Managing Career Transitions in Cardiothoracic Surgery.

Transitions during a career in cardiothoracic surgery include transition to practice following residency, multiple transitions over the course of the career, and transition to retirement. Each carries some degree of uncertainty and stress, and early preparation for each transition is key to success. A clear understanding of both professional and personal goals drives decisions and choices along the course of a career. It is crucial to seek legal counsel with expertise in physician employment contracts. Developing collegial and collaborative relationships should be a focus throughout one's career. This article outlines the key elements to successful career progression.

Management of Native Lung Malignancy in a Lung Transplant Recipient.

A 75-year-old male patient with a history of previous right lung transplant presented with left upper lobe squamous cell carcinoma. Endobronchial ultrasound and positron emission tomography displayed no mediastinal lymphadenopathy. A ventilation-perfusion scan displayed minimal perfusion to the native lung. Left robot-assisted lysis of adhesions, decortication, left upper lobectomy, and mediastinal lymphadenectomy were performed. The patient tolerated the procedure well. Final pathology displayed pT2a, n0, m0. Lobectomy is a safe and efficient treatment of native lung malignancy in the setting of previous lung transplant with minimally functioning native lung.

The EPIC procedure (Endoscopic-assisted Pilonidal Irrigation and Cleaning): a simple and effective treatment for pilonidal disease.

BACKGROUND: Pilonidal disease (PD) is a common condition of the sacrococcygeal region leading to inflammation and abscess formation. PD is a topic of renewed interest due to the lack of satisfactory management options. Minimally invasive techniques have recently been investigated, with promising results in adult and pediatric populations. Our technique, the "EPIC procedure," Endoscopic-assisted Pilonidal Irrigation and Cleaning, involves removal of hair under direct visualization using a small endoscope while flushing saline through the cavity via an angiocatheter. We aim to show that the EPIC procedure is a safe and effective operation for the treatment of pilonidal disease in the pediatric population. MATERIALS AND METHODS: We performed a retrospective chart review including 20 consecutive patients. All had a primary sacrococcygeal pilonidal sinus; all underwent the EPIC procedure. Post-operative care instructions included daily bathing and weekly depilatory application. We evaluated gender, age, weight, disease severity, operative duration, recurrence of PD, and other complications. RESULTS: In the 20 patients studied, 22 EPIC procedures were performed. The median follow-up duration was 27.95 (range 0.63-45.27) months. The mean operative duration was 28.8 (SD 10.2) min. There was a 15% recurrence rate (95% CI 0.00%, 30.65%). CONCLUSIONS: The EPIC procedure is an endoscopic-assisted operation that simplifies previously published techniques in pursuit of reduced operative complexity, cost, and time, with comparable recurrence and complication rates. All three recurrences occurred in patients that did not follow instructions for post-operative depilatory care. Two of these patients underwent repeat EPIC procedure and had no further complications. The third was lost to follow-up. The EPIC procedure provides a simple, effective, and minimally invasive approach to the treatment of pilonidal disease.

Social Disparities in Benign Lung Diseases.

The many socioeconomic disparities in the myriad of diagnoses that make up benign lung diseases are unfortunately a global issue that was most recently highlighted by the COVID-19 pandemic of 2020. In this chapter, we will be reviewing the socioeconomic disparities in benign lung disease from both a United States perspective as well as a global perspective. We will cover the spectrum of infectious, obstructive, and restrictive lung disease and review the evidence on how social disparities affect these populations and their access to medical care.

Unusual Presentation of a Gastrointestinal Stromal Tumor in a Small Intestine Diverticulum.

A 50-year-old female with no significant medical history initially presented to an urgent care center with symptoms of acute onset abdominal pain, nausea, and emesis. Chest and abdominal X-ray revealed free air under the diaphragm, prompting immediate transfer to the emergency department. Continued abdominal tenderness and pain were concerning for perforated viscus. The patient was transferred to the operating room, and diagnostic laparoscopy was performed. Inflammation and contamination were discovered in the right side of the abdomen and pelvis secondary to a small bowel (SB) perforation. Segmental SB resection revealed a perforated diverticulum. Pathological examination confirmed a diagnosis of gastrointestinal stromal tumor (GIST) at the perforated segment. On postoperative day 5, the patient was discharged home, and at 30-month follow-up, the patient continued to do well. Although rare, SB diverticula are commonly false (i.e., pseudodiverticula). The concomitant presence of a GIST in a true SB diverticulum presenting with perforation has not yet been reported.

Donor quality assessment and size match in lung transplantation.

Careful donor quality assessment and size match can impact long-term survival in lung transplantation. With this article, we review the conceptual and practical aspects of the preoperative donor lung quality assessment and size matching.

