Surgical management of adrenal metastases.

In the presence of a history of cancer, adrenal masses are commonly, but not exclusively, metastases. Depending upon the status of the patient's ongoing cancer therapy, overall tumor burden, and performance score, adrenalectomy is a viable treatment option. Herein we review the prevalence, diagnostic evaluation, and selection for surgical treatment of adrenal metastases. Additional attention is paid to recent data supporting the safety and oncologic efficacy of laparoscopic adrenalectomy.

Splenectomy to treat splenic lesions: an analysis of 148 cases at a cancer center.

BACKGROUND AND OBJECTIVES: Solid and cystic splenic masses discovered on imaging studies often pose diagnostic and management dilemmas. This study analyses a large series of splenectomies to identify preoperative factors associated with malignant splenic masses. METHODS: Pathology records at a single institution were reviewed for all splenectomies. Those performed as a component of a larger resection, such as staging or debulking were excluded. Demographic and clinicopathologic factors were obtained. Univariate and multivariate analyses identified factors associated with an increased risk of malignancy. RESULTS: Between 1986 and 2012, 2,743 patients underwent a splenectomy, 148 of which were performed for lesions identified on imaging. The indications were suspicion of malignancy (120, 81%), growth over time (28, 19%), or symptoms (39, 26%). Resected splenic lesions were malignant in 93 patients (63%); the most common pathologies included ovarian cancer (n = 39), melanoma (n = 14), and colorectal cancer (n = 9). On multivariate analysis of clinicopathologic factors, a previous history of cancer was the only independent predictor of malignancy in the splenic lesion (odds ratio 6.3; 95% CI, 2.32-16.97; P = 0.001). CONCLUSION: While the spleen is an uncommon site of metastatic disease, in patients with a history of cancer, splenic masses selected for resection are frequently malignant.

Family engagement regarding the critically ill patient.

The Institute of Medicine strongly recommends a health care system that supports family members. Nowhere is the need for family-centered care greater than with critically ill patients. Simplistically, family-centered care is primarily about communication. Unfortunately, family perception of communication in the intensive care unit (ICU) is quite poor. This article reviews some strategies to improve communication, including family meetings and family presence at resuscitation. It also highlights some of the areas within the realm of ICU care in which family engagement is particularly important, including advance directives, end-of-life care, brain death, and organ donation.

Physician attitudes regarding advance directives for high-risk surgical patients: a qualitative analysis.

BACKGROUND: Advance directive (AD) use is uncommon in surgical patients, yet the exact reasons for this are unknown. Our aim was to identify and describe beliefs held by surgeons regarding ADs. A qualitative exploration of physicians' opinions of ADs for surgical patients was designed. This methodology is preferred to quantitative techniques, which are subject to bias when an issue's underlying themes are unknown. METHODS: A purposive sample of physicians, primarily surgeons performing high-risk operations, was interviewed using a semi-structured questionnaire. Representation from several subspecialties established maximum transferability. Data collection continued until theoretical saturation was achieved. Transcribed audiotapes were first coded independently and then collaboratively using a coding scheme developed through grounded theory and deductive approaches. Modeling identified themes and trends to ensure faithful data representation. RESULTS: Three significant themes emerged, illustrating the conflicting attitudes surgeons harbor with respect to ADs. Surgeons described a general benefit of ADs in providing a framework for discussion ("It [AD] is a useful framework to begin discussion in the end of life issues for the patient."), but they also exhibited frustration with the disconnect between reality and written ADs ("What they [patients] really mean and what the words say are totally different.") and felt conflicted between the battle for surgical cure and the treatment limitations that occur with ADs in practice ("[ADs] may tie a surgeon's hands that might influence my judgment in performing the operation."). CONCLUSION: Surgeons describe conflicting feelings about ADs for high-risk surgical patients. These beliefs and attitudes may be an underlying factor for the limited use of ADs by surgical patients. Methods for improving effective use of ADs in surgical practice must address these attitudes.

Structured teaching versus experiential learning of palliative care for surgical residents.

