The Current Status of Minimally Invasive Adrenalectomy for Aldosterone Producing Adenoma: Controversial Issues, and Realistic Expectations of Clinical Cure
Implementation of a formal sleep center-based screening protocol for primary aldosteronism in patients with obstructive sleep apnea
BACKGROUND:There is a bidirectional association between primary aldosteronism and obstructive sleep apnea, with evidence suggesting that the treatment of primary aldosteronism can reduce obstructive sleep apnea severity. Current guidelines recommend screening for primary aldosteronism in patients with comorbid hypertension and obstructive sleep apnea, identifying potential candidates for treatment. However, emerging data suggest current screening practices are unsatisfactory. Moreover, data regarding the true incidence of primary aldosteronism among this population are limited. This study aimed to assess the primary aldosteronism screening rate among patients with obstructive sleep apnea and hypertension at our institution and estimate the prevalence of primary aldosteronism among this population. METHODS:Sleep studies conducted at our institution between January and September 2021 were retrospectively reviewed. Adult patients with a sleep study diagnostic of obstructive sleep apnea (respiratory disturbance index â‰¥5) and a diagnosis of hypertension were included. Patient medical records were reviewed and laboratory data of those with biochemical screening for primary aldosteronism were assessed by an experienced endocrinologist. Screening rates were compared before and after initiation of a screening protocol in accordance with the 2016 Endocrine Society guidelines. RESULTS:A total of 1,005 patients undergoing sleep studies were reviewed; 354 patients had comorbid obstructive sleep apnea and hypertension. Patients were predominantly male (67%), with a mean age of 58 years (standard deviationÂ = 12.9) and mean body mass index of 34 (standard deviationÂ = 8.1). The screening rate for primary aldosteronism among included patients was 19% (nÂ = 67). The screening rate was significantly higher after initiation of a dedicated primary aldosteronism screening protocol (23% vs 12% prior; PÂ = .01). Fourteen screens (21%) were positive for primary aldosteronism, whereas 45 (67%) were negative and 8 (12%) were indeterminate. Four had prior abdominal cross-sectional imaging, with 3 revealing an adrenal adenoma. Compared with patients without primary aldosteronism, patients with positive primary aldosteronism screens were more likely to have a history of hypokalemia (36% vs 4.4%; PÂ = .002). The frequency of hyperlipidemia, diabetes mellitus, and left ventricular hypertrophy did not differ between patients with positive versus negative screens. CONCLUSION/CONCLUSIONS:Current screening practices for primary aldosteronism among patients with comorbid obstructive sleep apnea and hypertension are suboptimal. Patients evaluated at sleep centers may represent an optimal population for screening, as the prevalence of primary aldosteronism among this cohort appears high.
The role of minimally invasive approaches to hepatic and splenic surgery
Treatment of splenic cysts
Splenic cysts are a relatively rare entity with variable etiology. They are typically classified as primary or secondary cysts, and primary cysts are divided into parasitic and non-parasitic cysts. Parasitic cysts are typically caused by Echinococcus granulosis or multilocularis. Secondary cysts lack an epithelial lining and are therefore considered psuedocysts. They are frequently discovered incidentally and otherwise typically present with symptoms related to mass effect of the cyst. The management is greatly dependent upon size and symptomatology. Cysts that are parasitic, large, or symptomatic require operative intervention. Cysts that present with rupture or infection also require operative intervention. Laparoscopic surgery is safe and effective in surgical management of splenic cysts, and spleen preservation is preferable whenever it is possible, though splenectomy vaccines should be given if spleen preservation seems unlikely. There are a variety of techniques in operative management of splenic cysts. They can be managed by partial splenectomy, decapsulation, cyst fenestration, or unroofing of the cyst. The other technique that can be used in patients who are of prohibitive surgical risk is "PAIR" which stands for Puncture of cyst, Aspiration of cyst contents, Injection to sterilize the cyst, and Re-aspiration. This has a greater recurrence rate as does any technique that leaves any remaining cyst wall behind.
Increasing age is associated with worse outcomes in elderly patients with severe liver injury
While the incidence of geriatric trauma continues to increase, outcomes following severe blunt liver injury (BLI) are unknown. We sought to investigate independent predictors of mortality among elderly trauma patients with severe BLI. A retrospective study of the NTDB (2014-15) identified patients with isolated, high-grade BLI. Patients were stratified into two groups, non-elderly (<65 years) and elderly (â‰¥65 years), and then two management groups: operative within 24Â h of admission and non-operative. Demographics and outcomes were compared. Multivariable logistic regression was used to estimate association with mortality. A total of 1133 patients met our inclusion criteria. 107 patients required surgery and 1011 patients were managed non-operatively. Age was independently associated with mortality (AOR 1.04, pÂ <Â .001). For patients <65 years, need for operative intervention was associated with a 55 times greater likelihood of death (AOR 55.1, pÂ <Â .001). In patients â‰¥65 years, operative intervention was associated with a 122 times greater likelihood of death (AOR 122.09, pÂ =Â .005). Age is independently associated with mortality in patients with high grade BLI.
