Laparoscopic surgery for adrenocortical carcinoma: Estimating the risk of margin-positive resection

BACKGROUND

Over recent years, there has been increasing adoption of minimally invasive surgery (MIS) in the treatment of adrenocortical carcinoma (ACC). However, MIS has been associated with noncurative resection and locoregional recurrence. We aimed to identify risk factors for margin-positivity among patients who undergo MIS resection for ACC. We hypothesized that a simple nomogram can accurately identify patients most suitable for curative MIS resection.

METHODS

Curative-intent resections for ACC were identified through the National Cancer Database spanning 2010-2018. Trends in MIS utilization were reported using Pearson correlation coefficients. Factors associated with margin-positive resection were identified among preoperatively available variables using multivariable logistic regression, then incorporated into a predictive model. Model quality was cross validated using an 80% training data set and 20% test data set.

RESULTS

Among 1260 ACC cases, 38.6% (486) underwent MIS resection. MIS utilization increased over time at nonacademic centers (R = 0.818, p = 0.007), but not at academic centers (R = 0.009, p = 0.982). Factors associated with margin-positive MIS resection were increasing age, nonacademic center (odds ratio [OR]: 1.8, p = 0.006), cT3 (OR: 4.7, p < 0.001) or cT4 tumors (OR: 14.6, p < 0.001), and right-sided tumors (OR: 2.0, p = 0.006). A predictive model incorporating these four factors produced favorable c-statistics of 0.75 in the training data set and 0.72 in the test data set. A pragmatic nomogram was created to enable bedside risk stratification.

CONCLUSIONS

An increasing proportion of ACC are resected via minimally invasive operations, particularly at nonacademic centers. Patient selection based on a few key factors can minimize the risk of noncurative surgery.

A Novel Thyroid Ultrasound Proficiency Metric Designed Through a Multidisciplinary Delphi Approach

BACKGROUND

Thyroid ultrasounds extend surgeons' outpatient capabilities and are essential for operative planning. However, most residents are not formally trained in thyroid ultrasound. The purpose of this study was to create a novel thyroid ultrasound proficiency metric through a collaborative Delphi approach.

METHODS

Clinical faculty experienced in thyroid ultrasound participated on a Delphi panel to design the thyroid Ultrasound Proficiency Scale (UPS-Thyroid). Participants proposed items under the categories of Positioning, Technique, Image Capture, Measurement, and Interpretation. In subsequent rounds, participants voted to retain, revise, or exclude each item. The process continued until all items had greater than 70% consensus for retention. The UPS-Thyroid was pilot tested across 5 surgery residents with moderate ultrasound experience. Learning curves were assessed with cumulative sum.

RESULTS

Three surgeons and 4 radiologists participated on the Delphi panel. Following 3 iterative Delphi rounds, the panel arrived at >70% consensus to retain 14 items without further revisions or additions. The metric included the following items on a 3-point scale for a maximum of 42 points: Positioning (1 item), Technique (4 items), Image Capture (2 items), Measurement (2 items), and Interpretation (5 items). A pilot group of 5 residents was scored against a proficiency threshold of 36 points. Learning curve inflection points were noted at between 4 to 7 repetitions.

CONCLUSIONS

A multidisciplinary Delphi approach generated consensus for a thyroid ultrasound proficiency metric (UPS-Thyroid). Among surgery residents with moderate ultrasound experience, basic proficiency at thyroid ultrasound is feasible within 10 repetitions.

American Association of Endocrine Surgeons Guidelines for Adrenalectomy: Executive Summary

Importance

Adrenalectomy is the definitive treatment for multiple adrenal abnormalities. Advances in technology and genomics and an improved understanding of adrenal pathophysiology have altered operative techniques and indications.

Objective

To develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy.

Evidence Review

A multidisciplinary panel identified and investigated 7 categories of relevant clinical concern to practicing surgeons. Questions were structured in the framework Population, Intervention/Exposure, Comparison, and Outcome, and a guided review of medical literature from PubMed and/or Embase from 1980 to 2021 was performed. Recommendations were developed using Grading of Recommendations, Assessment, Development and Evaluation methodology and were discussed until consensus, and patient advocacy representation was included.

Findings

Patients with an adrenal incidentaloma 1 cm or larger should undergo biochemical testing and further imaging characterization. Adrenal protocol computed tomography (CT) should be used to stratify malignancy risk and concern for pheochromocytoma. Routine scheduled follow-up of a nonfunctional adrenal nodule with benign imaging characteristics and unenhanced CT with Hounsfield units less than 10 is not suggested. When unilateral disease is present, laparoscopic adrenalectomy is recommended for patients with primary aldosteronism or autonomous cortisol secretion. Patients with clinical and radiographic findings consistent with adrenocortical carcinoma should be treated at high-volume multidisciplinary centers to optimize outcomes, including, when possible, a complete R0 resection without tumor disruption, which may require en bloc radical resection. Selective or nonselective α blockade can be used to safely prepare patients for surgical resection of paraganglioma/pheochromocytoma. Empirical perioperative glucocorticoid replacement therapy is indicated for patients with overt Cushing syndrome, but for patients with mild autonomous cortisol secretion, postoperative day 1 morning cortisol or cosyntropin stimulation testing can be used to determine the need for glucocorticoid replacement therapy. When patient and tumor variables are appropriate, we recommend minimally invasive adrenalectomy over open adrenalectomy because of improved perioperative morbidity. Minimally invasive adrenalectomy can be achieved either via a retroperitoneal or transperitoneal approach depending on surgeon expertise, as well as tumor and patient characteristics.

Conclusions and Relevance

Twenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.

