Use of Simulation For Training Advanced Colorectal Procedures

OBJECTIVE

Simulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC).

DESIGN

LLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses.

SETTING

Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri.

PARTICIPANTS

Senior general surgery residents at large academic surgery program.

RESULTS

Fifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts.

CONCLUSIONS

Surgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

Conjugation to the sigma-2 ligand SV119 overcomes uptake blockade and converts dm-Erastin into a potent pancreatic cancer therapeutic

Cancer-selective drug delivery is an important concept in improving treatment while minimizing off-site toxicities, and sigma-2 receptors, which are overexpressed in solid tumors, represent attractive pharmacologic targets. Select sigma-2 ligands have been shown to be rapidly internalized selectively into cancer cells while retaining the capacity to deliver small molecules as drug cargoes. We utilized the sigma-2-based drug delivery concept to convert Erastin, a clinically underperforming drug, into a potent pancreatic cancer therapeutic. The Erastin derivative des-methyl Erastin (dm-Erastin) was chemically linked to sigma-2 ligand SV119 to create SW V-49. Conjugation increased the killing capacity of dm-Erastin by nearly 35-fold in vitro and reduced the size of established tumors and doubled the median survival in syngeneic and patient-derived xenograft models when compared to non-targeted dm-Erastin. Mechanistic analyses demonstrated that cell death was associated with robust reactive oxygen species production and could be efficiently antagonized with antioxidants. Mass spectrometry was employed to demonstrate selective uptake into pancreatic cancer cells. Thus, targeted delivery of dm-Erastin via conjugation to the sigma-2 ligand SV119 produced efficient tumor control and prolonged animal survival with minimal off-target toxicities, and SW V-49 represents a promising new therapeutic with the potential to advance the fight against pancreatic cancer.

Surgeon Variation in Intraoperative Supply Cost for Pancreaticoduodenectomy: Is Intraoperative Supply Cost Associated with Outcomes?

BACKGROUND

With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes.

STUDY DESIGN

Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level.

RESULTS

There were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p < 0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p > 0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p < 0.001).

CONCLUSIONS

In a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.

Interferon-based chemoradiation followed by gemcitabine for resected pancreatic adenocarcinoma: long-term follow-up

To report long-term follow up of a phase II, single-arm trial of resectable pancreatic ductal adenocarcinoma (PDAC) treated with adjuvant interferon-based chemoradiation followed by gemcitabine to determine survival, recurrence, and complications.

METHODS

From 2002 to 2005, 53 patients with PDAC underwent pancreaticoduodenectomy and received adjuvant interferon-based chemoradiation consisting of external-beam irradiation and simultaneous 3-drug chemotherapy of continuous daily 5-fluorouracil infusion, weekly intravenous bolus cisplatin, and subcutaneous interferon-α, followed by two months of weekly intravenous gemcitabine.

RESULTS

Actual overall survival for the 5- and 10-year periods were 26% and 10%, respectively, with a median overall survival of 25 months (95% CI: 16.4-38.5). Adverse prognostic factors on multivariate analysis were positive tumor margin (p < 0.035), lymphovascular invasion (p < 0.015), and perineural invasion (p < 0.026). Median time to recurrence was 11 months. Positive tumor margin was associated with lymph node involvement (p < 0.005), portal vein resection (p < 0.038), and metastases (p < 0.018). Late complications were frequent and predominated by gastrointestinal and infectious complications.

CONCLUSIONS

Adjuvant interferon-based chemoradiation for PDAC improves long-term survival compared to standard therapy. However, recurrence rates and long-term complications remain high, thus further studies are indicated to assess patient characteristics that indicate a favorable treatment profile.

