analysis, and reporting were eliminated through e-mail evaluator notification, direct data entry, and real-time analysis. Evaluator satisfaction was subjectively higher using the Web-based model. CONCLUSIONS: The Web-based 360-degree evaluation model improves third-year medical student assessment by including residents, reducing time and cost, and by providing a faster, more inclusive, and efficient evaluation.

Grasshoppers (Orthoptera: Acrididae) could serve as reservoirs and vectors of vesicular stomatitis virus.

Vesicular stomatitis (VS) is an economically devastating disease of livestock in the Americas. Despite strong circumstantial evidence for the role of arthropods in epizootics, no hematophagous vector explains the field evidence. Based on the spatiotemporal association of grasshopper outbreaks and VS epizootics, we investigated the potential role of these insects as vectors and reservoirs of the disease. The critical steps in the grasshopper-bovine transmission cycle were demonstrated, including 1) 62% of grasshoppers [Melanoplus sanguinipes (F.)] fed vesicular stomatitis virus (VSV) from cell culture became infected, with titers reaching 40,000 times the inoculative dose; 2) 40% of grasshoppers that cannibalized VSV-infected grasshopper cadavers became infected, amplifying virus up to 1,000-fold; 3) one of three cattle consuming VSV-infected grasshopper cadavers contracted typical VS and shed virus in saliva; and 4) 15% of grasshoppers became infected when fed saliva from this infected cow. The ecological conditions and biological processes necessary for these transmissions to occur are present throughout much of the Americas. Field studies will be required to show these findings are relevant to the natural epidemiology of VSV.

Sequential dermal-peritumoral radiocolloid injection for sentinel node biopsy for breast cancer: the University of Florida experience.

Although sentinel lymph node (SLN) biopsy is rapidly becoming the standard of care for small breast cancers the optimal radiocolloid injection technique remains controversial. We report our experience with sequential dermal-peritumoral radiocolloid injection that takes advantage of both techniques. One hundred eighteen patients with clinical stage T(is), T1, T2 and N0 breast cancer underwent SLN biopsy at the University of Florida. Twelve to 18 hours before surgery patients received either an injection of 0.5 to 1.0 mCi 50:50 filtered:unfiltered technetium sulfur colloid into the dermis overlying the tumor and/or a peritumoral injection of a 3 to 4-mCi of radiocolloid 30 minutes later. Dynamic lymphoscintigraphy was performed and the topographical location of all imaged lymph nodes was marked on the skin. The next morning the surgeon utilized a hand-held gamma probe to remove all SLN(s) defined as any lymph node with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN [internal mammary (IM) nodes were not removed]. The SLN identification rate was 98.5 per cent (3 IM nodes) for dermal injection (d.), 83.3 per cent (1 IM node) for peritumoral injection (p.), and 100 per cent (14 IM nodes) for sequential dermal-peritumoral injection (d.p.) (p < 0.05 DP versus D). Sequential d.p. 50:50 filtered:unfiltered technetium sulfur colloid injection results in a rapid, high SLN identification rate that persists until surgery the next morning. Delineation of nonaxillary SLNs may lead to more accurate breast cancer staging and may also influence the delivery of IM node radiation.

Evaluation of face-mounted binocular video display for laparoscopy: outcomes of psychometric skills testing and surgeon satisfaction.

OBJECTIVES: Improved digital video cameras and high-resolution video displays have greatly enhanced laparoscopic surgery. However, the size and distance of the video display and the location of the monitor continue to be impediments in laparoscopy, providing unsatisfactory operative visualization and causing the development of neck and back strain in surgeons performing long procedures. The purpose of this study was to evaluate the use of a face-mounted binocular high-resolution video display by means of standardized measurements of laparoscopic skill, and to compare procedure speed and surgeon satisfaction with the binocular display, open operative visualization, and standard laparoscopic monitor views. METHODS: The surgical faculty and resident trainees (n = 22) underwent two standardized laparoscopic psychometric skills tests of fine motor control and bimanual operative facility. Testing was performed first with the use of laparoscopic instruments in direct view of the participants; sufficient repetitions were allowed so that plateau levels were obtained in task speed. Video camera-based imaging displayed on the face-mounted binocular video display and a standard video monitor were then used to repeat identical tests. Test times were compared between the open view, face-mounted display (FMD) view, and standard laparoscopic monitor view groups. A Likert-scale based assessment was conducted to examine operator impressions of neck and back strain, visual acuity, and overall satisfaction. RESULTS: Performance with the standard laparoscopic monitor was significantly slower than with the direct view on both fine motor (mean, 85.0 +/- 7.1 s vs. 56.4 +/- 5.7 s; P <.0001) and bimanual (mean, 80.8 +/- 7.0 s vs. 40.2 +/- 2.6 s; P =.009) psychometric skills tests. The FMD view performance was significantly faster than the standard laparoscopic monitor performance for both the bimanual (mean, 72.2 +/- 7.6 s vs. 85.0 +/- 7.2 s; P =.001) and fine motor (mean, 59.3 +/- 4.7 s vs. 80.8 +/- 7.0 s; P =.004) tests. The scores on a Likert Scale satisfaction survey of the use of the FMD unit for neck and back strain (mean, 4.27 +/- 0.20), visual acuity (mean, 3.93 +/- 0.10), and overall satisfaction (mean, 4.16 +/- 0.20) were high (scale: 1, worst; 5, ideal). CONCLUSIONS: A face-mounted high-resolution video display unit reduces neck and back strain and improves both visualization and overall satisfaction in comparison with standard laparoscopic display monitors; surgical performance is better than with standard laparoscopic imaging as assessed by standardized psychometric skills testing.