Stereotactic radiosurgery before bilateral adrenalectomy is associated with lowered risk of Nelson's syndrome in refractory Cushing's disease patients

BACKGROUND

Nelson's syndrome is a rare but challenging sequelae of Cushing's disease (CD) after bilateral adrenalectomy (BLA). We sought to determine if stereotactic radiosurgery (SRS) of residual pituitary adenoma performed before BLA can decrease the risk of Nelson's syndrome.

METHODS

Consecutive patients with CD who underwent BLA after non-curative resection of ACTH secreting pituitary adenoma and had at least one follow-up visit after BLA were studied. Nelson's syndrome was diagnosed based on the combination of rising ACTH levels, increasing volume of the pituitary adenoma and/or hyperpigmentation.

RESULTS

Fifty patients underwent BLA for refractory CD, and 43 patients (7 men and 36 women) had at least one follow-up visit after BAL. Median endocrine, imaging, and clinical follow-up were 66 months, 69 months, and 80 months, respectively. Nine patients (22%) were diagnosed with the Nelson's syndrome at median time after BLA at 24 months (range: 0.6-119.4 months). SRS before BLA was associated with reduced risk of the Nelson's syndrome (HR = 0.126; 95%CI [0.022-0.714], p=0.019), while elevated ACTH level within 6 months after BLA was associated with increased risk for the Nelson's syndrome (HR = 9.053; 95%CI [2.076-39.472], p=0.003).

CONCLUSIONS

SRS before BLA can reduce the risk for the Nelson's syndrome in refractory CD patients requiring BLA and should be considered before proceeding to BLA. Elevated ACTH concentration within 6 months after BLA is associated with greater risk of the Nelsons' syndrome. When no prior SRS is administered, those with a high ACTH level shortly after BLA may benefit from early SRS.

New endocrine fellowship programs do not decrease the endocrine surgery experience of residents in co-located general surgery programs

BACKGROUND

New pediatric and vascular surgical fellowship programs decrease resident operative experience in those subspecialties in co-located general surgery programs.After 2 decades of increases, the mean number of endocrine surgery cases performed by general surgery residents nationally has decreased since 2010 to 2011. We hypothesized that new endocrine surgery fellowship programs lead to a decrease in the number of endocrine surgery cases performed by co-located general surgery residents and may be a contributing factor in the recent national decline in endocrine surgery cases performed by general surgery residents.

METHODS

Endocrine surgery fellowship programs associated with a single, Accreditation Council of Graduate Medical Education-accredited general surgery program that have completed training of 1 fellow by the 2014-2015 academic year were identified. Endocrine surgery cases performed by general surgery residents who completed co-located general surgery programs from 2002 to 2003 through 2017 to 2018 were recorded. Descriptive statistics are shown as mean ± standard deviation. Statistical significance was calculated using the Mann-Whitney U Test.

RESULTS

In the 13 general surgery programs with 5 years of case log data after the matriculation of the first fellow, the mean number of total endocrine surgery cases/resident increased from 47 ± 23 in year 0 to 57 ± 25 in year 5 (z-score = 2.53; P < .05).

CONCLUSION

New endocrine surgery fellowship programs do not decrease the endocrine surgery cases performed by general surgery residents and have not contributed to the national decline in endocrine surgery cases by general surgery residents.

Surgeon-performed Ultrasound for Primary Hyperparathyroidism

The role of preoperative parathyroid imaging continues to evolve. This study evaluated whether surgeon-performed ultrasound (U/S) obviates the need for other imaging studies and leads to a focused exploration with a high degree of surgical success. From July 2010 to February 2012, 200 patients presenting with nonfamilial primary hyperparathyroidism underwent neck U/S in the surgeon's office. The U/S interpretation was classified as Class 1 if an adenoma was identified with high confidence, Class 2 if a possible but not definite enlarged gland was imaged, and Class 0 (zero) if no adenoma was identified. The findings were correlated with subsequent intra-operative findings. There were 144 Class 1 U/Ss (72%); of 132 patients coming to surgery, 96.2 per cent had surgical findings concordant with preoperative U/S and all had apparent surgical cure. Twenty-nine patients (14.5%) had Class 2 U/S; the 31 per cent confirmed false-positives in this group were usually colloid nodules. Fourteen of 27 with Class 0 U/S underwent surgery after being offered dynamically enhanced computed tomography scan. All 200 patients were apparent surgical cures. Surgeon-performed U/S is expedient, convenient, inexpensive, and accurate. A clearly identified adenoma can safely lead to a focused limited exploration and avoid additional imaging 93 per cent of the time.

Comparison of Exponential and Biexponential Models of the Unimolecular Decomposition Probability for the Hinshelwood-Lindemann Mechanism

The traditional understanding is that the Hinshelwood-Lindemann mechanism for thermal unimolecular reactions, and the resulting unimolecular rate constant versus temperature and collision frequency ω (i.e., pressure), requires the Rice-Ramsperger-Kassel-Marcus (RRKM) rate constant k(E) to represent the unimolecular reaction of the excited molecule versus energy. RRKM theory assumes an exponential N(t)/N(0) population for the excited molecule versus time, with decay given by RRKM microcanonical k(E), and agreement between experimental and Hinshelwood-Lindemann thermal kinetics is then deemed to identify the unimolecular reactant as a RRKM molecule. However, recent calculations of the Hinshelwood-Lindemann rate constant k_uni(ω,E) has brought this assumption into question. It was found that a biexponential N(t)/N(0), for intrinsic non-RRKM dynamics, gives a Hinshelwood-Lindemann k_uni(ω,E) curve very similar to that of RRKM theory, which assumes exponential dynamics. The RRKM k_uni(ω,E) curve was brought into agreement with the biexponential k_uni(ω,E) by multiplying ω in the RRKM expression for k_uni(ω,E) by an energy transfer efficiency factor β_c. Such scaling is often done in fitting Hinshelwood-Lindemann-RRKM thermal kinetics to experiment. This agreement between the RRKM and non-RRKM curves for k_uni(ω,E) was only obtained previously by scaling and fitting. In the work presented here, it is shown that if ω in the RRKM k_uni(ω,E) is scaled by a β_c factor there is analytic agreement with the non-RRKM k_uni(ω,E). The expression for the value of β_c is derived.

