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ImportanceAdrenalectomy 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.ObjectiveTo develop evidence-based recommendations to enhance the appropriate, safe, and effective approaches to adrenalectomy.Evidence ReviewA 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.FindingsPatients 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 RelevanceTwenty-six clinically relevant and evidence-based recommendations are provided to assist surgeons with perioperative adrenal care.

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. 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. 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). 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.

The aim of this study was to determine trends in the experience of general surgery residents with endocrine surgery cases.American Association of Endocrine Surgeons national general surgery case logs from 1989 through 2019 were reviewed. The numbers of individuals completing residency and the mean and median number of endocrine surgery cases by type and by level of operating resident surgeon were abstracted from annual data and analyzed. Descriptive statistics and linear regression analyses were performed modeling endocrine surgery cases over time and stratified by procedure type and resident level.The number of individuals completing general surgery residency each year increased from 981 to 1,219 (P.001). The average total number of endocrine surgery cases performed increased from 17 to 33.2 (P.001) but has declined since its peak at 36.9 in 2010 to 2011 (P = .014). Thyroid operations increased from 11.4 to 19.8 (P.001) but peaked at 23.5 in 2010 to 2011 and have since declined (P.001). Parathyroid operations more than doubled from 4.2 to 9.7 (P.001). Adrenal operations increased from 1 to 2.2 (P.001) and pancreatic endocrine operations increased from 0.2 to 1.5 (P.001). Surgeon Chief endocrine surgery cases peaked at 14.4 in 2003 to 2004 but have since declined by 22.2% (P.001). Surgeon Junior endocrine surgery cases increased overall (P.001) but peaked at 22.8 in 2011 to 2012. There was increasing heterogeneity over time in trainee experience (P.001).After having increased for 2 decades, the number of endocrine surgery cases performed by general surgery residents is currently in decline. Possible contributing factors include growth in the number of general surgery residents, variable and narrowed case mix, and encroachment by other learners.

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.

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 kuni(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 kuni(ω,E) curve very similar to that of RRKM theory, which assumes exponential dynamics. The RRKM kuni(ω,E) curve was brought into agreement with the biexponential kuni(ω,E) by multiplying ω in the RRKM expression for kuni(ω,E) by an energy transfer efficiency factor βc. Such scaling is often done in fitting Hinshelwood-Lindemann-RRKM thermal kinetics to experiment. This agreement between the RRKM and non-RRKM curves for kuni(ω,E) was only obtained previously by scaling and fitting. In the work presented here, it is shown that if ω in the RRKM kuni(ω,E) is scaled by a βc factor there is analytic agreement with the non-RRKM kuni(ω,E). The expression for the value of βc is derived.

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

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.

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.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.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).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.

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 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.

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.

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 (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., We present a case of gestational primary hyperparathyroidism due to ectopic parathyroid adenoma that was successfully diagnosed and treated with parathyroid sestamibi scan, cinacalcet, and surgery.

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.

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.

We propose a contaminant detection methodology suitable for robotic automation, which is able to not only locate the source(s) of the contaminant but also estimate its intensity in an environment that is allowed to evolve over both space and time. The essential idea is to flexibly model the contaminant field surface nonlinearly via radial basis functions and to utilize basic notions from the statistical design of experiments concerning optimal placement of observations in order to make incremental decisions about robot movements. Algorithms are presented for determining such movements and the subsequent collection of measurements in three different cases corresponding to different modes of spatio-temporal evolution. The result is an iterative scheme that gradually locates the peaks (sources), as well as the entire contaminant surface. The performance of the method is assessed through simulations from known surfaces. Theoretical issues concerning convergence of parameter estimates in a multiple robots scenario are examined. The method can accommodate measurement noise and does not rely on surface gradient information.

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 into2 hours

Background Safe performance of laparoscopic transabdominal adrenalectomy requires the application of a complex body of knowledge and skills, which are difficult to define, teach, and measure. This qualitative study aims to characterize expert behaviors, decisions, and other cognitive processes required to perform laparoscopic transabdominal adrenalectomy. Method Hierarchical and cognitive task analyses for right and left laparoscopic transabdominal adrenalectomy were performed using semi-structured interviews and field observations of experts. Verbal data was supplemented with published literature, coded and thematically analyzed using constructivist grounded-theory by 2 independent reviewers. Results A conceptual framework was synthesized. Sixty-eight tasks, 46 cognitive behaviors, and 52 potential errors were identified and categorized into 8 procedural steps and 8 fundamental principles: anticipation, exposure, teamwork or communication, physiology, dissection techniques, oncologic margins, tactical modification, and error recovery. Experts emphasized the importance of creating a 3-dimensional mental model of the anatomy or pathology (eg, aberrant vessels, tumor location) that is consistently fine-tuned throughout the operation, with conscious awareness of danger zones (eg, medial arc). Despite variations in dissection techniques, experts highlighted 2 themes: macrodissection and microdissection, with emphasis on nonlinear motions and effective transitions between the 2 when appropriate. Conclusion This study defines behaviors and competencies that are essential to performing laparoscopic transabdominal adrenalectomy effectively and safely.