Web-based minimally invasive surgery training: competency assessment in PGY 1-2 surgical residents.

OBJECTIVES: Little published literature describes accurate evaluation and assessment of surgical residents' technical competencies. Work-hour limitations and the proposed changes in training duration challenge our ability to provide core technical competencies, particularly during PGY-1-2. We identified minimally invasive surgery as a particularly challenging competency training area, requiring significant allocation of resident and faculty time and resources, with inconsistent training results. This project evaluated a standardized competency training curriculum in minimally invasive surgery in comparison to existing training. METHODS: The Laparoscopy 101-a Resource for Resident Education minimally invasive surgery competency training curriculum consists of CD-ROM-based self-paced didactic self-instruction modules, skills laboratories, and web-based testing, evaluation, and reporting. Five didactic self-study modules and their corresponding web-based examinations were selected for this study. PGY 1-2 residents (11/group) were enrolled. PGY-1 residents received no formal minimally invasive surgery training in our program before participating, whereas PGY-2 residents were exposed to the minimally invasive surgery training program in place in our department. PGY-1 residents completed the training modules and web-based testing over 4 days. PGY-2 residents underwent testing before (pre-test) and after (post-test) completing identical training modules and testing over an identical time period. Test results were examined and compared in both groups. A user-satisfaction survey assessed resident opinions about the quality of the curriculum, use of the CD-ROM/web-based system, and trainee perceptions about performance. RESULTS: PGY-2 Pre-test scores were equivalent to PGY-1 scores after training (mean overall performance, 52.4% vs 65.5% p = ns). PGY-2 Post-test scores were significantly higher when compared with pre-test scores (mean overall performance; pre: 52.4% vs post: 85.3% p <== 0.001). Interestingly, post-training scores were significantly higher for PGY-2 than PGY-1 (mean overall performance PGY-1: 52.4% vs PGY-2: 65.5% p = ns). Competencies achieved persisted 6 months after initial training in both PGY 1-2 groups without additional training using this curriculum. Overall user satisfaction was positive in each category evaluated. CONCLUSIONS: The Laparoscopy 101 minimally invasive surgery curriculum (1) p;rovides a structured self-paced curriculum for minimally invasive didactic training that is well accepted by trainees; (2) yields PGY-1 competencies equivalent to PGY-2 who receive training in our department's existing program; and (3) yields significant improvement in PGY-2 minimally invasive surgery competencies. Training effects persist to 6 months without reinforcement. Our observations of PGY-2 performance and competency suggest that this training would best be instituted during PGY-2.

Laboratory bioassays of vegetable oils as kairomonal phagostimulants for grasshoppers (Orthoptera: Acrididae).

Vegetable oils have kairomonal attractant properties to grasshoppers primarily due to the presence of linoleic and linolenic fatty acids. These fatty acids are dietary essentials for grasshoppers and, once volatilized, can be detected by the insects' olfactory receptors. A laboratory bioassay method has been developed to identify vegetable oils that have fatty acid profiles similar to grasshoppers and that induce grasshopper attraction and feeding. Such oils could be useful kairomonal adjuvants and/or carriers for acridicide formulations. Three sets of laboratory bioassays demonstrated that the addition of a standard aliquot of different vegetable oils resulted in varying degrees of grasshopper feeding on otherwise neutral substrates. Addition of olive oil stimulated the greatest feeding in all three sets of assays, regardless of the age of the tested insects. Furthermore, addition of canola or flax oils markedly enhanced grasshopper feeding. These three oils--i.e., olive, canola, and flax oil--proved to be the best performing grasshopper stimulants. A second group of oils included rapeseed-flax mix and rapeseed oils; however, their performance was not as consistent as oils in the first group--especially with regard to nymphal feeding. A third group of oils consisted of soybean, corn, peanut, and sunflower oil. Theoretical expectations regarding these oils varied wildly, suggesting that the results of a single bioassay should be cautiously interpreted as being negative.

Molecular classification system identifies invasive breast carcinoma patients who are most likely and those who are least likely to achieve a complete pathologic response after neoadjuvant chemotherapy.