Underrepresented Minorities in Surgical Residencies: Where are They? A Call to Action to Increase the Pipeline
OBJECTIVE:To describe and evaluate trends of general surgery residency applicants, matriculants, and graduates over the last 13 years. SUMMARY OF BACKGROUND DATA/BACKGROUND:The application and matriculation rates of URMs to medical school has remained unchanged over the last three decades with Blacks and Hispanics representing 7.1% and 6.3% of matriculants, respectively. With each succession along the surgical career pathway, from medical school to residency to a faculty position, the percentage of URMs decreases. METHODS:The Electronic Residency Application Service to General Surgery Residency and the Graduate Medical Education Survey of residents completing general surgery residency were retrospectively analyzed (2005-2018). Data were stratified by race, descriptive statistics were performed, and time series were charted. RESULTS:From 2005 to 2018, there were 71,687 Electronic Residency Application Service applicants to general surgery residencies, 26,237 first year matriculants, and 24,893 general surgery residency graduates. Whites followed by Asians represented the highest percentage of applicants (n = 31,197, 43.5% and n = 16,602, 23%), matriculants (n = 16,395, 62.5% and n = 4768, 18.2%), and graduates (n = 15,239, 61% and n = 4804, 19%). For URMs, the applicants (n = 8603, 12%, P < 0.00001), matriculants (n = 2420, 9.2%, P = 0.0158), and graduates (n = 2508, 10%, P = 0.906) remained significantly low and unchanged, respectively, whereas the attrition was significantly higher (3.6%, P = 0.049) when compared to Whites (2.6%) and Asians (2.9%). CONCLUSION/CONCLUSIONS:Significant disparities in the application, matriculation, graduation, and attrition rates for general surgery residency exists for URMs. A call to action is needed to re-examine and improve existing recommendations/paradigms to increase the number of URMs in the surgery training pipeline.
Is trauma center designation associated with disparities in discharge to rehabiliation centers among elderly patients with traumatic brain injury [Editorial]
Acute Care Surgeons' Response to the COVID-19 Pandemic: Observations and Strategies From the Epicenter of the American Crisis
Is trauma center designation associated with disparities in discharge to rehabilitation centers among elderly patients with Traumatic Brain Injury?
BACKGROUND:We sought to evaluate the role of trauma center designation in the association of race and insurance status with disposition to rehabilitation centers among elderly patients with Traumatic Brain Injury (TBI). METHODS:The National Trauma Data Bank (2014-2015) was used to identify elderly (ageÂ â‰¥Â 65) patients with isolated moderate to severe blunt TBI who survived to discharge. Race, insurance status, and outcomes were stratified by trauma center designation and compared. RESULTS:3,292 patients met the inclusion criteria. Black patients were 1.5 times less likely (AOR 0.64, pÂ =Â 0.01) and Latino patients were 1.7 times less likely (AOR 0.58, pÂ =Â 0 0.007) to be discharged to rehabilitation centers as compared with White patients. Asian patients at Level I hospitals were more likely to be discharged to rehabilitation centers if they had private vs. non-private insurance (42.9% versus 12.7%, pÂ =Â 0.01). CONCLUSION/CONCLUSIONS:Black and Latino patients were less likely to be discharged to rehabilitation centers compared to White patients. The etiology of these disparities deserves further study.
Artificial Intelligence Outperforms Clinical Judgment in Triage for Postoperative ICU Care: Prospective Preliminary Results [Meeting Abstract]
Introduction: The decision of admitting a stable patient to the ICU after major operation currently relies on clinical judgment and local hospital policies. We programmed an artificial intelligence (AI) to determine the appropriate level of care after major operation and compared its performance with clinician's judgement.
Method(s): ICU admission was deemed "appropriate" when at least 1 of 15 criteria (eg re-intubation, prolonged hypotension, new-onset arrhythmia) was observed. Using Institutional data (512 patients, 87 clinical variables), we programmed an AI to predict when ICU admission would have been appropriate. We prospectively evaluated whether surgeon, anesthesiologist, intensivist, or AI was the most accurate predictor in determining appropriateness of ICU admissions across 50 patients undergoing major surgery (general, vascular, urological). Accuracy of predictions was compared using receiver operating characteristic curve analysis.
Result(s): ICU care was appropriate (at least 1 of 15 objective criteria met) in 9 of 50 patients. Artificial intelligence correctly triaged to the appropriate level of care 82% of patients (surgeon 70%, anesthesiologist 58%, intensivist 64%). Receiver operating characteristic curve analysis revealed that AI's triage was the most accurate (area under the curve [AUC] 0.82), followed by anesthesiologist's (AUC 0.70), intensivist's (AUC 0.69), and surgeon's (AUC 0.60). Overall, clinicians leaned toward over-triaging patients to the ICU (Table).
Conclusion(s): Our study provides the first evidence that AI can have a role in supporting clinical decisions on postoperative triage. In the future, more sophisticated platforms can become integrated in daily clinical practice. [Figure presented]