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.

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.

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.

Fifty-five hospitals in the United States have been designated Ebola treatment centers (ETCs) by their state and local health authorities. Designated ETCs must have appropriate plans to manage a patient with confirmed Ebola virus disease (EVD) for the full duration of illness and must have these plans assessed through a CDC site visit conducted by an interdisciplinary team of subject matter experts. This study determined the clinical laboratory capabilities of these ETCs. ETCs were electronically surveyed on clinical laboratory characteristics. Survey responses were returned from 47 ETCs (85%). Forty-one (87%) of the ETCs planned to provide some laboratory support (e.g., point-of-care [POC] testing) within the room of the isolated patient. Forty-four (94%) ETCs indicated that their hospital would also provide clinical laboratory support for patient care. Twenty-two (50%) of these ETC clinical laboratories had biosafety level 3 (BSL-3) containment. Of all respondents, 34 (72%) were supported by their jurisdictional public health laboratory (PHL), all of which had available BSL-3 laboratories. Overall, 40 of 44 (91%) ETCs reported BSL-3 laboratory support via their clinical laboratory and/or PHL. This survey provided a snapshot of the laboratory support for designated U.S. ETCs. ETCs have approached high-level isolation critical care with laboratory support in close proximity to the patient room and by distributing laboratory support among laboratory resources. Experts might review safety considerations for these laboratory testing/diagnostic activities that are novel in the context of biocontainment care.

This presentation describes a new solution for geospatial Geiger-mode Avalanche Photodiode (GmAPD) LiDAR – a suite of sensors, processing tools and analytics born from a 15-year GmAPD legacy within certain DoD environments that will bring a significant increase in production efficiency to the commercial market. The objective of the sensor design was to support USGS LiDAR Quality Level 1 (and higher) data production over large areas from pressurized, fixed-wing aircrafts flying at altitudes of between 4 km and 10 km AGL. Topics to be covered include: 1) why GmAPD sensing is a significant advance in LiDAR collection efficiency, 2) how the ITI-1000 GmAPD LiDAR sensor supports cost-effective, wide-area, high-density collection, with coverage rates much greater than 1,000 km2/hr, and 3) how a high-volume production system, including noise reduction and photogrammetric registration techniques, is designed to reduce the production time for the GmAPD 3D point clouds while increasing data accuracy.

Background As of 2012, a downward trend in infection rates for hospital onset of both Clostridium difficile infections and methicillin-resistant Staphylococcus aureus bloodstream infections (2% and 4% decrease respectively) has been noted. Despite the success with these two organisms, several infectious pathogens in the healthcare setting have not decreased. This lack of downward trend highlights the importance of continuing to find and assess rapid detection methods to help confirm that hospital cleaning efforts meet and exceed standards of cleanliness demonstrated to reduce numbers of healthcare- associated infections (HAIs) of these pathogens. Methods This study set out to determine the effectiveness of the swab 3M™ Clean-Trace™ Adenosine Triphosphate (ATP) System over time by comparing the ATP measurements of the culturable organisms to the corresponding quantitative microbiology. The organisms evaluated included: Acinetobacter baumannii, Bacillus anthracis Sterne endospores and vegetative cells, Candida albicans, Clostridium difficile, Escherichia coli, Enterococcus faecalis, methicillin-resistant Staphylococcus aureus and Mycobacterium smegmatis. Results A combined organisms analysis did not demonstrate a significant reduction in measured ATP levels over the course of the organisms' exposures in a controlled environment. The quantitative microbiology did, however, demonstrate a large initial organism die-off within the first 60 min (P Conclusions This study did not demonstrate a significant effect of time in reducing ATP measures over the time periods evaluated. ATP measurements were approximately the same, regardless of the initial organism die-off. Additionally, the live versus dead analysis confirms that ATP bioluminescence is not sensitive enough to distinguish between viable organisms and organic debris remnants on sterilised equipment.