Compliance with the Accreditation Council for Graduate Medical Education duty hours in a general surgery residency program: Challenges and solutions in a teaching hospital

BACKGROUND

The inception of work hour restrictions for resident physicians in 2003 created controversial changes within surgery training programs. On a recent Accreditation Council for Graduate Medical Education survey at our institution, we noted a discrepancy between low recorded violations of the duty hour restrictions and the surgery resident's perception of poor duty hour compliance. We sought to identify factors that lead to duty hour violations and to encourage accurate reporting among surgery trainees.

METHODS

The A3/Lean methodology, an industry-derived, systematic, problem-solving approach, was used to investigate barriers to accurate reporting of duty hours by residents within the Department of Surgery at our academic institution. In partnership with our office of Graduate Medical Education, we encouraged a 6-month period where residents were asked to record duty hour accurately and to provide honest, descriptive explanations of violations without punitive effects on residents or the program. We performed a 6-month before-and-after analysis of duty hours violations after the A3/Lean implementation. Quantitative analysis was used to elucidate trends in violations by post graduate year and rotation. Qualitative evaluation by key thematic areas revealed resident attitudes and opinions about duty hour violations.

RESULTS

Residents reported concern for personal and programmatic, punitive measures, desire to retain control of their education, and frustration with the administrative burden after violations as deterrents to honest duty hour reporting. The intervention was successful in changing logging behavior with 10 total violations prior to A3 meeting and 179 violations afterward (P = .003). This change was driven largely from an increase in short break violations (4 vs 134, P = .021). Analysis of violations revealed trends by post-graduate year, rotation, and weekend cross-coverage. Key findings including less than anticipated violations of the 80-hour work week despite high rates of short break violations. The ability to participate in procedures voluntarily and a sense of professional responsibility emerged as the prevailing themes among surgery residents describing violations.

CONCLUSION

Systematic evaluation of duty hour reporting within a surgery training program can identify structural and cultural barriers to accurate reporting of duty hours. Accurate reporting can identify program-specific trends in duty hour violations that can be addressed though programmatic intervention.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time-related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients' home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1-107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

Effect of Travel Time for Thyroid Surgery on Treatment Cost and Morbidity

Regionalizing surgical care to high-volume centers has improved outcomes for endocrine surgery. This shift is associated with increased travel time, costs, and morbidity within certain patient populations. We examined travel time–related differences in demographics, health-care utilization, thyroid-specific disease, and cost for patients undergoing thyroid surgery at a single high-volume center. Data were extracted from the 2005 to 2014 ACS-NSQIP and clinical data repository for patients undergoing thyroid surgery. Travel times between patients’ home address and the hospital were calculated using Google Earth under assumptions of standard road conditions and speed restrictions. Travel time was divided into <2 hours versus ≥2 hours. Primary outcomes were hospital cost and 30-day morbidity. Factors associated with travel time and primary outcomes were analyzed using appropriate bivariate tests and multivariable regression modeling. A total of 1046 thyroid procedures were included, with median (IQR) travel time of 68.8 (40.1–107.2) minutes. Eight hundred forty-seven (80.9%) patients traveled <2 hours compared with 199 (19.1%) traveled ≥2 hours. Patients traveling ≥2 hours were more likely to have complex thyroid disease (37.7% vs 27.6%, P = 0.005), uninsured status (31.1% vs 11.8%, P < 0.001), lower preoperative morbidity risk (2.3% vs 2.7%, P = 0.02), and longer length of stay (1.21 vs 1.07 days, P = 0.04), but similar median operative times (163 vs 165 minutes, P = 0.89). Average cost was higher for patients traveling ≥2 hours ($7300 vs $6846 [2014 USD], P = 0.05). Despite observed patient differences, hospital costs and postoperative morbidity did not differ after adjustment. Existing management practices and the nature of the disease process may be protective against the potential negative effects of regionalization.

Resident-Specific Morbidity Reduced Following ACS NSQIP Data-Driven Quality Program

BACKGROUND

The Accreditation Council for Graduate Medical Education Milestone Project for general surgery provided a more robust method for developing and tracking residents' competence. This framework enhanced systematic and progressive development of residents' competencies in surgical quality improvement.

STUDY DESIGN

A 22-month interactive, educational program based on resident-specific surgical outcomes data culminated in a quality improvement project for postgraduate year 4 surgery residents. Self- assessment, quality knowledge test, and resident-specific American College of Surgeons National Surgical Quality Improvement Program Quality In-Training Initiative morbidity were compared before and after the intervention.

RESULTS

Quality in-training initiative morbidity decreased from 25% (82/325) to 18% (93/517), p = 0.015 despite residents performing more complex cases. All participants achieved level 4 competency (4/4) within the general surgery milestones improvement of care, practice-based learning and improvement competency. Institutional American College of Surgeons National Surgical Quality Improvement Program general surgery morbidity improved from the ninth to the sixth decile. Quality assessment and improvement self-assessment postintervention scores (M = 23.80, SD = 4.97) were not significantly higher than preintervention scores (M = 19.20, SD = 5.26), p = 0.061. Quality Improvement Knowledge Application Tool postintervention test scores (M = 17.4, SD = 4.88), were not significantly higher than pretest scores (M = 13.2, SD = 1.92), p = 0.12.

CONCLUSION

Sharing validated resident-specific clinical data with participants was associated with improved surgical outcomes. Participating fourth year surgical residents achieved the highest score, a level 4, in the practice based learning and improvement competency of the improvement of care practice domain and observed significantly reduced surgical morbidity for cases in which they participated.