Women and Minorities Underrepresented in Academic Cardiothoracic Surgery: It's Time for Next Steps.

BACKGROUND: Women and racial and ethnic minorities are underrepresented among U.S. physicians, but are limited data on cardiothoracic surgery diversity. This study characterizes current racial and ethnic and gender diversity in academic cardiothoracic surgery. METHODS: Accreditation Council for Graduate Medical Education and Association of American Medical Colleges databases were queried for racial and ethnic and gender demographics of residents and faculty. Cardiothoracic surgery was compared with other surgical subspecialties and medicine overall. RESULTS: A total of 17% of cardiothoracic faculty were women, compared with 27% of surgical faculty (P < .01) and 43% of clinical faculty (P < .01). A total of 63% of cardiothoracic faculty were White, compared with 70% of surgical faculty (P < .01) and 66% of clinical faculty (P = .10). A total of 24% of cardiothoracic faculty were Asian American/Pacific Islander, compared with 18% of surgical faculty (P < .01) and 20% of clinical faculty (P = .03). Black/African American and Hispanic physicians composed 3% and 5% of cardiothoracic faculty, respectively, similar to surgical and clinical faculty. A total of 24% of cardiothoracic trainees were women, compared with 36% of surgical residents (P < .01) and 46% of all residents (P < .01). A total of 66% of cardiothoracic residents were White, compared with 55% of residents overall (P < .01) and 65% of surgery residents (P = .68). A total of 18% of cardiothoracic residents were Asian American/Pacific Islander, compared with 17% of surgery residents (P = .87) and 24% of residents overall (P < .01). Black/African American and Hispanic residents composed 4% and 5% of cardiothoracic residents, respectively, similar to surgery and residents overall. CONCLUSIONS: Women and racial and ethnic minorities are significantly underrepresented among trainees and faculty in academic cardiothoracic surgery compared with surgery and medicine overall, demonstrating a need for concerted action.

Trends in surgery and disparities in receipt of surgery for intrahepatic cholangiocarcinoma in the US: 2005-2014.

BACKGROUND: Intrahepatic cholangiocarcinoma (IHC) is a malignancy with an increasing incidence. Surgery is the only treatment modality associated with long term survival. The objective of this study is to utilize a nationwide representative database to quantify the trends in incidence, and surgery for IHC in the United States from 2004-2014, as well as identify any disparities in the receipt of surgery. METHODS: All patients admitted with a diagnosis of IHC between 2005 and 2014 were identified from the Nationwide Inpatient Sample (NIS) database. Trends in the number of IHC admissions and surgery procedures as well as outcomes were examined, and a multivariate analysis was used to determine the effects of demographic and clinical co-variables on resection rates. RESULTS: An estimated total of 104,045 IHC related admissions occurred between 2005 and 2014. The hospitalization rate for IHC increased by nearly 2-fold in 2014 [38.9 per 100,000 (95% CI, 35.7-42.2)] from 18.1 per 100,000 (95% CI, 15.8-20.3) in 2005. Liver resections increased 248% (P<0.01) with an increasing majority being performed at teaching hospitals and 56% being minor resections. There was an increase in estimated hospital charges from $87,124 to $148,613 (P<0.001) and decrease in LOS from 12 days to 10 days (P<0.01). Inpatient mortality for IHC decreased significantly from 11% to 8.4% (P=0.004), from year 2005 to 2014 respectively. Age >80 years (OR =0.45; 95% CI, 0.33-0.60), Black race (OR =0.50; 95% CI, 0.39-063), Hispanic race (OR =0.59; 95% CI, 0.45-0.79), Medicaid insurance (OR =0.58; 95% CI, 0.42-0.79) and Elixhauser comorbidity score >3 (OR =0.58; 95% CI, 0.47-0.73) were associated with decreased rates of resection. CONCLUSIONS: Overall hospitalization and volume of surgery for IHC has increased dramatically over the past decade. There has been an increase in cost, decrease in LOS and inpatient mortality during the period. Socioeconomic and racial disparities were observed in the receipt of surgery for IHC. Additional work is needed to understand the complex interplay between socioeconomic status and race in in the treatment of IHC.

A Retrospective Review of Clinical Admissions to Afghan National Security Forces Health Care Institutions.