BACKGROUND: Previous end-of-life and palliative care curricula for surgical residents have shown improved learner confidence, but have not measured cognitive knowledge or skill acquisition. METHODS: A nonrandomized trial evaluated a structured palliative care curriculum for 7 postgraduate year 2 surgical residents (intervention group) compared with 6 postgraduate year 5 surgical residents (comparison group). Outcomes were measured using an 18-item knowledge test, a 20-minute objective structured clinical examination simulating an intensive care unit family conference, and a survey measuring self-confidence. RESULTS: The mean knowledge test scores for the intervention group, both before and after undergoing the structured palliative care curriculum, were no different from the comparison group. There was also no difference in objective structured clinical examination scores between the 2 groups. The intervention group felt less comfortable managing pain, breaking bad news, or addressing ethical issues. CONCLUSIONS: Junior surgical residents have similar palliative care knowledge to senior residents without a palliative care curriculum. After participating in a palliative care curriculum, they have simulated skills that are similar to chief residents. However, self-confidence is lower among junior residents despite undergoing a palliative care curriculum.

Injury severity and quality of life: whose perspective is important?

BACKGROUND: Ambiguity exists regarding factors that predict postinjury quality of life (QOL). We hypothesized that patient-perceived injury severity, not Injury Severity Score (ISS), would be correlated with QOL in a model that included severity of post-traumatic stress disorder (PTSD) symptoms. METHODS: Four hundred twenty-six trauma patients admitted to a Level I trauma center completed a questionnaire during inpatient stay and 6 months after injury. The questionnaire assessed physical component score and mental component score QOL with the SF-36, PTSD severity using the PTSD checklist, and used a four-point rating of perceived injury severity. ISS and demographic information were obtained from the trauma registry. Statistical analysis was done with Pearson's correlation and multiple regressions. RESULTS: ISS was not significantly correlated with perceived injury severity, PTSD symptom severity, physical component score, or mental component score. The majority of patients overestimated injury severity when compared with ISS. An increase in PTSD symptom severity and perceived injury severity significantly predicted both decreased physical and mental QOL at 6 months. CONCLUSIONS: ISS does not give the full picture of the severity of injury. Surgeons should consider early screening of patients for perception of injury severity and PTSD symptoms to determine which patients may need psychologic intervention to improve long-term QOL.

Addressing access to palliative care services in the surgical intensive care unit.

BACKGROUND: Proactive case-finding using consultation triggers is a currently unexplored technique of increasing access to palliative care for patients in the surgical intensive care unit (SICU). METHODS: A retrospective, pre- and postintervention study examined the effect of an initiative involving palliative care consultation in a 21-bed SICU at an urban, tertiary referral center. The initiative identified patients meeting a set of consultation triggers suggested by a group of physicians with expertise in surgical palliative care. The charts of 300 patients were reviewed retrospectively before the initiative (Group I), and 344 charts were reviewed after the initiative (Group II) for the presence of a trigger and/or subsequent palliative care consultation. RESULTS: Triggers were rare in both groups (Group I, 5.7%; Group II, 5.5%). Palliative care consultations were also infrequent, without change before and after the intervention (Group I, 2.3%; Group II, 3.1%). There was no difference in consultations for patients meeting a trigger after the initiative (17.6% to 27.3%; P = .704). CONCLUSION: Implementation of triggers does not increase palliative care consultations in the SICU. As an isolated intervention, triggers occur in too few patients to improve overall access to palliative care, suggesting that other methods should be further explored.

Surgical "buy-in": the contractual relationship between surgeons and patients that influences decisions regarding life-supporting therapy.

