Functionally Silent, Giant Pheochromocytoma Presenting With Varicocele.

Adrenal incidentalomas are a known entity that have been increasing in commonality with the advent of improved diagnostic and imaging techniques. There are a vast variety of causative pathologies to which this diagnosis can be attributed. Some of these pathologies are more common than others, while many remain extremely rare. One of the distinct entities that is a unique cause of incidentalomas is the diagnosis presented herein: pheochromocytoma. Pheochromocytomas are often an exceptional subset of incidentalomas that can certainly play a major role in treatment and management plans. However, the exclusivity of a pheochromocytoma diagnosis alone is not where the uniqueness of this case rests. The uniqueness in this patient is paramount to report due to 2 additional significant factors. The first was that the patient was entirely asymptomatic aside from complaints related to scrotal swelling due to a varicocele, for which this presentation of pheochromocytoma has been scarcely reported in the literature. Second, the patient had a pathology proven diagnosis of pheochromocytoma, while lacking both symptoms and biochemical findings to support the diagnosis, making it truly a silent pheochromocytoma.

Improving Compliance With Protocol-Driven Care in Adult Traumatic Brain Injury Patients by Implementing an Electronic Clinical Compliance Monitoring Tool.

Traumatic brain injury (TBI) remains a major cause of death and disability each year in the United States. Implementation of preestablished evidence-based guidelines has been associated with a decrease in overall TBI mortality and disability. OBJECTIVES: An electronic clinical monitoring tool was developed for monitoring compliance with evidence-based TBI treatment protocols to improve the overall care and outcomes in this patient population. METHODS: This project was designed as a process improvement project. For the preimplementation cohort of TBI patients, aggregate compliance data (by patient) were obtained from the Brain Trauma Foundation Trial patient registry maintained at Conemaugh Memorial Medical Center for the time between 2011 and 2012. The postimplementation cohort includes all patients older than 18 years who have sustained a TBI requiring clinical monitoring devices. RESULTS: There was a statistical significance between groups; the TBI-2017 group demonstrated better compliance with anticonvulsant use and cerebral perfusion pressure maintenance. In addition, overall compliance was better in the TBI-2017 cohort compared with the TBI-2012 cohort. CONCLUSIONS: Traumatic brain injury-specific education and frequent assessments improved compliance between TBI-2012 and TBI-2017, resulting in a higher percentage in overall survivors in the latter group.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies.

PURPOSE: Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. METHOD: Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. RESULTS: A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. CONCLUSIONS: Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

The Geriatric Trauma Institute: reducing the increasing burden of senior trauma care.

BACKGROUND: Owing to parallel advances in health care and an aging population, geriatric injury has become an increasing burden to trauma systems, suggesting that specific clinical pathways may improve the care of this cohort. We created a dedicated Geriatric Trauma Institute, with multidisciplinary support, as a part of our existing trauma program, theorizing that the Geriatric Trauma Institute would promote quality care, reduce the length of stay, and reduce hospital charges. METHODS: We performed a retrospective analysis of the prospective database of our level 1 trauma center. Patients aged 65 years or older were identified over 12 months, representing 5 months prior and also after the implementation of the new program. RESULTS: The mean length of stay was reduced for admissions to a nontrauma vs geriatric trauma service (5.64 vs 4.43 days; P = .03), generating a charge reduction of 21.4% in only the first 5 months after program implementation. CONCLUSIONS: Our preliminary findings, which require longer-term analysis, suggest that a dedicated geriatric trauma multidisciplinary system promotes quality patient care, improves throughput, and results in significant cost savings via reduced length of stay and concomitant hospital charges.

Incentives for scholarly activity at university and independent general surgery residencies: current practices.

BACKGROUND: Teaching physicians and academic medical centers may find it more difficult to meet clinical productivity expectations and still contribute to scholarly activity in the present economic climate of health care. METHODS: A multiquestion survey was developed and distributed via the Association of Program Directors in Surgery list-serve. RESULTS: There were 80 respondents (31% response rate), 29 university program (UP), 43 independent program (IP), and 8 "other." Although most programs had designated teaching faculty (72% UP, 93% IP), the trend was not to compensate for scholarly activity whether voluntary (100% UP, 91% IP), employed (82% UP, 74% IP), or contracted (57% UP, 85% IP; P = not specified). Most (69% UP, 75% IP) programs had no incentives for scholarly activities, despite dissatisfaction with involvement of volunteer faculty (19% UP, 55% IP; P = .04). Most compensation plans (79% UP, 66% IP) were discretionary or atypical. CONCLUSIONS: Most programs, UP and IP, did not compensate for scholarly activity for teaching faculty. There was a significant proportion that believed compensation would improve teaching efforts.

Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training.

BACKGROUND: Human patient simulation (HPS) has been used since 1969 for teaching purposes. Only recently has technology advanced to allow application to the complex field of trauma resuscitation. The purpose of our study was to validate an advanced HPS as an evaluation tool of trauma team resuscitation skills. METHODS: The pilot study evaluated 10 three-person military resuscitation teams from community hospitals that participated in a 28-day rotation at a civilian trauma center. Each team consisted of physicians, nurses, and medics. Using the HPS, teams were evaluated on arrival and again on completion of the rotation. In addition, the 10 trauma teams were compared with 5 expert teams composed of experienced trauma surgeons and nurses. Two standardized trauma scenarios were used, representing a severely injured patient with multiple injuries and with an Injury Severity Score of 41 (probability of survival, 50%). Performance was measured using a unique human performance assessment tool that included five scored and eight timed tasks generally accepted as critical to the initial assessment and treatment of a trauma patient. Scored tasks included airway, breathing, circulation, and disability assessments as well as overall organizational skills and a total score. The nonparametric Wilcoxon test was used to compare the military teams' scores for scenarios 1 and 2, and the comparison of the military teams' final scores with the expert teams. A value of p < 0.05 was considered significant. RESULTS: The 10 military teams demonstrated significant improvement in four of the five scored (p < or = 0.05) and six of the eight timed (p < or = 0.05) tasks during the final scenario. This improvement reflects the teams' cumulative didactic and clinical experience during the 28-day trauma refresher course as well as some degree of simulator familiarization. Improved final scores reflected efficient and coordinated team efforts. The military teams' initial scores were worse than the expert group in all categories, but their final scores were only lower than the expert groups in 2 of 13 measurements (p < or = 0.05). CONCLUSION: No studies have validated the use of the HPS as an effective teaching or evaluation tool in the complex field of trauma resuscitation. These pilot data demonstrate the ability to evaluate trauma team performance in a reproducible fashion. In addition, we were able to document a significant improvement in team performance after a 28-day trauma refresher course, with scores approaching those of the expert teams.