Vessel Ligation Fundamentals: A Comparison of Technical Evaluations by Crowdsourced Nonclinical Personnel and Surgical Faculty

BACKGROUND

Evaluation of fundamental surgical skills is invaluable to the training of medical students and junior residents. This study assessed the effectiveness of crowdsourcing nonmedical personnel to evaluate technical proficiency at simulated vessel ligation.

STUDY DESIGN

Fifteen videos were captured of participants performing vessel ligation using a low-fidelity model (5 attending surgeons and 5 medical students before and after training). These videos were evaluated by nonmedical personnel recruited through Amazon Mechanical Turk, as well as by 3 experienced surgical faculty. Evaluation criteria were based on Objective Structured Assessment of Technical Skills (scale: 5-25). Results were compared using Wilcoxon signed rank-sum and Cronbach's alpha (α).

RESULTS

Thirty-two crowd workers evaluated all 15 videos. Crowd workers scored attending surgeon videos significantly higher than pretraining medical student videos (20.5 vs 14.9, p < 0.001), demonstrating construct validity. Across all videos, crowd evaluations were more lenient than expert evaluations (19.1 vs 14.5, p < 0.001). However, average volunteer evaluations correlated more strongly with average expert evaluations (α = 0.95) than the strength of correlation between any 2 individual expert evaluators (α = 0.72-0.88). Combined reimbursement for all workers was $80.00.

CONCLUSION

After adjustments for score inflation, crowdsourced can evaluate surgical fundamentals with excellent validity. This resource is considerably less costly and potentially more reliable than individual expert evaluations.

Observed variation in N95 respirator use by nurses demonstrating isolation care

Video review and scoring was used to evaluate the behaviors of nurses wearing N95 filtering face piece respirators while providing isolation care in a simulated patient care environment. This study yielded a detailed description of behaviors related to N95 respirator use in a health care setting. Developing a more robust and systematic behavior analysis tool for use in demonstration, simulation, and clinical care would allow for improved respiratory protection of health care workers.

The National Ebola Training and Education Center: Preparing the United States for Ebola and Other Special Pathogens

The National Ebola Training and Education Center (NETEC) was established in 2015 in response to the 2014-2016 Ebola virus disease outbreak in West Africa. The US Department of Health and Human Services office of the Assistant Secretary for Preparedness and Response and the US Centers for Disease Control and Prevention sought to increase the competency of healthcare and public health workers, as well as the capability of healthcare facilities in the United States, to deliver safe, efficient, and effective care to patients infected with Ebola and other special pathogens nationwide. NYC Health + Hospitals/Bellevue, Emory University, and the University of Nebraska Medical Center/Nebraska Medicine were awarded this cooperative agreement, based in part on their experience in safely and successfully evaluating and treating patients with Ebola virus disease in the United States. In 2016, NETEC received a supplemental award to expand on 3 initial primary tasks: (1) develop metrics and conduct peer review assessments; (2) develop and provide educational materials, resources, and tools, including exercise design templates; (3) provide expert training and technical assistance; and, to add a fourth task, create a special pathogens clinical research network.

A Highly Infectious Disease Care Network in the US Healthcare System

During the 2014-15 Ebola outbreak in West Africa, the United States responded by stratifying hospitals into 1 of 3 Centers for Disease Control and Prevention (CDC)-designated categories-based on the hospital's ability to identify, isolate, assess, and provide care to patients with suspected or confirmed Ebola virus disease (EVD)-in an attempt to position the US healthcare system to safely isolate and care for potential patients. Now, with the Ebola epidemic quelled, it is crucial that we act on the lessons learned from the EVD response to broaden our national perspective on infectious disease mitigation and management, build on our newly enhanced healthcare capabilities to respond to infectious disease threats, develop a more cost-effective and sustainable model of infectious disease prevention, and continue to foster training so that the nation is not in a vulnerable position once more. We propose the formal creation of a US Highly Infectious Disease Care Network (HIDCN) modeled after 2 previous highly infectious disease consensus efforts in the United States and the European Union. A US Highly Infectious Disease Care Network can provide a common platform for the exchange of training, protocols, research, knowledge, and capability sharing among high-level isolation units. Furthermore, we envision the network will cultivate relationships among facilities and serve as a means of establishing national standards for infectious disease response, which will strengthen domestic preparedness and the nation's ability to respond to the next highly infectious disease threat.

Preoperative Molecular Markers in Thyroid Nodules

The need for distinguishing benign from malignant thyroid nodules has led to the pursuit of differentiating molecular markers. The most common molecular tests in clinical use are Afirma^® Gene Expression Classifier (GEC) and Thyroseq^® V2. Despite the rapidly developing field of molecular markers, several limitations exist. These challenges include the recent introduction of the histopathological diagnosis "Non-Invasive Follicular Thyroid neoplasm with Papillary-like nuclear features", the correlation of genetic mutations within both benign and malignant pathologic diagnoses, the lack of follow-up of molecular marker negative nodules, and the cost-effectiveness of molecular markers. In this manuscript, we review the current published literature surrounding the diagnostic value of Afirma^® GEC and Thyroseq^® V2. Among Afirma^® GEC studies, sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) ranged from 75 to 100%, 5 to 53%, 13 to 100%, and 20 to 100%, respectively. Among Thyroseq^® V2 studies, Se, Sp, PPV, and NPV ranged from 40 to 100%, 56 to 93%, 13 to 90%, and 48 to 97%, respectively. We also discuss current challenges to Afirma^® GEC and Thyroseq^® V2 utility and clinical application, and preview the future directions of these rapidly developing technologies.

