The Florida Pancreas Collaborative Next-Generation Biobank: Infrastructure to Reduce Disparities and Improve Survival for a Diverse Cohort of Patients with Pancreatic Cancer.

Background: Well-annotated, high-quality biorepositories provide a valuable platform to support translational research. However, most biorepositories have poor representation of minority groups, limiting the ability to address health disparities. Methods: We describe the establishment of the Florida Pancreas Collaborative (FPC), the first state-wide prospective cohort study and biorepository designed to address the higher burden of pancreatic cancer (PaCa) in African Americans (AA) compared to Non-Hispanic Whites (NHW) and Hispanic/Latinx (H/L). We provide an overview of stakeholders; study eligibility and design; recruitment strategies; standard operating procedures to collect, process, store, and transfer biospecimens, medical images, and data; our cloud-based data management platform; and progress regarding recruitment and biobanking. Results: The FPC consists of multidisciplinary teams from fifteen Florida medical institutions. From March 2019 through August 2020, 350 patients were assessed for eligibility, 323 met inclusion/exclusion criteria, and 305 (94%) enrolled, including 228 NHW, 30 AA, and 47 H/L, with 94%, 100%, and 94% participation rates, respectively. A high percentage of participants have donated blood (87%), pancreatic tumor tissue (41%), computed tomography scans (76%), and questionnaires (62%). Conclusions: This biorepository addresses a critical gap in PaCa research and has potential to advance translational studies intended to minimize disparities and reduce PaCa-related morbidity and mortality.

Tissue-based coronary surgery simulation: medical student deliberate practice can achieve equivalency to senior surgery residents.

OBJECTIVE: The study objective was to assess the impact of dedicated instruction and deliberate practice on fourth-year medical students' proficiency in performing a coronary anastomosis using a porcine heart model, compared with nonsimulator-trained senior general surgery residents. METHODS: Ten fourth-year medical students were trained to perform a coronary anastomosis using the porcine simulator. Students trained for 4 months using deliberate practice methodology and one-on-one instruction. At the end of the training, each student was filmed performing a complete anastomosis. Eleven senior general surgery residents were filmed performing an anastomosis after a single tutorial. All films were graded by 3 independent cardiac surgeons in a blinded fashion. The primary outcome was the median final score (range, 1-10) of a modified Objective Structured Assessment of Technical Skill scale. The secondary outcome was time to completion in seconds. Statistical analysis used both parametric (Student t test) and nonparametric (Wilcoxon rank-sum) methods. RESULTS: The median combined final score for medical students was 3 (interquartile range, 2.3-4.8), compared with 4 (interquartile range, 3.3-5.3) for residents (P = .102). The overall median individual final scores were 3 (interquartile range, 2-6) for grader 1, 3 (interquartile range, 2-5) for grader 2, and 4 (interquartile range, 3-5) for grader 3. For each individual grader, there was no difference in median final scores between medical students and residents. The mean time to completion was 792.7 seconds (95% confidence interval, 623.4-962) for medical students and 659 seconds (95% confidence interval, 599.1-719) for residents (P = .118). CONCLUSIONS: Dedicated instruction of fourth-year medical students with deliberate and distributed practice of microvascular techniques using a porcine end-to-side coronary artery anastomosis simulation model results in performance comparable to that of senior general surgery residents. These results suggest that focused tissue simulator training can compress the learning curve to acquire technical proficiency in comparison with real-time training.

Obesity increases operating room time for lobectomy in the society of thoracic surgeons database.

BACKGROUND: Obesity has become a major epidemic in the United States. Although research suggests obesity does not increase major morbidity or mortality after thoracic operations, it likely results in greater use of health care resources. METHODS: We examined all patients in The Society of Thoracic Surgeons General Thoracic Surgery database with primary lung cancer who underwent lobectomy from 2006 to 2010. We investigated the impact of body mass index (BMI) on total operating room time using a linear mixed-effects regression model and multiple imputations to account for missing data. Secondary outcomes included postoperative length of stay and 30-day mortality. Covariates included age, sex, race, forced expiratory volume, smoking status, Zubrod score, prior chemotherapy or radiation, steroid use, number of comorbidities, surgical approach, hospital lobectomy volume, hospital percent obesity, and the addition of mediastinoscopy or wedge resection. RESULTS: A total of 19,337 patients were included. The mean BMI was 27.3 kg/m2, with 4,898 patients (25.3%) having a BMI of 30 kg/m2 or greater. The mean total operating room time, length of stay, and 30-day mortality were 240 minutes, 6.7 days, and 1.8%, respectively. For every 10-unit increase in BMI, mean operating room time increased by 7.2 minutes (range, 4.8 to 8.4 minutes; p<0.0001). Higher hospital lobectomy volume and hospital percentage of obese patients did not affect the association between BMI and operative time. Body mass index was not associated with 30-day mortality or increased length of stay. CONCLUSIONS: Increased BMI is associated with increased total operating room time, regardless of institutional experience with obese patients.

Patient education level affects functionality and long term mortality after major lower extremity amputation.

BACKGROUND: The aim of this study was to examine the relationship between patient education level and 5-year mortality after major lower extremity amputation. METHODS: The records of all patients who underwent above-knee or below-knee amputation at the Nashville Veterans Affairs Medical Center by the vascular surgery service between January 2000 and August 2006 were retrospectively reviewed. Formal levels of education of the study patients were recorded. Outcomes were compared between those patients who had completed high school and those who had not. Bivariate analysis using χ(2) and Student's t tests and multivariate logistic regression were performed. RESULTS: Five-year mortality for patients who had completed high school was lower than for those who had not completed high school (62.6% vs 84.3%, P = .001), even after adjusting for important clinical factors (odds ratio for death, .377; 95% confidence interval, .164-.868; P = .022). CONCLUSION: Patients with less education have increased long-term mortality after lower extremity amputation.