The ability to decontaminate a room potentially containing the Ebola virus is important to healthcare facilities in the United States. The 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 the 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 (360 ppm concentration to 780 ppm-hr exposure, 65%...

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.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.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.

Objective This report will describe the preparations for and the provision of care of two patients with Ebola virus disease in the biocontainment unit at the University of Nebraska Medical Center. Data sources Patient medical records. Study selection Not applicable. Data extraction Not applicable. Data synthesis Not applicable. Conclusions Safe and effective care of patients with Ebola virus disease requires significant communication and planning. Adherence to a predetermined isolation protocol is essential, including proper donning and doffing of personal protective equipment. Location of the patient care area and the logistics of laboratory testing, diagnostic imaging, and the removal of waste must be considered. Patients with Ebola virus disease are often dehydrated and need adequate vascular access for fluid resuscitation, nutrition, and phlebotomy for laboratory sampling. Advanced planning for acute life-threatening events and code status must be considered. Intensivist scheduling should account for the significant amount of time required for the care of patients with Ebola virus disease. With appropriate precautions and resources, designated hospitals in the United States can safely provide care for patients with Ebola virus disease.

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.

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.

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 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.

Overview: In 2014, the authors published the results of a study investigating nurses’ use of personal protective equipment (PPE) in the care of a live simulated patient requiring contact and airborne precautions. The 24 participants were video-recorded as they donned and doffed PPE. Variations in practices that had the potential to cause contamination were noted. In this article, the authors comment on those variations, analyzing each element of proper PPE protocols and examining why the behaviors are a safety concern for the nurse and a potential risk for disease transmission in the hospital or other clinical area. The authors note that making use of reflective practice for complicated care situations such as infection control may help nurses improve decision making in isolation care.

Background Decontamination of hospital isolation rooms can be conducted using vaporised hydrogen peroxide (VHP). A more rapid biological indicator, such as adenosine triphosphate (ATP) bioluminescence, could allow rooms to be reoccupied sooner and reduce down time. Aim This study examined the ATP bioluminescence assay as a way to evaluate biological indicators to confirm decontamination following the use of VHP. Methods Response to VHP exposure was evaluated using microbial inactivation by standard culture methods and by the ATP bioluminescence assay. Range finding determined the approximate exposure time necessary to achieve partial and complete inactivation of the organisms. Two-hundred-and-fifty parts per million of VHP was delivered to the chamber during the exposure cycle. Fifty cm 2 stainless steel coupons were inoculated with 50 mL of organism suspensions containing >10 9 colony forming units (CFU) of the following: Acinetobacter baumannii, Klebsiella pneumoniae , and methicillin-resistant Staphylococcus aureus . The standard manufactured biological indicator stainless steel discs containing concentrations of 10 4 , 10 5 and 10 6 CFU/surface of Geobacillus stearothermophilus spores were also evaluated. Findings Multiple log-reductions were shown utilising standard culture methods for each organism, but the ATP bioluminescence assay did not show a corresponding log-reduction. Conclusion The ATP bioluminescence assay was not considered an effective alternate to standard culture-based methodologies for the confirmation of VHP decontamination.

The 30-day readmission rate is a quality metric under the Affordable Care Act. Readmission rates after thyroidectomy and parathyroidectomy and associated factors remain ill-defined. We evaluated patient and perioperative factors for association with readmission after thyroidectomy and parathyroidectomy.The American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) data for thyroid (n = 3,711) and parathyroid (n = 3,358) resections were analyzed. Patient- and operation-related factors were assessed by univariate and multivariate analyses.Among 7,069 patients, 30-day readmission rate was 4.0%: 4.1% after thyroidectomy and 3.8% after parathyroidectomy. Significant associations for 30-day readmission included declining functional status (odds ratio [OR], 6.4-10.1), preoperative hemodialysis (OR, 2.6; 95% CI, 1.5-4.7), malnutrition (OR, 3.4; 95% CI, 1.2-10.1), increasing American Society of Anesthesiologists class (OR 1.3-4.7), unplanned reoperation (OR, 61.6), and length of stay (LOS)24 hours (OR, 0.61; 95% CI, 0.45-0.85; all P.05). Readmission was associated with greater total and postoperative LOS and major postoperative complications, including renal insufficiency (all P.01).Thirty-day readmission after cervical endocrine resection occurs in 4% of patients. Discharge within 24 hours of operation does not affect the likelihood of readmission. Risk factors for readmission are multifactorial and driven by preoperative conditions. Decreasing the index hospital stay and preventing major postoperative complications may decrease readmissions and improve quality metrics.

