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The incidence of hyperparathyroidism has increased in the USA. The previous work from our institution detected environmental chemicals (EC) within hyperplastic parathyroid tumors. The National Health and Nutrition Examination Survey (NHANES) is a program designed to assess the health status of people in the USA and includes measurements of EC in serum. Our aim was to determine which EC are associated with elevated parathyroid hormone (PTH) and calcium levels within NHANES.NHANES was queried from 2003-2016 for our analysis with calcium. A separate subgroup was queried from 2003-2006 that included PTH levels. Subjects with elevated calcium, and elevated PTH and normal Vitamin D levels were identified. Wilcoxon rank sum tests were used to analyze levels of EC in those with elevated calcium, and those with elevated PTH in the subgroup. All EC with p 0.05 were then included in separate multivariate models adjusting for serum vitamin D and creatinine for PTH and albumin for calcium.There were 51,395 subjects analyzed, and calcium was elevated in 2.1% (1080) of subjects. Our subgroup analysis analyzed 14,681 subjects, and PTH was elevated without deficient Vitamin D in 9.4% (1,377). Twenty-nine different polychlorinated biphenyls and the organochlorine pesticides hexachlorobenzene, transnonachlor, oxychlordane, and p,p'-dichlorodiphenyldichloroethylene (DDE) were found to be associated with elevated calcium and separately with elevated PTH (all p 0.05).In NHANES, 33 ECs were found to be associated with elevated calcium as well as elevated PTH levels on our subgroup analysis. These chemicals may lead us toward a causal link between environmental factors and the development of hyperparathyroidism and should be the focus of future studies looking at chemical levels within specimens.

The 2009 American Thyroid Association (ATA) guidelines for medullary thyroid cancer (MTC) were created to unify national practice patterns. Our aims were to (1) evaluate national adherence to ATA guidelines before and after 2009, (2) identify factors that are associated with concordance with guidelines, and (3) evaluate whether there is an association between survival and concordant treatment.Patients with MTC were identified from the 2009 to 2015 National Cancer Database. Adherence to ATA recommendations regarding extent of surgery (R61-R66) was analyzed. Logistic regression was used to determine predictors of discordance and propensity score matching was used to compare concordant treatment rates between time periods. Kaplan-Meier survival analysis was used to determine association between survival and concordant treatment.There were 3421 patients with MTC, and of these 3087 had M0 disease and 334 had M1 disease. We found that 72% of M0 cases adhered to R61-66, and 68% of M0 cases without advanced local disease were adherent to R61-63. Following propensity score matching, the adherence rate was 67% before 2009 and 74% after. Patient factors associated with discordant treatment were female gender, older age, treatment at a nonacademic facility, and living within 50 miles of the treatment facility. Adherence to guidelines was associated with improved overall survival (OS) (p 0.01).Treatment of MTC was discordant from guidelines in 26% of cases from 2009 to 2015 compared with 33% prior to 2009 in a propensity matched analysis, and was most often in cases with localized, noninvasive disease. Improved adherence to guidelines may improve overall survival.

We sought to derive and validate a prediction model of survival and recurrence among Western patients undergoing resection of gastric cancer.Patients who underwent curative-intent surgery for gastric cancer at seven US institutions and a major Italian center from 2000 to 2020 were included. Variables included in the multivariable Cox models were identified using an automated model selection procedure based on an algorithm. Best models were selected using the Bayesian information criterion (BIC). The performance of the models was internally cross-validated via the bootstrap resampling procedure. Discrimination was evaluated using the Harrell's Concordance Index and accuracy was evaluated using calibration plots. Nomograms were made available as online tools.Overall, 895 patients met inclusion criteria. Age (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.17-1.84), presence of preoperative comorbidities (HR 1.66, 95% CI 1.14-2.41), lymph node ratio (LNR; HR 1.72, 95% CI 1.42-2.01), and lymphovascular invasion (HR 1.81, 95% CI 1.33-2.45) were associated with overall survival (OS; all p 0.01), whereas tumor location (HR 1.93, 95% CI 1.23-3.02), T category (Tis-T1 vs. T3: HR 0.31, 95% CI 0.14-0.66), LNR (HR 1.82, 95% CI 1.45-2.28), and lymphovascular invasion (HR 1.49; 95% CI 1.01-2.22) were associated with disease-free survival (DFS; all p 0.05) The models demonstrated good discrimination on internal validation relative to OS (C-index 0.70) and DFS (C-index 0.74).A web-based nomograms to predict OS and DFS among gastric cancer patients following resection demonstrated good accuracy and discrimination and good performance on internal validation.