The Psychosocial Challenges of Caring for Patients with Ebola Virus Disease

Caring for highly infectious patients in biocontainment units is a new phenomenon, and little is known about the behavioral health of workers in this setting. This is a qualitative study exploring the unique experiences of workers involved in the care of patients with Ebola virus disease (EVD) at Nebraska Medicine during the 2014 Ebola outbreak. Twenty-one in-depth interviews were conducted focused on topics of personal memories, interpersonal experiences, stress response, and patient management. Five themes were identified: (1) positive experiences were emotional while challenges were technical; (2) a significant percentage of workers encountered interpersonal stressors, with 29% of respondents having feelings of isolation, 33% having alterations in home life, and 25% experiencing at least 1 episode of discrimination; (3) physicians and nurses had stressors primarily related to patient care; (4) mental health was an important supportive service, with 45% of respondents using behavioral health counseling; and (5) working in the biocontainment unit during activation was more stressful than everyday work for 60% of respondents. Differences were also noted based on employee occupation and leadership level: nurses, physicians, and members of the leadership team tended to focus on emotional experiences and were more likely to utilize behavioral health counseling services than support staff and nonleadership personnel. These findings provide a framework for thinking about the unique aspects of caring for highly infectious patients, and understanding these issues will improve training, enable management to better support staff, and provide insights to those establishing biocontainment units.

Advancing Preparedness for Highly Hazardous Contagious Diseases: Admitting 10 Simulated Patients with MERS-CoV

The Ebola outbreak of 2014-2016 highlighted the need for the development of a more robust healthcare infrastructure in the United States to provide isolation care for patients infected with a highly hazardous contagious disease. Routine exercises and skills practice are required to effectively and safely prepare care teams to confidently treat this special population of patients. The Nebraska Biocontainment Unit (NBU) at Nebraska Medicine in Omaha has been conducting exercises since 2005 when the unit was opened. Previous activities and exercises conducted by the Nebraska Biocontainment Unit have focused on transporting and caring for up to 3 patients with Ebola virus disease or other special pathogens. Changes in regional and national mandates, as well as the increased potential for receiving multiple patients at once, at a single location, have resulted in a greater demand to exercise protocols for the treatment of multiple patients. This article discusses in detail the planning, execution, and outcomes of a full-scale exercise involving 10 simulated patients with a highly infectious pathogen transmitted by the airborne route.

Gestational Primary Hyperparathyroidism Due to Ectopic Parathyroid Adenoma: Case Report and Literature Review

Gestational primary hyperparathyroidism (GPHPT) is a rare condition with fewer than 200 cases reported. We present the case of a 21-year-old woman who presented at 10 weeks’ gestation with severe hypercalcemia. Laboratory investigation was consistent with primary hyperparathyroidism. Neck ultrasound did not reveal any parathyroid enlargement. Due to the persistence of severe hypercalcemia, she was treated with 4 weeks of cinacalcet therapy, which was poorly tolerated due to nausea and vomiting. At 14 weeks’ gestation, she underwent neck exploration with right lower, left upper, and partial right upper parathyroid gland excision. Intra- and postoperative parathyroid hormone (PTH) and calcium levels remained elevated. After a thorough discussion of risks/benefits, the patient requested further treatment. A parathyroid sestamibi scan (PSS) revealed an ectopic adenoma in the left mediastinum. The adenoma was removed via video-assisted thorascopic parathyroidectomy with intraoperative PTH declining to nearly undetectable levels. She ultimately delivered a physically and developmentally normal infant at 37 weeks’ gestation.

Appropriate treatment of severe GPHPT may prevent the maternal and fetal complications of hypercalcemia. This case, in which cinacalcet therapy and PSS were used, adds to the body of literature regarding treatment of severe GPHPT.

Ultraviolet (UV)-reflective paint with ultraviolet germicidal irradiation (UVGI) improves decontamination of nosocomial bacteria on hospital room surfaces

An ultraviolet germicidal irradiation (UVGI) generator (the TORCH, ClorDiSys Solutions, Inc.) was used to compare the disinfection of surface coupons (plastic from a bedrail, stainless steel, and chrome-plated light switch cover) in a hospital room with walls coated with ultraviolet (UV)-reflective paint (Lumacept) or standard paint. Each surface coupon was inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE), placed at 6 different sites within a hospital room coated with UV-reflective paint or standard paint, and treated by 10 min UVC exposure (UVC dose of 0-688 mJ/cm² between sites with standard paint and 0-553 mJ/cm² with UV-reflective paint) in 8 total trials. Aggregated MRSA concentrations on plastic bedrail surface coupons were reduced on average by 3.0 log₁₀ (1.8 log₁₀ Geometric Standard Deviation [GSD]) with standard paint and 4.3 log₁₀ (1.3 log₁₀ GSD) with UV-reflective paint (p = 0.0005) with no significant reduction differences between paints on stainless steel and chrome. Average VRE concentrations were reduced by ≥4.9 log₁₀ (<1.2 log₁₀ GSD) on all surface types with UV-reflective paint and ≤4.1 log₁₀ (<1.7 log₁₀ GSD) with standard paint (p < 0.05). At 5 aggregated sites directly exposed to UVC light, MRSA concentrations on average were reduced by 5.2 log₁₀ (1.4 log₁₀ GSD) with standard paint and 5.1 log₁₀ (1.2 log₁₀ GSD) with UV-reflective paint (p = 0.017) and VRE by 4.4 log₁₀ (1.4 log₁₀ GSD) with standard paint and 5.3 log₁₀ (1.1 log₁₀ GSD) with UV-reflective paint (p < 0.0001). At one indirectly exposed site on the opposite side of the hospital bed from the UVGI generator, MRSA concentrations on average were reduced by 1.3 log₁₀ (1.7 log₁₀ GSD) with standard paint and 4.7 log₁₀ (1.3 log₁₀ GSD) with UV-reflective paint (p < 0.0001) and VRE by 1.2 log₁₀ (1.5 log₁₀ GSD) with standard paint and 4.6 log₁₀ (1.1 log₁₀ GSD) with UV-reflective paint (p < 0.0001). Coating hospital room walls with UV-reflective paint enhanced UVGI disinfection of nosocomial bacteria on various surfaces compared to standard paint, particularly at a surface placement site indirectly exposed to UVC light.