The Nebraska Biocontainment Unit through the Nebraska Medical Center in Omaha, Nebraska, recently received patients with confirmed Ebola virus from West Africa. The Nebraska Biocontainment Unit and Omaha Fire Department’s emergency medical services (EMS) coordinated patient transportation from airport to the high-level isolation unit. Transportation of these highly infectious patients capitalized on over 8 years of meticulous planning and rigorous infection control training to ensure the safety of transport personnel as well as the community during transport. Although these transports occurred with advanced notice and after confirmed Ebola virus disease (EVD) diagnosis, approaches and key lessons acquired through this effort will advance the ability of any EMS provider to safely transport a confirmed or suspected patient with EVD. Three critical areas have been identified from our experience: ambulance preparation, appropriate selection and use of personal protective equipment,and environmentaldecontamination.Key words: Ebola; EMS; transport

Background Although an emphasis has been placed on protecting patients by improving health care worker compliance with infection control techniques, challenges associated with patient isolation do exist. To address these issues, a more consistent mechanism to evaluate specific clinical behaviors safely is needed. Methods The research method described in this study used a high fidelity simulation using a live standardized patient recorded by small cameras. Immediately after the simulation experience, nurses were asked to view and comment on their performance. A demographic survey and a video recorded physical evaluation provided participant description. A questionnaire component 1 month after the simulation experience offered insight into the timing of behavior change in clinical practice. Results Errors in behaviors related to donning and doffing equipment for isolation care were noted among the nurses in the study despite knowing they were being video recorded. This simulation-based approach to clinical behavior analysis provided rich data on patient care delivery. Conclusion Standard educational techniques have not led to ideal compliance, and this study demonstrated the potential for using video feedback to enhance learning and ultimately reduce behaviors, which routinely increase the likelihood of disease transmission. This educational research method could be applied to many complicated clinical skills.

Adrenal-mediated hypertension (AMH) has been increasingly treated by laparoscopic adrenalectomy (LA). Metabolic derangements in patients with AMH could result in perioperative complications and mortality. Long-term operative and clinical outcomes after laparoscopic treatment of AMH have not been evaluated using large clinical databases. The institutional National Surgical Quality Improvement Program (NSQIP) data for patients undergoing adrenalectomy for AMH between 2002 and 2012 were reviewed. Patient demographics, perioperative variables, and outcomes were analyzed and compared with national NSQIP adrenalectomy data. Improvement in AMH was recorded when discontinuation or reduction of antihypertensive medication occurred or with a decrease of blood pressure on the preoperative antihypertensive regimen. Ninety-four patients underwent adrenalectomy. There were 48 patients with pheochromocytoma (PHE) and 46 patients with aldosterone-producing adenoma (APA). Eighty-five patients (90%) were taking antihypertensive medications preoperatively compared with 36 patients (38%) post-operatively ( P < 0.0001). Patients with PHE were more likely to discontinue all medications compared with the patients with APA (80 vs 20%, respectively, P < 0.0001). Patients with PHE and APA, respectively, took an average of 2.0 and 3.2 antihypertensive medications preoperatively compared with 0.3 and 1.2 postoperatively. There were no conversions to open procedures or 30-day mortality. Our results were 0 per cent for cerebral vascular accident, 0 per cent for myocardial infarction, and 0.5 per cent for transfusions compared with the national NSQIP data of 0.2, 0, and 6.7 per cent, respectively. Patients presenting with significant AMH including PHE and APA can be effectively and safely treated with LA with minimal complications and with a significant number of patients eliminating or decreasing their need for antihypertensive medications.

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 diffe...