Reoperative parathyroid surgery (REOPS) is often associated with lower cure rates and greater risk of nerve injury and hypoparathyroidism. The aim of this study was to evaluate cure rates, pathology, complications, and the efficacy of preoperative localization in patients requiring REOPS. Between 1992 and 2017, 2491 consecutive patients underwent parathyroidectomy for primary hyperparathyroidism. With Institutional Review Board approval, our prospectively collected parathyroidectomy outcomes database was queried for operative findings, outcomes, pathology, and localization methodology. Three hundred forty-six patients had REOPS (111 men/32% and 235 women/68%), with an overall cure rate of 91 per cent and a mean follow-up of 1.9 ± 0.7 years. The average preoperative serum calcium and parathyroid hormone were 11 ± 1 mg/dL and 373 ± 796 pg/mL, respectively. Normalization of intraoperative parathyroid hormone occurred in 248 patients and it was predictive of cure in 98.8 per cent of patients. A single adenoma was resected in 253 patients (75%), and the superior gland location was most common at 57 per cent. Ectopic glands were identified in only 33 patients. When preoperative imaging localized a lesion, a tumor was identified in that location in 75.4 per cent of sestamibi or SPECT/CT scans, 57.8 per cent of CT, 61.2 per cent of MRI, and 46.2 per cent of US. When at least two imaging modalities were concordant, sensitivity improved to 91.6 per cent (

Insulinomas are rare endocrine malignancies of the pancreas that require surgical resection but can be difficult to localize preoperatively. We sought to review and improve the accuracy of preoperative localization techniques at our institution. We retrospectively reviewed all insulinomas that underwent resection at our institution between 1998 and 2016. Localization techniques include selective arterial calcium stimulation (CaStim), CT, MRI, angiography, and somatostatin receptor scintigraphy. Thirty-eight patients had pathologically proven insulinomas on surgical resection. Localization accuracies of CaStim, CT, and MRI were 89 per cent (31/35), 67 per cent (22/33), and 46 per cent (11/24), respectively. When compared with CT alone and CaStim alone, the combination of these two modalities resulted in 100 per cent preoperative localization (30/30), whereas the use of CaStim alone resulted in 80 per cent (4/5) localization and the use of CT alone resulted in 66 per cent (2/3) localization. Four of our patients had both negative CT and MRI. Among these patients, CaStim was 100 per cent localizing and the only positive modality for these patients. These data confirm that CaStim is accurate in preoperatively identifying single and multiple insulinomas; and when combined with CT, this accuracy is increased to 100 per cent. Based on these data, we propose that a dual imaging approach is a superior means of preoperative localization.

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous thromboembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.

Neuropsychiatric symptoms (NPSs) of sporadic primary hyperparathyroidism (PHPT) are often subtle and effects of parathyroidectomy (PTX) on symptoms remains poorly characterized. Our aim was to evaluate effects of PTX on NPS in patients with PHPT. A prospective questionnaire was distributed to all patients undergoing PTX and to a thyroidectomy (TX) control group. The questionnaire included the validated scales Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) to assess for depression and anxiety respectively, as well as questions modified from Pasieka's Parathyroid Assessment of Symptoms (M-PAS). Point values were assigned to questionnaire answers to create a score, with a maximum of 63. Fifty-eight patients underwent PTX (58.6%) and 41 TX (41.4%). Mean preoperative scores were greater in PTX versus TX patients in total score, PHQ-9, GAD-7, and M-PAS (all P0.05). Post-PTX scores were lower than pre-PTX in total score, PHQ-9, GAD-7, and M-PAS (all P0.05), but not in pre- and post-TX. Post-PTX 69.0 and 82.8 per cent of patients showed no symptoms of depression and anxiety, respectively, compared with 37.9 and 56.9 per cent pre-PTX. A total of 16.2 and 10.3 per cent of patients had moderately severe to severe depression and anxiety, which fell to 0 per cent post-PTX. NPSs are more common in patients with PHPT when compared with TX. Patients undergoing PTX have improvements in NPS. NPS scoring should occur in all patients with PHPT and severity of NPS should be considered a relative indication for PTX.

Introduction For the hospitalized patient, prevention of pressure ulcers requires vigilant surveillance by a dedicated care team. It is estimated that 10–15% of patients who are in the ICU for one week develop a pressure sore. Nursing-home patients have a 10–30% prevalence of pressure ulcers, whereas spinal cord injury patients have a 50–80% lifetime risk. Numerous patient factors, including malnutrition, obesity, smoking, immobility, diabetes, neurologic injury, and hip fractures, are associated with the development of pressure ulcers. Prolonged pressure with resultant tissue ischemia, shear stress, and edema all lead to tissue necrosis. Moisture and infection are factors which may cause additional progression of severity. Pressure ulcers typically occur over bony prominences where pressure and shear stress are the greatest. The most common sites are found over the ischial tuberosities, sacrum, greater trochanters, and heels. Without prompt recognition and treatment, pressure ulcers will progress through stages of increasing tissue damage. Table 94.1 shows the current pressure ulcer staging system, which is based on gross appearance. Stages I and II will usually resolve with conservative treatment including topical creams, such as silver sulfadiazine, frequent changes in patient position, air fluid beds, protective bandages, and improved nutrition. Few stage III ulcers can be treated effectively with conservative measures and progression to stage IV generally requires operative intervention. Effective management requires a multidisciplinary team including nurses, dieticians, physical therapists, social workers, and surgeons. Because of the difficulty in treating these wounds and the high rate of recurrence, prevention is of paramount importance. Frequent weight shifts to relieve pressure, proper hygiene, optimal nutrition, and primary education are important measures for prevention.