BACKGROUND: Few published reports have examined the numbers of civilian injuries treated at Military Treatment Facilities in the Afghan Theater of Operations. However, review of Department of Defense Trauma Registry revealed a persistent percentage of civilians treated by NATO, and this study compares the proportion of civilians served by Afghan and Coalition military hospitals between 2009 and 2013. METHODS: A retrospective review of records from Department of Defense trauma Registry for Coalition data, and Afghan data from the Office of the Inspector General. We assessed changes in the proportion of civilians served between 2009 and 2013 at Afghan and Coalition hospitals. RESULTS: There was a significant percentage (≥21.55%) of civilians served at both Afghan and Coalition hospitals. Although the total population of Afghan Nationals treated remained steady, the number of total civilians decreased over this time period. To account for this, the percentage of military personnel increased at Afghan military hospitals. In Coalition hospitals, the civilian population increased between 2009 and 2011 and then decreased between 2011 and 2013. CONCLUSIONS: For all hospitals, whether Afghan or Coalition hospitals, there was a persistent level of civilian admissions. A downward trend for civilian patients in the Coalition hospitals and a similar increase in Afghan hospitals was expected. However, the numbers for Afghan hospitals instead showed a downward trend, potentially from the loss of logistical assistance provided by Coalition forces in transferring patients to Afghan hospitals. As evidenced by our data, future missions should plan to provide care for this civilian population, by allocating funding and appropriately training personnel. Additionally, logistical concerns of transferring to host-nation facilities and training host-nation providers will require foresight, planning, and diplomatic overtures, not always included in tactical decision-making.

An unusual case of jaundice: Biliary tumor thrombus in fibrolamellar hepatocellular carcinoma.

BACKGROUND: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare and unique variant of hepatocellular carcinoma (HCC) whose presentation remains inadequately described. We present a resectable case of FL-HCC which involved tumor thrombus of the common bile duct. PRESENTATION: A 27 year-old male presenting with jaundice, abdominal pain, vomiting, hepatic dysfunction and hyperbilirubinemia was found to have a large liver mass and lymphadenopathy on preoperative imaging. A right hepatectomy with perihepatic lymph node dissection and cholecystectomy was performed. Intraoperative cholangiogram demonstrated common bile duct (CBD) obstruction. CBD exploration revealed biliary tumor thrombus relieved with biliary thrombectomy. DISCUSSION: FL-HCC can initially present with invading obstructing biliary tumor thrombus of the CBD causing jaundice. CONCLUSION: Preoperative surgical approach should consider CBD exploration on an individual basis for underlying obstructive biliary tumor thrombus.

Population model of bladder motion and deformation based on dominant eigenmodes and mixed-effects models in prostate cancer radiotherapy.

In radiotherapy for prostate cancer irradiation of neighboring organs at risk may lead to undesirable side-effects. Given this setting, the bladder presents the largest inter-fraction shape variations hampering the computation of the actual delivered dose vs. planned dose. This paper proposes a population model, based on longitudinal data, able to estimate the probability of bladder presence during treatment, using only the planning computed tomography (CT) scan as input information. As in previously-proposed principal component analysis (PCA) population-based models, we have used the data to obtain the dominant eigenmodes that describe bladder geometric variations between fractions. However, we have used a longitudinal analysis along each mode in order to properly characterize patient's variance from the total population variance. We have proposed is a mixed-effects (ME) model in order to separate intra- and inter-patient variability, in an effort to control confounding cohort effects. Other than using PCA, bladder shapes are represented by using spherical harmonics (SPHARM) that additionally enables data compression without information lost. Based on training data from repeated CT scans, the ME model was thus implemented following dimensionality reduction by means of SPHARM and PCA. We have evaluated the model in a leave-one-out cross validation framework on the training data but also using independent data. Probability maps (PMs) were thus generated with several draws from the learnt model as predicted regions where the bladder will likely move and deform. These PMs were compared with the actual regions using metrics based on mutual information distance and misestimated voxels. The prediction was also compared with two previous population PCA-based models. The proposed model was able to reduce the uncertainties in the estimation of the probable region of bladder motion and deformation. This model can thus be used for tailoring radiotherapy treatments.

Cortical surface reconstruction based on MEG data and spherical harmonics.

Estimates of coefficients of a spherical harmonic Fourier decomposition of the cortical surface can be obtained solely using MEG/EEG data and free energy as objective function. A stochastic methodology based on a Metropolis Search followed by a Bayesian Model Averaging is proposed to reconstruct cortical anatomy based functional information.

Pacemaker implantation site neuralgia treated with lidocaine patches: case report / Neuralgia en el sitio de implantación de un marcapasos tratada con parches de lidocaína: reporte de caso

La neuralgia luego de la implantación de un marcapasos es una complicación rara que, muchas veces, requiere manejo quirúrgico. La etiología es desconocida; sin embargo, se han postulado diferentes teorías. Este artículo describe un caso exitoso de manejo médico con parche de lidocaína, y se hace una revisión del tema...