An institutional comparison of total abdominal colectomy and diverting loop ileostomy and colonic lavage in the treatment of severe, complicated Clostridium difficile infections

BACKGROUND

Total abdominal colectomy (TAC) is the standard surgical treatment of Clostridium difficile infection (CDI). An alternative therapy, loop ileostomy and colonic lavage (IL), was described in 2011, but the results have never been validated.

METHODS

Patients treated surgically for CDI between April 2011 and June 2015 were included. Bivariable analysis was used to compare 30-day mortality, 1-year mortality, CDI recurrence, colon preservation and ileostomy reversal.

RESULTS

Ten IL patients and thirteen TAC patients were identified. 30-day mortality (30% vs 23%, p = 1.0) and 1-year mortality (40% vs 46%, p = 1.0) were similar. Four IL and three TAC patients (57% vs 30%, p = 0.35) experienced recurrent CDI. All six surviving IL patients had successful colon preservation; five underwent ileostomy reversal compared to three in the TAC group (83% vs 43%, p = 0.27).

CONCLUSIONS

Although IL allowed colon preservation and return of intestinal continuity in most patients, IL did not decrease mortality or recurrent CDI when compared to TAC.

Containment Care Units for Managing Patients With Highly Hazardous Infectious Diseases: A Concept Whose Time Has Come

The concept of containment care for patients with highly hazardous infectious diseases originated in conjunction with the development of sophisticated biosafety level 4 laboratories at the US Army Medical Research Institute of Infectious Diseases in the late 1960s. Over time, the original containment facility served as a model for the development of other facilities in the United States at government and academic centers. The Ebola outbreak of 2014-2015 brought the issue of containment care into the mainstream and led to the development of such capabilities at strategic points around the country. We describe the original concepts behind development of such facilities, how the concept and acceptance has evolved over time, and how the guidelines for managing patients infected with viral hemorrhagic fevers have evolved as new information has been learned about protecting medical care providers from highly hazardous infectious pathogens.

Comparison of hospital room surface disinfection using a novel ultraviolet germicidal irradiation (UVGI) generator

The estimated 721,800 hospital acquired infections per year in the United States have necessitated development of novel environmental decontamination technologies such as ultraviolet germicidal irradiation (UVGI). This study evaluated the efficacy of a novel, portable UVGI generator (the TORCH, ChlorDiSys Solutions, Inc., Lebanon, NJ) to disinfect surface coupons composed of plastic from a bedrail, stainless steel, chrome-plated light switch cover, and a porcelain tile that were inoculated with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus faecalis (VRE). Each surface type was placed at 6 different sites within a hospital room and treated by 10-min ultraviolet-C (UVC) exposures using the TORCH with doses ranging from 0-688 mJ/cm(2) between sites. Organism reductions were compared with untreated surface coupons as controls. Overall, UVGI significantly reduced MRSA by an average of 4.6 log10 (GSD: 1.7 log10, 77% inactivation, p < 0.0001) and VRE by an average of 3.9 log10 (GSD: 1.7 log10, 65% inactivation, p < 0.0001). MRSA on bedrail was reduced significantly (p < 0.0001) less than on other surfaces, while VRE was reduced significantly less on chrome (p = 0.0004) and stainless steel (p = 0.0012) than porcelain tile. Organisms out of direct line of sight of the UVC generator were reduced significantly less (p < 0.0001) than those directly in line of sight. UVGI was found an effective method to inactivate nosocomial pathogens on surfaces evaluated within the hospital environment in direct line of sight of UVGI treatment with variation between organism and surface types.

Declining Operative Experience for Junior-Level Residents: Is This an Unintended Consequence of Minimally Invasive Surgery?

INTRODUCTION

Our group has previously demonstrated an upward shift from junior to senior resident participation in common general surgery operations, traditionally performed by junior-level residents. The objective of this study was to evaluate if this trend would correct over time. We hypothesized that junior resident case volume would improve.

METHODS

A sample of essential laparoscopic and open general surgery procedures (appendectomy, inguinal herniorrhaphy, cholecystectomy, and partial colectomy) was chosen for analysis. The American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried for these procedures between 2005 and 2012. Cases were stratified by participating resident post-graduate year with "junior resident" defined as post-graduate year1-3. Logistic regression was performed to determine change in junior resident participation for each type of procedure over time.

RESULTS

A total of 185,335 cases were included in the study. For 3 of the operations we considered, the prevalence of laparoscopic surgery increased from 2005-2012 (all p < 0.001). Cholecystectomy was an exception, which showed an unchanged proportion of cases performed laparoscopically across the study period (p = 0.119). Junior resident participation decreased by 4.5%/y (p < 0.001) for laparoscopic procedures and by 6.2%/y (p < 0.001) for open procedures. The proportion of laparoscopic surgeries performed by junior-level residents decreased for appendectomy by 2.6%/y (p < 0.001) and cholecystectomy by 6.1%/y (p < 0.001), whereas it was unchanged for inguinal herniorrhaphy (p = 0.75) and increased for partial colectomy by 3.9%/y (p = 0.003). A decline in junior resident participation was seen for all open surgeries, with appendectomy decreasing by 9.4%/y (p < 0.001), cholecystectomy by 4.1%/y (p < 0.002), inguinal herniorrhaphy by 10%/y (p < 0.001) and partial colectomy by 2.9%/y (p < 0.004).