Abstract B58: Combination therapy with the novel small molecule drug conjugate SW V-49 and gemcitabine is a potent pancreatic cancer therapeutic

Cancer-selective drug delivery is an important concept in improving treatment while minimizing off-site toxicities, and sigma-2 receptors, which are overexpressed in solid tumors, represent attractive pharmacologic targets. Select sigma-2 ligands have been shown to be rapidly internalized selectively into cancer cells while retaining the ability to deliver small molecules as drug cargoes. We previously conjugated a derivative of Erastin, a small molecule with cytotoxic activity in cells bearing KRAS mutations, to sigma-2 ligand SV119, forming the novel small molecule drug conjugate SW V-49. SW V-49 demonstrated a reduction in tumor burden and improved median survival in multiple murine models of pancreatic cancer compared to either sigma-2 ligand (SV119), Erastin, or vehicle treatment alone. In the present work, we report on the selective and targeted delivery of SW V-49 to pancreatic tumors as well as the enhanced efficacy of treatment in combination with gemcitabine, a standard chemotherapeutic for pancreatic cancer. To determine delivery and uptake of SW V-49 in vivo, C57BL/6 mice bearing orthotopic KP-2 tumors were treated with SW V-49, and mass spectrometry was utilized to assess drug concentration within tissue. We observed increased delivery of SW V-49 to the tumor-bearing pancreas compared to liver, kidney, and muscle over 24 hours. To validate drug delivery in a genetically-engineered murine model, mass spectrometry was utilized to assess tissue uptake of SW V-49 in KPPC (p48-CRE/LSL-KRas/p53flox/flox) mice bearing palpable pancreatic tumors. Further evidence of SW V-49 tumor cell specificity is demonstrated by the significant reduction in EpCAM-positive neoplastic cells in the pancreatic tumors of C57BL/6 mice bearing orthotopic syngeneic KCKO tumors after treatment with SW V-49. In addition, we performed in vivo experimentation to demonstrate SW V-49 and gemcitabine combination therapy was superior in both subcutaneous and orthotopic murine models of pancreatic cancer. The KP-2 syngeneic subcutaneous tumor model demonstrated dense stroma similar to that of the human disease, and combination therapy with SW V-49 and gemcitabine resulted in significantly superior tumor reduction relative to all controls. We validated the utility of combination therapy in the KCKO syngeneic orthotopic model and again demonstrated the smallest tumor burden in the combination therapy group compared to control-treated animals. Together, these findings suggest that combination therapy utilizing the targeted therapeutic SW V-49 with systemic gemcitabine has potential translational utility. SW V-49 was successfully delivered in vivo to pancreatic tumors and reduced EpCAM-positive neoplastic cells, and combination therapy was superior to either agent alone and reduced tumor burden in multiple murine models of pancreatic cancer. Thus, SW V-49 is a promising novel therapeutic for pancreatic cancer and warrants further investigation.

Citation Format: Kerri A. Ohman, Timothy M. Nywening, Suwanna Vangveravong, Dirk Spitzer, William G. Hawkins.{Authors}. Combination therapy with the novel small molecule drug conjugate SW V-49 and gemcitabine is a potent pancreatic cancer therapeutic. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr B58.

Subscores of the FAB differentiate frontotemporal lobar degeneration from AD

OBJECTIVE

To determine the clinical utility of the Frontal Assessment Battery (FAB), a short test of frontal lobe functions, in differentiating frontotemporal lobar degeneration (FTLD) from Alzheimer disease (AD).

METHODS

FAB total scores and subscores for 23 subjects with FTLD and 31 subjects with AD were compared for sensitivity, specificity, and positive predictive value. Concurrent validity of the FAB with the Mini-Mental State Examination (MMSE) and other scales was also assessed.

RESULTS

The FAB did not have positive predictive value for FTLD. Total FAB scores did not differ between the FTLD and AD groups. However, three subtests of the FAB (mental flexibility, motor programming, and environmental autonomy) demonstrated significant differences between the two groups. Total FAB scores correlated with scores on the MMSE, a more general test of cognition.

CONCLUSION

The Frontal Assessment Battery did not discriminate subjects with frontotemporal lobar degeneration from those with Alzheimer disease, though certain subtests may be helpful in differential diagnosis.

The transformational leadership of critical care nurse-managers

This study of transformational leadership found critical care nurse-managers to be highly transformational, using inspiration, motivation, and vision to empower staff, rather than intervening only when problems arise. Significant positive relationships were found between transformational leadership and previous leadership experience. The findings have implications for the recruitment, selection, and development of nursing leaders.