Severe chronic pacemaker pocket pain neuralgia is a rare complication of implanted pacemakers, and may require surgical management. Etiology of this disease is unknown, many theories, however, have been postulated. This paper analyzes onesuccessful case, managed with lidocaine patches, and reviews the literature...

Random location of multiple sparse priors for solving the MEG/EEG inverse problem.

MEG/EEG brain imaging has become an important tool in neuroimaging. Current techniques based in Bayesian approaches require an a-priori definition of patch locations on the cortical manifold. Too many patches results in a complex optimisation problem, too few an under sampling of the solution space. In this work random locations of the possible active regions of the brain are proposed to iteratively arrive at a solution. We use Bayesian model averaging to combine different possible solutions. The proposed methodology was tested with synthetic MEG datasets reducing the localisation error of the approaches based on fixed locations. Real data from a visual attention study was used for validation.

Desarrollo de un modelo generalizado para realimentación de fuerza y torque en cirugía cardiotorácica robótica mínimamente invasiva: determinación de condiciones y restricciones / Development of a generalized model for force and torque feedback in robotic minimally invasive cardiothoracic surgery: identification of conditions and restrictions

INTRODUCCIÓN: los procedimientos de cirugía cardiotorácica mínimamente invasiva (MICS, su sigla en Inglés) buscan reducir las complicaciones de las grandes disecciones. No obstante, ante la falta de contacto directo con el tejido por parte del cirujano, éste recibe una sensación parcial de tacto y fuerza, lo que puede originar errores de procedimiento, inadecuada fuerza aplicada al tejido y fatiga durante el acto quirúrgico. La inclusión de dispositivos robóticos con la técnica MICS ha potencializado las habilidades del cirujano para la manipulación de los tejidos, y aunque los desarrollos del mercado no cuentan aún con retroalimentación táctil, se trabaja en prototipos robóticos que incorporan realimentación de fuerza y torque. OBJETIVO: proponer las condiciones y restricciones relacionadas con la incorporación de realimentación de fuerza y torque en MICS robótica, aplicables a diferentes configuraciones de manipuladores, y analizar la implementación de dichas condiciones en un simulador quirúrgico. MATERIAL Y MÉTODOS: partiendo del análisis de necesidades durante procedimientos cardiotorácicos y las condiciones de cirugía mínimamente invasiva, se identificaron los requerimientos para garantizar reflexión de fuerza y se realizó un análisis matemático de dichas consideraciones. Finalmente, se verificaron los análisis matemáticos mediante técnicas de modelización y simulación utilizando la plataforma computacional Matlab®. RESULTADOS: se argumentaron tres tipos de consideraciones: a) Cinemático: la existencia de un punto fijo, las formas de garantizarlo durante procedimientos MICS robóticos, y las trayectorias de movimiento que el manipulador sigue en aplicaciones de cirugía cardiotorácica; b) Dinámico: la repercusión de fuerzas externas en el manipulador y la manera de considerarlas en el desarrollo de controladores que permitan al cirujano percibir una sensación de contacto con el tejido; c) Sensorial: requerimientos de los sensores de fuerza y relación necesaria entre el número de sensores y actuadores para realimentar fuerza en MICS robótica. Posteriormente se implementaron dichas consideraciones en un simulador y se verificó el cumplimiento de las mismas. CONCLUSIONES: las condiciones relacionadas con la incorporación de un sensor de fuerza y la percepción del cirujano en cuanto al tacto y la fuerza aplicada, resultan ser importantes en procedimientos de MICS robótica y requiere la inclusión de un sistema de control que permita la optimización de procedimientos por telepresencia.

INTRODUCTION: the procedures in minimally invasive cardiothoracic surgery (MICS) aim to reduce the complications of major dissections. However, in the absence of direct contact of the surgeon with the tissue, he receives a partial sense of touch and strength, which can lead to procedural errors, inadequate force applied to the tissue and fatigue during surgery. The inclusion of robotic devices with the MICS technique has enhanced the technical skills of the surgeon to manipulate tissue, and although the market devices still do not have tactile feedback, research in robotic prototypes that incorporate feedback of force and torque is being done. OBJECTIVE: to propose the conditions and restrictions related to the integration of force and torque feedback in robotics MICS applicable to different configurations of manipulators and analyze the implementation of those conditions in a surgical simulator. MATERIAL AND METHODS: from the analysis of needs during cardiothoracic procedures and conditions of minimally invasive surgery, we identified the requirements to ensure reflection of force and performed a mathematical analysis of such considerations. Finally, mathematical analysis were verified by modeling and simulation techniques using the Matlab® computing platform. RESULTS: three types of considerations were argued: a) Kinematic: the existence of a fixed point; the way to guarantee it for robotic MICS procedures, and the trajectories of motion followed by the controller in the applications of Cardiothoracic Surgery, b) Dynamic: the impact of external forces on the manipulator and the way to consider them in the development of controllers that allow the surgeon to feel a sense of contact with the tissue, c) Sensory: requirements of the force sensors and necessary relationship between the number of sensors and actuators to feedback force in MICS robotics. Subsequently these considerations were implemented in a simulator and were checked for compliance. CONCLUSIONS: the conditions related to the incorporation of a force sensor and the perception of the surgeon in terms of touch and force applied turns out to be important in robotics MICS procedures and requires the inclusion of a control system that enables the optimization of telepresence procedures.