CONCLUSIONS

Along with the proliferation of laparoscopy for common general surgical procedures there has been a concomitant reduction in the participation of junior-level residents. As previously thought, familiarity with laparoscopy has not translated to redistribution of basic operations from senior to junior residents. This trend has significant implications for general surgery resident education.

Kinetic Analysis of Biomarkers in a Cohort of US Patients With Ebola Virus Disease

BACKGROUND

Ebola virus (EBOV) infection causes a severe and often fatal disease. Despite the fact that more than 30 000 individuals have acquired Ebola virus disease (EVD), the medical and scientific community still does not have a clear understanding of the mechanisms by which EBOV causes such severe disease.

METHODS

In this study, 54 biomarkers in plasma samples serially collected from 7 patients with EVD were analyzed in an attempt to define the kinetics of inflammatory modulators. Two clinical disease groups were defined (moderate and severe) based on the need for clinical support. Biomarkers were evaluated for correlation with viremia and clinical disease in an effort to identify pathways that could be useful targets of therapeutic intervention.

RESULTS

Patients with severe disease had higher viremia than those with moderate disease. Several biomarkers of immune activation and control were significantly elevated in patients with moderate disease. A series of pro-inflammatory cytokines and chemokines were significantly elevated in patients with severe disease.

CONCLUSIONS

Biomarkers that were associated with severe EVD were proinflammatory and indicative of endothelial or coagulation cascade dysfunction, as has been seen historically in patients with fatal outcomes. In contrast, biomarkers that were associated with moderate EVD were suggestive of a strong interferon response and control of both innate and adaptive responses. Therefore, clinical interventions that modulate the phenotype and magnitude of immune activation may be beneficial in treating EVD.

Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism

BACKGROUND

Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes.

METHODS

A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings.

RESULTS

Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14 mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240 g compared with 1,300 g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6 months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol.

CONCLUSION

With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be considered to avoid unnecessary radiation exposure.

Use of Postexposure Prophylaxis After Occupational Exposure to Zaire ebolavirus

From September 2014 to April 2015, 6 persons who had occupational exposures to Zaire ebolavirus in West Africa received investigational agent rVSV-ZEBOV or TKM-100802 for postexposure prophylaxis and were monitored in the United States. All patients experienced self-limited symptoms after postexposure prophylaxis; none developed Ebola virus disease.

Ebola virus disease: preparedness and infection control lessons learned from two biocontainment units

PURPOSE OF REVIEW

This review details infection control issues encountered in the management of patients with Ebola virus disease (EVD), with emphasis on how these issues were confronted in two biocontainment patient care units in the United States.

RECENT FINDINGS

There is a notable paucity of medical literature to guide infection control policies and procedures when caring for patients with EVD. Thus, the experience of the Serious Communicable Diseases Unit at Emory University Hospital and the Nebraska Biocontainment Unit at the University of Nebraska Medical Center serves as the basis for this review. Facility issues, staffing, transportation logistics, and appropriate use of personal protective equipment are detailed. Other topics addressed include the evaluation of patients under investigation and ethical issues concerning the safe utilization of advanced life support.

SUMMARY

This review intends to serve as a reference for facilities that are in the process of creating protocols for managing patients with EVD. Given the lack of literature to support many of the recommendations discussed, it is important to utilize the available referenced guidelines, along with the practical experiences of biocontainment units, to optimize the care provided to patients with EVD while strictly adhering to infection control principles.

Personal protective equipment processes and rationale for the Nebraska Biocontainment Unit during the 2014 activations for Ebola virus disease

In response to the Ebola virus disease outbreak of 2014, specific procedures for personal protective equipment use were developed in the Nebraska Biocontainment Unit for the isolation care of patients with the illness. This brief report describes the 2 different levels used for patient care and presents the rationales for the specialized processes.

Surrogate testing suggests that chlorine dioxide gas exposure would not inactivate Ebola virus contained in environmental blood contamination

The ability to decontaminate a room potentially containing the Ebola virus is important to healthcare facilities in the United States. Ebola virus remains viable in body fluids, a room that has housed a patient with Ebola virus disease must have all surfaces manually wiped with an approved disinfectant, which increases occupational exposure risk. This study evaluated the efficacy of gaseous chlorine dioxide inactivation of bacterial organisms in blood as Ebola virus surrogates and as the organisms used by the Nebraska Biocontainment Unit to provide the margin of safety for decontamination. Bacillus anthracis, Escherichia coli, Enterococcus faecalis, and Mycobacterium smegmatis blood suspensions that were exposed to ClO₂ gas concentrations and exposure limits. The log reduction in Colony Forming Units (CFU) was determined for each bacterial blood suspension. Exposure parameters approximating industry practices for ClO₂ environmental decontamination (360ppm concentration to 780 ppm-hrs exposure, 65% relative humidity) as well as parameters exceeding current practice (1116 ppm concentration to 1400 ppm-hrs exposure; 1342ppm concentration to 1487 ppm-hrs exposure) were evaluated. Complete inactivation was not achieved for any of the bacterial blood suspensions tested. Reductions were observed in concentrations of B. anthracis spores (1.3 -3.76 log) and E. faecalis vegetative cells (1.3 log) whereas significant reductions in vegetative cell concentrations for E. coli and M. smegmatis blood suspensions were not achieved. Our results showed that bacteria in the presence of blood were not inactivated using gaseous ClO₂ decontamination. ClO₂ decontamination alone should not be used for Ebola virus, but decontamination processes should first include manual wiping of potentially contaminated blood; especially for microorganisms as infectious as the Ebola virus.