Poor survival for veterans with pathologic stage I non-small-cell lung cancer.

BACKGROUND: Pathologic stage (pStage) IA and IB non-small-cell lung cancer (NSCLC) has a median survival time of 119 and 81 months, respectively. We describe the outcomes of veterans with pStage I NSCLC. METHODS: A retrospective review of 78 patients with pStage I NSCLC who underwent cancer resection was performed at the Tennessee Valley Veterans Affairs Hospital between 2005 and 2010. All-cause 30-day, 90-day, and overall mortality were determined. Survival was assessed with the Kaplan-Meier and Cox proportional hazards methods. RESULTS: There were 55 (71%) pStage IA and 23 (29%) IB patients. Thirty- and 90-day mortality was 3.8% (3 of 78) and 6.4% (5 of 78), respectively. Median survival was 59 and 28 months for pStage 1A and 1B, respectively. Postoperative events were associated with impaired survival on multivariable analysis (hazard ratio, 1.26, P = .03). CONCLUSIONS: Veterans with pStage I NSCLC at our institution have poorer survival than the general population. More research is needed to determine the etiology of this disparity.

Successful treatment of atrioesophageal fistula by cervical esophageal ligation and decompression.

Atrioesophageal fistula is a rare yet devastating complication of transcatheter ablation for atrial fibrillation. This condition requires urgent intervention, but the optimal treatment strategy is yet to be defined. Reported therapies range from endoscopic stenting to direct atrial repair or reconstruction while on cardiopulmonary bypass. Here, we describe the successful management of an atrioesophageal fistula by cervical esophageal ligation and decompression, along with gastric drainage.

Validation of an aneurysmal subarachnoid hemorrhage grading scale in 1532 consecutive patients.

OBJECTIVE: The two most commonly used aneurysmal subarachnoid hemorrhage grading scales are the Hunt and Hess and World Federation of Neurological Societies scales. Neither has achieved universal acceptance, however, owing to concerns regarding either subjectivity or lack of correlation with outcomes, respectively. A grading scale based entirely on the Glasgow Coma Scale (GCS) was recently proposed. We have prospectively evaluated the GCS grading system and compared it with the Hunt and Hess and World Federation of Neurological Societies scales for predictive accuracy. METHODS: Data from 1532 consecutive patients with intracranial aneurysms admitted to our institution between January 1991 and June 2005 were analyzed. The Glasgow Outcome Scale was the primary outcome measure. Mortality and length of stay were secondary measures. The scales were evaluated using simple and multivariable logistic and linear regression. Receiver operating characteristic curves were used to assess predictive accuracy for the Glasgow Outcome Scale. Prognostic factors were assessed with ordinal multivariable logistic regression. RESULTS: The GCS grading system was most strongly associated with all outcome measures and was the strongest predictor of mortality and persistent vegetative state. Age, vasospasm, hydrocephalus, and intracranial hematoma were found to be significant prognostic elements. CONCLUSION: The GCS grading system is more strongly associated with outcomes than either the Hunt and Hess or World Federation of Neurological Societies scales, and it is an equivalent to a slightly better predictor of Glasgow Outcome Scale outcomes. Its simplicity, proven inter-rater reliability, and wide level of familiarity among health care personnel render the GCS grading system a superior grading scale for aneurysmal subarachnoid hemorrhage severity, warranting its consideration for universal use.

Robot-assisted cortical-sparing adrenalectomy in a patient with Von Hippel-Lindau disease and bilateral pheochromocytomas separated by 9 years.

Von Hippel-Lindau disease is a heritable syndrome that confers an increased risk of developing various benign and malignant tumors to those with a germline mutation of the tumor suppressor gene. We present a case of a male patient who initially presented at age 9 with headaches, fevers, and fatigue. He was found to have a left pheochromocytoma which was successfully managed with open total adrenalectomy. He presented again at age 18 with a second pheochromocytoma in the right adrenal gland. DNA analysis revealed a de novo Val84Leu mutation in the Von Hippel-Lindau gene, not seen in either parent. The challenge presented was that of balancing the obvious benefits of cortical- sparing adrenalectomy with the risk of tumor recurrence in spared tissue. Ultimately, management consisted of a robot-assisted laparoscopic partial right adrenalectomy with successful preservation of adrenocortical function.

Light-mediated inhibition of protein synthesis.

The regulation of protein synthesis is vital for a host of cell biological processes, but investigating roles for protein synthesis have been hindered by the inability to selectively interfere with it. To inhibit protein synthesis with spatial and temporal control, we have developed a photo-releasable anisomycin compound, N-([6-bromo-7-hydroxycoumarin-4-yl]methyloxycarbonyl)anisomycin (Bhc-Aniso), that can be removed through exposure to UV light. The area of protein synthesis inhibition can be restricted to a small light-exposed region or, potentially, the volume of two-photon excitation if a pulsed IR laser is the light source. We have tested the compound's effectiveness with an in vitro protein-translation system, CHO cells, HEK293 cells, and neurons. The photo-released anisomycin can inhibit protein synthesis in a spatially restricted manner, which will enable the specific inhibition of protein synthesis in subsets of cells with temporal and spatial precision.