OBJECTIVE: There is a general consensus by intensivists and nonsurgical providers that surgeons hesitate to withdraw life-sustaining therapy on their operative patients despite a patient's or surrogate's request to do so. The objective of this study was to examine the culture and practice of surgeons to assess attitudes and concerns regarding advance directives for their patients who have high-risk surgical procedures. DESIGN: A qualitative investigation using one-on-one, in-person interviews with open-ended questions about the use of advance directives during perioperative planning. Consensus coding was performed using a grounded theory approach. Data accrual continued until theoretical saturation was achieved. Modeling identified themes and trends, ensuring maximal fit and faithful data representation. SETTING: Surgical practices in Madison and Milwaukee, WI. SUBJECTS: Physicians involved in the performance of high-risk surgical procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We describe the concept of surgical "buy-in," a complex process by which surgeons negotiate with patients a commitment to postoperative care before undertaking high-risk surgical procedures. Surgeons describe seeking a commitment from the patient to abide by prescribed postoperative care, "This is a package deal, this is what this operation entails," or a specific number of postoperative days, "I will contract with them and say, 'look, if we are going to do this, I am going to need 30 days to get you through this operation.'" "Buy-in" is grounded in a surgeon's strong sense of responsibility for surgical outcomes and can lead to surgeon unwillingness to operate or surgeon reticence to withdraw life-sustaining therapy postoperatively. If negotiations regarding life-sustaining interventions result in treatment limitation, a surgeon may shift responsibility for unanticipated outcomes to the patient. CONCLUSIONS: A complicated relationship exists between the surgeon and patient that begins in the preoperative setting. It reflects a bidirectional contract that is assumed by the surgeon with distinct implications and consequences for surgeon behavior and patient care.

Cost-effectiveness of prolonged thromboprophylaxis after cancer surgery.

BACKGROUND: Consensus guidelines recommend prolonged thromboprophylaxis for up to 4 weeks after major abdominopelvic cancer operations. Several factors impede widespread adoption of these guidelines. These include lack of awareness, cost, increased bleeding complications, increased incidence of heparin-induced thrombocytopenia, and poor patient compliance. METHODS: A cost-effectiveness model was constructed comparing four potential strategies to postdischarge thromboprophylaxis in surgical oncology patients: (1) low-molecular-weight heparin (LMWH) once daily; (2) low-dose unfractionated heparin (LDUH) three times daily; (3) oral aspirin once daily; or (4) no prolonged prophylaxis. Probabilities and costs were estimated on the basis of published literature and average Medicare reimbursement. The decision analysis was conducted from the perspective of the health care system, with the primary end point being cost per patient without venous thromboembolism (VTE). Sensitivity analyses tested the robustness of the results. RESULTS: LDUH was most cost-effective, saving $154 per patient without VTE compared with no prophylaxis. LMWH was not cost-effective, incurring a cost of $230 per patient without VTE compared with no prophylaxis. Aspirin was a viable alternative to LDUH, saving $123 compared with no prophylaxis. When poor compliance was considered, aspirin became the dominant strategy. Sensitivity analyses failed to show any instance where LMWH was cost-effective. In terms of population costs, widespread use of LDUH after discharge would save $30.3 million per year in the United States. CONCLUSIONS: Although all chemical prophylaxis is effective in preventing VTE in the outpatient setting after cancer surgery, either LDUH or aspirin are the most cost-effective, depending on patient compliance.

Emergency contraception and physicians' rights of conscience: a review of current legal standards in Wisconsin.

Recent legislation in Wisconsin mandating provision of emergency contraception to victims of sexual assault may create a conflict of conscience for some health care professionals. Although disputes exist over the exact mechanism of action of emergency contraception, those professionals who espouse a particularly strict stance may be reluctant to dispense the medication for fear that it could prevent a fertilized embryo from implanting in the uterus. While no objection of conscience clause was written into the new law, Wisconsin law has a long tradition of recognizing rights of conscience in matters of religious conflict. This legal tradition both at statutory and common law levels is summarized with application to the recent emergency contraception mandate. A case is made for a potential legal defense should a health care professional abstain from dispensing emergency contraception.

Roman Catholic doctrine guiding end-of-life care: a summary of the recent discourse.

Recent statements emanating from high-level church authorities have reignited discussion over the traditional Roman Catholic doctrine guiding end-of-life care. Although these statements concerned the specific issue of artificial nutrition and hydration for patients in a persistent vegetative state, they contain principles that might be applied to other life-prolonging interventions. This paper examines the origins of the Catholic moral tradition that guides end-of-life care. Included is a discussion of the "ordinary-extraordinary" distinction, as well as the Catholic definition of "euthanasia by omission." Further discussion focuses on those recent statements that have reaffirmed the Church's teaching regarding life-sustaining interventions. Although a source of some consternation, these statements should spark healthy discussion within Catholic health care facilities and among patients seeking advice about advance care planning within a Catholic framework. Moreover, the statements rightly reaffirm the Church's unwavering commitment to delivering compassionate palliative care.

Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit.

OBJECTIVE: The convergence of end-of-life care and surgical practice often occurs in the surgical intensive care unit (SICU). Because many patients who encounter difficult end-of-life issues in the SICU do not receive palliative care services, there is a need to educate surgeons on how to better identify those patients. DESIGN: A group of 29 national and local experts were identified based on qualifications as surgical intensivists, palliative care specialists, or members of the American College of Surgeons Surgical Palliative Care Task Force. A smaller representative group initially identified responses to the question, "Which patients in the SICU should receive a palliative care consultation?" Using a modified Delphi technique, 31 proposed criteria were distributed electronically to the larger group and ranked through three rounds to generate a final list of ten. SETTING: E-mail-based Delphi consensus panel. SUBJECTS: National and local surgical palliative care experts. INTERVENTIONS: Survey in three rounds. RESULTS: Thirteen participants responded to the first round and 12 to the second. In the third round, the entire group was given the ten criteria for final approval. One half of the respondents were national authorities and the other half were local experts. The top five "triggers" for a palliative care consultation in descending order were: family request; futility considered or declared by the medical team; family disagreement with the medical team, the patient's advance directive, or each other lasting >7 days; death expected during the same SICU stay; and SICU stay >month. CONCLUSIONS: We offer a set of consensus guidelines derived from expert opinion that identifies critically ill surgical patients who would benefit from palliative care consultation. These criteria can be used to educate surgeons at large on the variety of clinical scenarios where palliative care specialists can offer support.

Core competencies in palliative care for surgeons: interpersonal and communication skills.

Surgeons are an important part of the multidisciplinary approach to the care of terminally ill and dying patients. Some surgical residencies have recognized the need to incorporate palliative care-related topics into graduate surgical education. One core competency of utmost importance to palliative care is the effective use of interpersonal and communication skills. Four areas of surgical practice are identified where these communication skills are important: during preoperative counseling, when presenting a devastating diagnosis or poor prognosis, when discussing error, and when discussing death. Case examples and recommendations for the appropriate words and actions to use in these scenarios are offered. It is important for both surgeons in practice and those in training to achieve proficiency with these communication skills.

Combined genetic assessment of transforming growth factor-beta signaling pathway variants may predict breast cancer risk.

There is growing evidence that common variants of the transforming growth factor-beta (TGF-beta) signaling pathway may modify breast cancer risk. In vitro studies have shown that some variants increase TGF-beta signaling, whereas others have an opposite effect. We tested the hypothesis that a combined genetic assessment of two well-characterized variants may predict breast cancer risk. Consecutive patients (n = 660) with breast cancer from the Memorial Sloan-Kettering Cancer Center (New York, NY) and healthy females (n = 880) from New York City were genotyped for the hypomorphic TGFBR1*6A allele and for the TGFB1 T29C variant that results in increased TGF-beta circulating levels. Cases and controls were of similar ethnicity and geographic location. Thirty percent of cases were identified as high or low TGF-beta signalers based on TGFB1 and TGFBR1 genotypes. There was a significantly higher proportion of high signalers (TGFBR1/TGFBR1 and TGFB1*CC) among controls (21.6%) than cases (15.7%; P = 0.003). The odds ratio [OR; 95% confidence interval (95% CI)] for individuals with the lowest expected TGF-beta signaling level (TGFB1*TT or TGFB1*TC and TGFBR1*6A) was 1.69 (1.08-2.66) when compared with individuals with the highest expected TGF-signaling levels. Breast cancer risk incurred by low signalers was most pronounced among women after age 50 years (OR, 2.05; 95% CI, 1.01-4.16). TGFBR1*6A was associated with a significantly increased risk for breast cancer (OR, 1.46; 95% CI, 1.04-2.06), but the TGFB1*CC genotype was not associated with any appreciable risk (OR, 0.89; 95% CI, 0.63-1.21). TGFBR1*6A effect was most pronounced among women diagnosed after age 50 years (OR, 2.20; 95% CI, 1.25-3.87). This is the first study assessing the TGF-beta signaling pathway through two common and functionally relevant TGFBR1 and TGFB1 variants. This approach may predict breast cancer risk in a large subset of the population.