Protein network prediction and topological analysis in Leishmania major as a tool for drug target selection.

BACKGROUND: Leishmaniasis is a virulent parasitic infection that causes a worldwide disease burden. Most treatments have toxic side-effects and efficacy has decreased due to the emergence of resistant strains. The outlook is worsened by the absence of promising drug targets for this disease. We have taken a computational approach to the detection of new drug targets, which may become an effective strategy for the discovery of new drugs for this tropical disease. RESULTS: We have predicted the protein interaction network of Leishmania major by using three validated methods: PSIMAP, PEIMAP, and iPfam. Combining the results from these methods, we calculated a high confidence network (confidence score > 0.70) with 1,366 nodes and 33,861 interactions. We were able to predict the biological process for 263 interacting proteins by doing enrichment analysis of the clusters detected. Analyzing the topology of the network with metrics such as connectivity and betweenness centrality, we detected 142 potential drug targets after homology filtering with the human proteome. Further experiments can be done to validate these targets. CONCLUSION: We have constructed the first protein interaction network of the Leishmania major parasite by using a computational approach. The topological analysis of the protein network enabled us to identify a set of candidate proteins that may be both (1) essential for parasite survival and (2) without human orthologs. These potential targets are promising for further experimental validation. This strategy, if validated, may augment established drug discovery methodologies, for this and possibly other tropical diseases, with a relatively low additional investment of time and resources.

Neuronavegacion: Experiencia en biopsia intracraneana / Neuronavegation: the experience with brain biopsies in neurosurgycal service in Bogota

Introducción. La continua evolución de las aplicaciones tecnológica permite ofrecer a los pacientes procedimientos, cada vez menos cruentos, más seguros y de mejor costo-efectividad. Tal sucede con la cirugía guiada por imágenes TAC; RM; angiografia etc., también denominada neuronavegación. Objetivo: Presentar la experiencia del servicio de neurocirugía del Hospital Central de la Policía (HOCEN) de Bogotá en la obtención de biopsias cerebrales por neuronavegación. Material y Métodos. Se utilizó el sistema Vectorvisión, en el cual se cargan los estudios previo del paciente (TAC, RM;angiografia efe) para obtener mediante neuronavegación biopsias cerebrales que permitieron concretar el diagnóstico de diversas lesiones del sistema nervioso central. Se comparó el rendimiento del sistema de neuronavegación mediante el Vectorvisión, con el de biopsia estereotáctica (guiada por TAC} realizado en el mismo servicio. Resultados. De 125 procedimientos guiados por imágenes 64 fueron biopsias, 15 de las cuales se realizaron con el Vectorvison; la duración promedio de este procedimiento fue de 100 minutos (DS 27,22) menor que la requerida para una biopsia estereotáctica. Se hizo diagnóstico hispatopatológico en todos los casos, con una baja tasa de complicaciones (4,7 por ciento).

Anticuerpos antiespermatozoide en la infertilidad / Anti-spermatozoa antibodies in infertility

Utilizando la tecnica de macro-aglutinacion en gelatina propuesta por Kibrick, se estudio la presencia de anticuerpos antiespermatozoide en parejas infertiles. De 52 parejas, 33 consultaron por infertilidad primaria (63.6%) y 19 por secundaria (36.5%). El 46.1% de todas estas mujeres presentaron anticuerpos circulantes a titulos de 1:16 a 1:128, contra solo 3.8% en el grupo control. La frecuencia de anticuerpos circulantes por infertilidad primaria que en aquellas que lo hicieron por infertilidad secundaria (36.8). Solo 12 hombres dentro del grupo estudiado, presentaron anticuerpos a titulos menores o iguales a 1:16; no hubo en ellos correlacion ninguna con la calidad de los espermatozoides. No se encontro ninguna relacion entre la patologia gineco-obstetrica y la presencia de los anticuerpos circulantes