Background: High prevalence and high mortality rates associated with healthcare-associated Infections (HAI) indicate there is a need to prevent HAIs from spreading. Cleaning and disinfection of hospital surfaces are fundamental to preventing HAIs, as is the confirmation of the success of these processes. Adenosine triphosphate bioluminescence has been identified as a quicker way to confirm cleaning, but questions remain regarding its specificity regarding microorganisms important to HAIs. Methods: This study evaluated ATP bioluminescence' se fficacy in determining microbial contamination on 17 surfaces from the healthcare environment, and to determine if the ATP measurements of Acinetobacter baumannii, Candida albicans, Enterococcus faecalis, Escherichia coli, Mycobacterium smegmatis, and methicillin-resistant Staphylococcus aureus corresponded to quantitative microbiology. Results: A strong positive correlation was discovered for each of the six organisms associated with HAIs, as well as an additional 'all organisms' analysis that combined all the six organisms. Conclusion: This study demonstrated a correlation between ATP bioluminescence measurements and quantitative microbiology; however, it was not as strong at low bacterial concentrations. Additional keywords: Acinetobacter baumannii, Adenosine triphosphate (ATP), ATP measurement, Candida albicans, Enterococcus faecalis, Escherichia coli, healthcare-associated infections, Mycobacterium smegmatis, and methicillin-resistant Staphylococcus aureus.

Objective.To assess the effect of adenosine triphosphate (ATP) device measurement of hospital room cleaning and feedback of pooled results to environmental service workers (EVS) to improve cleaning efficacy.Design.Nonrandomized controlled trial conducted over 20 months.Setting.Three hospitals of varying size.Participants.EVS workers, randomly selected on the basis of convenience sample of rooms.Interventions.Environmental cleanliness composite scores were combined with layered educational interventions and used to provide feedback to EVS workers on specific hospital units. Trends in cleaning efficacy were observed after the interventions.Results.Cleaning efficacy improved significantly with each intervention (P < .01) and decreased during the washout period.Conclusions.The ATP detection device combined with educational feedback for EVS workers resulted in significant improvement in cleaning efficacy of the hospital room environment.

Background Robotic technology is increasingly being utilized by general surgeons. However, the impact of introducing robotics to surgical residency has not been examined. This study aims to assess the financial costs and training impact of introducing robotics at an academic general surgery residency program. Methods All patients who underwent laparoscopic or robotic cholecystectomy, ventral hernia repair (VHR), and inguinal hernia repair (IHR) at our institution from 2011-2015 were identified. The effect of robotic surgery on laparoscopic case volume was assessed with linear regression analysis. Resident participation, operative time, hospital costs, and patient charges were also evaluated. Results We identified 2260 laparoscopic and 139 robotic operations. As the volume of robotic cases increased, the number of laparoscopic cases steadily decreased. Residents participated in all laparoscopic cases and 70% of robotic cases but operated from the robot console in only 21% of cases. Mean operative time was increased for robotic cholecystectomy (+22%), IHR (+55%), and VHR (+61%). Financial analysis revealed higher median hospital costs per case for robotic cholecystectomy (+$411), IHR (+$887), and VHR (+$1124) as well as substantial associated fixed costs. Conclusions Introduction of robotic surgery had considerable negative impact on laparoscopic case volume and significantly decreased resident participation. Increased operative time and hospital costs are substantial. An institution must be cognizant of these effects when considering implementing robotics in departments with a general surgery residency program.

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 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.

Two new stochastic search methods are proposed for optimizing the knot locations and/or smoothing parameters for least-squares or penalized splines. One of the methods is a golden-section-augmented blind search, while the other is a continuous genetic algorithm. Monte Carlo experiments indicate that the algorithms are very successful at producing knot locations and/or smoothing parameters that are near optimal in a squared error sense. Both algorithms are amenable to parallelization and have been implemented in OpenMP and MPI. An adjusted GCV criterion is also considered for selecting both the number and location of knots. The method performed well relative to MARS in a small empirical comparison.

Background The environment is increasingly appreciated as a factor in healthcare associated infections. Several methods for measuring environmental contamination are available. Our goal was to compare quantitative microbiology to adenosine triphosphate (ATP) detection on a sample of hospital surfaces both pre- and post-cleaning, and to assess fluorescent marker results in the same rooms. Methods In a sample of 10 rooms, ATP readings by relative light units (RLU) and quantitative determination of colony forming units (CFU) were measured pre- and post-cleaning on 10 high-touch hospital environmental surfaces. Removal of fluorescent markers (FM) was evaluated post-cleaning in the same rooms. Methods were compared using correlational analyses. Results The ATP readings were usually higher than CFU readings compared with their respective norms for cleanliness. The direction of change in cleanliness assessment (usually down after cleaning) was consistent between the RLU and CFU methods. In addition, CFU and RLU values correlated pre-cleaning, but not postcleaning. Areceiver operating characteristic (ROC) curve suggested a ‘clean' cutoff of 8 RLU/cm 2 for the ATP assay, higher than 2.5 RLU/cm 2 cutoff most often used. Neither method correlated well with FM results. Conclusions The methods for measuring environmental cleanliness have shown inconsistent correlation, but measure different parameters. Additional studies are needed to assess the correlation and predictive value of the three methods for room cleanliness assessment.