Summary This paper outlines the over-all project for development and installation of a low-profile, caisson-installed subsea Christmas tree. After various design studies and laboratory and field tests of key components, a system for installation inside a 30-in. conductor was ordered in July 1978 from Cameron Iron Works Inc. The system is designed to have all critical-pressure-containing components below the mudline and, with the reduced profile (height) above seabed, provides for improved safety of satellite underwater wells from damage by anchors, trawl boards, and even icebergs. In addition to the innovative nature of the tree design, the completion includes improved 3 1/2-in. through flowline (TFL) pumpdown completion equipment with deep set safety valves and a dual detachable packer head for simplified workover capability. The all-hydraulic control system incorporates a new design of sequencing valve for both Christmas tree control and remote flowline connection. A semisubmersible drilling rig was used to initiate the first end flowline connection at the wellhead for subsequent tie-in to the prelaid, surface-towed, all-welded subsea pipeline bundle. The acceptance stack-up tests in the U.S. and the subsequent land tests in Brunei also are described in this paper. paper. Introduction The insert tree is the 11th satellite underwater well to be completed in the northwest Borneo area. The earlier completions all have employed the conventional above-seabed type of underwater Christmas tree, and the last five trees stand about 35 ft above the seabed. This has increased concern about the vulnerability of subsea completions. We conducted various studies to improve the safety and simplification of satellite underwater well design. The insert tree completion system evolved from these studies. Although the total system (including the downhole completion design, control system, and flowline installation) is described, the tree, its design, testing, and installation are the primary subjects of this paper. paper. The Insert Tree Concept This project is the first attempt to lower substantially the profile of subsea Christmas trees above the seabed. The profile of subsea Christmas trees above the seabed. The insert concept (Fig. 1) entails the installation of the wellhead tubing hanger, master valve block, and flow loops inside the marine conductor of an underwater well. The design was achieved following close study of the purpose of the various valves in conventional surface and purpose of the various valves in conventional surface and subsea Christmas trees. On the basis of favorable long-term experience with TFL as a servicing method, vertical access for wireline servicing by use of swab valves and a wye spool are not strictly necessary, and these items safely can be eliminated if desired. Similarly. for a subsea tree. the working wing valves are at the platform, and the subsea valves are used only to shut in the well safely during an emergency or routine testing. This philosophy yields the valve configuration shown in Fig. 2. As indicated. plugs also can be installed in the tubing hanger or above the Christmas tree valves by pumpdown methods, circulating through the normally pumpdown methods, circulating through the normally open production crossover valve. During the completion stage, these plugs can be set and pulled vertically by wireline from the drilling rig before finalization of the completion. P. 2125

ventricular diameter exhibits benefits in recovering left ventricular function in accordance with the concept proposed by Batista. The possibility of compromise ventricular stroke volume is always present. However, if we consider the base of the papillary muscle as a mark to limit our ventricular reduction, this risk becomes very low, as demonstrated in the echocardiographic results of our latest patient obtained 7 months postoperatively, which present a normal ventricular cavity and normal ventricular ejection fraction. Although this study involved few patients, this simple technical variation could be used to close the ventricular septal rupture without any residual shunt and could represent one more alternative to resolve a difficult surgical problem. References 1. Skillington PD, Lamb RD, Monro JL, et al. Surgical treatment of infarct related ventricular septal defects: improved early results combined with analysis of late functional status. J Thorac Cardiovasc Surg. 1990;99: 798-808. 2. Kitamura S, Mendez A, Kidy JM. Ventricular septal defect following myocardial infarction: experience with surgical repair through a left ventriculotomy and review of literature. J Thorac Cardiovasc Surg. 1971;61:186-99. 3. David TE, Dale L, Sun Z. Postinfarction ventricular septal rupture: repair by endocardial patch with infarction exclusion. J Thorac Cardiovasc Surg. 1995;110:1315-22. 4. Jatene AD. Left Ventricular aneurysmectomy: resection or reconstruction. J Thorac Cardiovasc Surg. 1985;89:321-31. 5. Batista R. Partial left ventriculectomy—the Batista procedure. Eur J Cardiothorac Surg. 1999;15(suppl 1):S12-9.