Learning from Ebola: Interprofessional practice in the Nebraska Biocontainment Unit

Caring for patients with Ebola virus disease (EVD) in the Nebraska Biocontainment Unit (NBU) has necessitated and enabled extensive interprofessional relationships and the creation of a collaborative care model. Critical aspects of NBU functionality include a constructive leadership environment, staff inclusion and consideration during protocol development, and a culture of partnership and communication.

Smallpox Vaccination of Laboratory Workers at US Variola Testing Sites

To evaluate the need to revaccinate laboratory workers against smallpox, we assessed regular revaccination at the US Laboratory Response Network’s variola testing sites by examining barriers to revaccination and the potential for persistence of immunity. Our data do not provide evidence to suggest prolonging the recommended interval for revaccination.

Administration of Brincidofovir and Convalescent Plasma in a Patient With Ebola Virus Disease

From 2014 to May 2015, >26 000 Ebola virus disease (EVD) cases were reported from West Africa. We present a patient with EVD who received brincidofovir and convalescent plasma. The relative contributions of supportive care, investigational therapies, and patient's immune-response on survival could not be determined. Randomized trials are needed.

Elective Laparoscopic Adrenalectomy Outcomes in 1099 ACS NSQIP Patients: Identifying Candidates for Early Discharge

This study evaluates the risk of complications associated with elective laparoscopic adrenalectomy (LA) as reported in a national dataset. We hypothesize that the risk for major complication is associated with identifiable perioperative variables. This information may aid in understanding who safely could be discharged early after surgery, including same-day discharge. Elective LA from 2009 to 2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File were reviewed. A priori selection of likely risk factors for complications was assessed for their association with morbidity. Sequential bivariable logistic regression was used to measure the statistical significance of each risk factor's observed association with the occurrence of major morbidity after surgery. The potential for multiple comparisons bias was accounted for by using a high threshold ( P < 0.01) for identifying statistically significant associations. One thousand ninety-nine patients were identified. The 30-day mortality rate was 0.18 per cent, and 4.8 per cent of patients experienced a major morbidity within 30 days of surgery. Return to the operating room occurred in 1.46 per cent of cases. Statistically significant associations occurred for 15 patient characteristics at P < 0.05. Diabetes, nonindependent functional status before surgery, American Society of Anesthesiologists classification >2, and operative time were statistically significant at P < 0.01. Complications are rare events among elective LA patients. However, several readily identifiable patient characteristics are associated with the occurrence of complications among these patients. These patient characteristics should be taken into account when considering future trials of early discharge after LA, including same-day discharge.

Construct validation of a cost-effective vessel ligation benchtop simulator

OBJECTIVE

Many benchtop surgical simulators assess laparoscopic proficiency, yet few address core open surgical skills. The purpose of this study is to describe a cost-effective benchtop vessel ligation simulator and provide construct validation.

DESIGN

A prospective comparison of blinded proficiency assessments among participants performing a benchtop vessel ligation simulation task. Evaluations were performed using Objective Structured Assessments of Technical Skills.

SETTING

This study took place at the University of Virginia, School of Medicine: a large academic medical institution.

PARTICIPANTS

The participants included fourth-year medical students participating in a focused surgical elective course (n = 16), postgraduate year 2 to 3 surgery residents (n = 6), and surgical faculty (n = 5).

RESULTS

The total fixed costs of the vessel ligation simulator was $30. Flexible costs of operation were less than $0.20 per attempt. The median task-specific checklist scores among the medical students, residents, and faculty were 4.83, 7.33, and 7.67, respectively. Median global rating scores across the 3 groups were 2.29, 4.43, and 4.76, respectively. Significant proficiency differences were noted between the students and the residents/faculty for both the metrics (p < 0.001).

CONCLUSIONS

A cost-effective benchtop simulator can effectively measure proficiency with basic open surgical techniques such as vessel ligation. Among the junior surgical trainees, this tool can identify learning gaps and improve operative skills in a preclinical setting.

Planning and response to Ebola virus disease: An integrated approach

The care of patients with Ebola virus disease (EVD) requires the application of critical care medicine principles under conditions of stringent infection control precautions. The care of patients with EVD requires a number of elements in terms of physical layout, personal protective apparel, and other equipment. Provision of care is demanding in terms of depth of staff and training. The key to safely providing such care is a system that brings many valuable skills to the table, and allows communication between these individuals. We present our approach to leadership structure and function--a variation of incident command--in providing care to 3 patients with EVD.

Elective laparoscopic adrenalectomy outcomes in 1099 ACS NSQIP patients: identifying candidates for early discharge

This study evaluates the risk of complications associated with elective laparoscopic adrenalectomy (LA) as reported in a national dataset. We hypothesize that the risk for major complication is associated with identifiable perioperative variables. This information may aid in understanding who safely could be discharged early after surgery, including same-day discharge. Elective LA from 2009 to 2010 American College of Surgeons National Surgical Quality Improvement Program Participant Use File were reviewed. A priori selection of likely risk factors for complications was assessed for their association with morbidity. Sequential bivariable logistic regression was used to measure the statistical significance of each risk factor's observed association with the occurrence of major morbidity after surgery. The potential for multiple comparisons bias was accounted for by using a high threshold (P < 0.01) for identifying statistically significant associations. One thousand ninety-nine patients were identified. The 30-day mortality rate was 0.18 per cent, and 4.8 per cent of patients experienced a major morbidity within 30 days of surgery. Return to the operating room occurred in 1.46 per cent of cases. Statistically significant associations occurred for 15 patient characteristics at P < 0.05. Diabetes, nonindependent functional status before surgery, American Society of Anesthesiologists classification >2, and operative time were statistically significant at P < 0.01. Complications are rare events among elective LA patients. However, several readily identifiable patient characteristics are associated with the occurrence of complications among these patients. These patient characteristics should be taken into account when considering future trials of early discharge after LA, including same-day discharge.