Background The environment has increasingly been shown to be involved in transmission of healthcare-associated infections, but data on environmental cleanliness assessment are relatively sparse. Method Environmental samples were collected from 18 high touch surfaces in 10 different acute care hospital rooms before cleaning to provide data on the rank order of cleanliness by site using both adenosine triphosphate (ATP) detection and quantitative microbiology. In addition, pre-and post-cleaning pooled samples of surfaces from 10 rooms were analysed by culture and sensitivity analysis to detect organisms of concern in the hospital. Results Four surfaces were ranked in the top six for contamination by both ATP and culture detection (bedrail control panel, nurse call light, patient phone, and bedrail). Additionally, the top three areas for cleanliness were identical between the two methods (main light switch, mattress, and bathroom interior door handle). Overall, quantitative microbiology andATPanalysisshowed directional agreement in assessment of environmental cleanliness with higher ATP readings found on surfaces designated as ‘dirty' by quantitative microbiology. Several organisms of concern for hospital infection control were seldomdetected in the pre-cleaning environmental samples, and not at all in the post-cleaning samples. Conclusions In this study environmental bioburden decreased after cleaning, and few hazardous nosocomial organisms were noted. Although quantitative microbiology and ATP detection measure somewhat different aspects of environmental contamination, they both generally agree in distinguishing clean from dirty surfaces.

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.

This secondary analysis from a larger mixed methods study with a sequential explanatory design investigates the clinical challenges for nurses providing patient care, in an airborne and contact isolation room, while using a computer on wheels for medication administration in a simulated setting. Registered nurses, who regularly work in clinical care at the patient bedside, were recruited as study participants in the simulation and debriefing experience. A live volunteer acted as the standardized patient who needed assessment and intravenous pain medication. The simulation was video recorded in a typical hospital room to observe participating nurses conducting patient care in an airborne and contact isolation situation. Participants then reviewed their performance with study personnel in a formal, audio-recorded debriefing. Isolation behaviors were scored by an expert panel, and the debriefing sessions were analyzed. Considerable variation was found in behaviors related to using a computer on wheels while caring for a patient in isolation. Currently, no nursing care guidelines exist on the use of computers on wheels in an airborne and contact isolation room. Specific education is needed on nursing care processes for the proper disinfection of computers on wheels and the reduction of the potential for disease transmission from environmental contamination.

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, p0.0001) and VRE by an average of 3.9 log10 (GSD: 1.7 log10, 65% inactivation, p0.0001). MRSA on bedrail was reduced significantly (p0.0001) 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 (p0.0001) 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.

Anterior cruciate ligament (ACL) injury is the most common injuries involving the knee. Bone-patella tendon-bone (BPTB) allograft repair is an option for ACL reconstruction. Infectious complications after ACL reconstruction with allograft are rare. We present a case of Candida glabrata septic arthritis after ACL reconstruction with a BPTB allograft.

Background Sarcopenia, a loss of skeletal muscle mass associated with aging, is a practical measure of frailty and has been previously identified as a predictor of outcomes in surgical cohorts including cancer resection and elderly patients. We hypothesized that sarcopenia, as measured by preoperative computerized tomography (CT) scan, predicts mortality and morbidity in emergent laparotomy. Methods Institutional American College of Surgeons National Surgical Quality Improvement Program data were queried for adult patients who underwent open emergency abdominal surgery between 2008 and 2013. Patients with abdominal CT scans within 30 d before surgery were included, and cross-sectional areas of the psoas muscles at vertebral level L4 were summed, normalized by patient height, and stratified by sex. The influence of this total psoas area (TPA) on postoperative morbidity and mortality was evaluated using univariate and multivariate analysis. Results Of 781 surgeries, 593 (75.9%) had appropriate preoperative CT scans. Median patient age was 61 years old, median TPA was 1719 mm2, and median body mass index was 26.7. Univariate analysis demonstrated a significant association between TPA and total postoperative morbidity (P = 0.0133), increased length of stay ( Conclusions Sarcopenia, as measured by TPA, significantly predicted mortality in univariate analysis but lost significance in multivariate analysis when factors such as American Society of Anesthesiologists score were included. Because TPA is readily available at no additional risk or cost, it is a convenient additional tool for preoperative risk assessment and counseling.