BACKGROUND: The molecular classification system categorizes invasive breast carcinomas according to their key driving biomarkers. In the current study, the authors evaluated whether response to neoadjuvant chemotherapy was correlated with the molecular classification groups. METHODS: Using immunohistochemistry, the molecular classification group (luminal-A, luminal-B, HER-2-variant, HER-2-classic, and basal phenotype) was retrospectively determined in 68 breast cancer patients who received neoadjuvant treatment. RESULTS: A total of 28 carcinoma patients (41.2%) achieved a compete pathologic response (CPR), including 2 of 15 patients classified as having luminal-A (13.3%), 4 of 16 patients classified as having luminal-B (25.0%), 10 of 12 patients classified as having HER-2-classic (83.3%), none of the 4 patients classified as having HER-2-variant, and 12 of 21 patients classified as having basal phenotype (57.1%) neoplasms. The CPR rate among patients with the HER-2-classic and basal neoplasms was 67% (22 of 33 neoplasms), compared with 17.1% (6 of 35 neoplasms) in the non-HER-2-classic/basal combined group (P < .001). Eleven carcinomas were initially diagnosed as invasive lobular carcinomas (pleomorphic and classic), 4 of which were luminal-A, 4 of which were luminal-B, 2 of which were HER-2-classic, and 1 of which was basal. On review, only 3 of these 11 cases remained classified as classic lobular carcinoma, all of which were classified as luminal-A, and none of these patients achieved a CPR. Four of the other 8 patients achieved a CPR. CONCLUSIONS: The molecular classification system is useful for identifying carcinoma patients who are most likely and those who are least likely to achieve a CPR. In the current study, all the morphologically classic lobular carcinomas were classified as luminal-A neoplasms, which may explain the low rate of CPR reported.

The use of molecular assays to establish definitively the clonality of ipsilateral breast tumor recurrences and patterns of in-breast failure in patients with early-stage breast cancer treated with breast-conserving therapy.

BACKGROUND: Results from numerous trials have indicated that breast-conserving therapy (BCT) produces outcomes equivalent to those produced by mastectomy in terms of both locoregional control and survival. However, conservative treatment has resulted in the dilemma of how best to address recurrences when they appear in a breast treated previously with radiation therapy. Attempts have been made to characterize ipsilateral breast tumor recurrences (IBTRs) as either true recurrences of the treated malignancy or new primary carcinomas, because cancers that represent new primary tumors may be associated with a more favorable prognosis compared with cancers that represent true recurrences. METHODS: The authors studied the clonality of IBTRs relative to the initial invasive carcinomas by using a polymerase chain reaction loss-of-heterozygosity molecular comparison assay in 29 patients who received breast-conserving therapy (BCT). RESULTS: Twenty-two IBTRs (76%) were related clonally to the initial carcinoma, and 7 IBTRs (24%) were clonally different. Clonally related IBTRs were more frequently higher grade (72.2% vs 14.3%; P = .009) and developed sooner after initial treatment (mean time to IBTR, 4.04 years in clonally related IBTRs vs 9.25 years in clonally different IBTRs; P = .002). Six patients subsequently developed distant metastases, and 5 of those patients (83.3%) had clonally related IBTRs. Clinical IBTR classification and molecular clonality assay results differed in 30% of all patients. The proportion of IBTRs that were related clonally at 5 years, 10 years, and 15 years after BCT were 93%, 67%, and 33%, respectively. CONCLUSIONS: Clinical classifications of IBTRs were unreliable methods for determining clonality in many patients. Molecular clonality assays provided a reliable means of identifying patients who may benefit from aggressive systemic therapy at the time of IBTR and also provided a more accurate assessment of the efficacy of various forms of local therapy.

Patient outcomes after axillary lymph node dissection for breast cancer: use of postoperative continuous local anesthesia infusion.

BACKGROUND: Although considered a safe surgical procedure, axillary lymph node dissection (ALND) is associated with postoperative numbness, paresthesias, pain, and muscle weakness. Despite meticulous surgical technique and the absence of long thoracic or thoracodorsal nerve injury, the risk of these complications are reported as great as 35% to 50%, with a subset of patients developing chronic pain syndromes. METHODS: Female patients (n = 27) undergoing Level I-II ALND for breast cancer were recruited. After ALND, patients were randomized to three groups. Group 1 received standard axillary lymph node dissection. Patients assigned to group 2 or 3 (double-blinded) received 120 h continuous 0.9% saline solution or 0.5% bupivacaine using a catheter placed into the axilla and delivered by an elastomeric pump device. After routine postoperative care, patients were discharged with oral opioid analgesics. Twice-daily assessment of pain, sedation, and nausea were conducted using validated visual-analog scale measures. Daily and total opioid analgesic requirements after surgery were recorded. RESULTS: Patients treated with a continuous infusion of bupivacaine experienced significantly lower pain scores (P < 0.001) during the first 5 postoperative days. Postoperative opioid analgesic requirements also were significantly decreased in the bupivacaine group, and these effects persisted until postoperative day 14 (P < 0.001). Concomitant to the observed decreases in pain and oral opioid requirements, nausea and morning sedation also were significantly reduced. There were no pump-related complications, wound infections, or postoperative axillary fluid collections. CONCLUSIONS: The use of continuous administration of bupivicaine after ALND significantly decreases pain and opioid analgesic requirements, with concomitant decreases in nausea and sedation. This study provides encouraging evidence of the therapeutic benefits of continuous infusion of local anesthesia and may represent a valuable adjunct for surgical patients who require ALND, including those with breast cancer and melanoma.