Laparoscopic hand-assisted adrenalectomy for tumours larger than 5 cm.

OBJECTIVE: Adrenal surgery remains a distinct surgical challenge. Technical challenges associated with laparoscopic adrenalectomy are tumour size, haemorrhage control and oncological compromise. Hand-assisted laparoscopic (HAL) adrenalectomy, utilizing a hand-port device, offers minimally invasive surgery with the advantages and safety of tactile feedback. We aimed to assess the efficacy of HAL for patients requiring adrenalectomy for tumours over 5 cm in size. CONTEXT: Hand-assisted laparoscopic surgery is used in several surgical specialities over totally laparoscopic surgery to manage sizeable pathology, reduce operating time and conversion rates. HAL adrenalectomy is demonstrated in this series as a safe alternative to laparoscopic adrenalectomy for large adrenal tumours. DESIGN: A retrospective analysis of all HAL adrenalectomies performed over 8 years (October 2006-May 2015) by a single surgeon was performed. This case series is the largest study of this technique. PATIENTS: All patients who were fit for surgery with adrenal tumours (over 5 cm) were included. ANALYSIS: Primary endpoints were overall mortality, operating time, hospital stay, complications and conversion to open surgery. RESULTS: A total of 56 patients underwent the procedure. A total of 43 had unilateral and 13 bilateral lesions. Most lesions (45) were histologically benign. These included functioning and non-functioning tumours. Median tumour size was 8 cm (range 5-19 cm). There was one (1.8%) intra-operative conversion and no peri-operative mortality. Postoperative complications occurred in 8 (14%) patients, all self-limiting. The median length of stay was 6 days (range 2-21). There was one recurrence of pathology with repeat surgery. CONCLUSION: Hand-assisted laparoscopic surgery offers a safe reproducible approach to adrenal surgery combining minimally invasive surgery with tactile integration. Although previously described in small numbers, this represents the largest case series to date. HAL is a safe minimally invasive surgical option for larger tumours, including malignancies. The HAL technique may additionally offer a shorter learning curve for trainee adrenal surgeons.

Using Indian Health Service (IHS) counseling techniques in an independent community pharmacy to improve adherence rates among patients with diabetes, hypertension, or hyperlipidemia.

OBJECTIVES: To 1) identify barriers to medication adherence and 2) examine the relationship between the Indian Health Service (IHS) 3 prime questions and medication adherence in patients with diabetes, hypertension, or hyperlipidemia before and 6 months after intervention. METHODS: This quasi-experimental study evaluated the effectiveness of an adherence program at an independent community pharmacy. Patients who met inclusion criteria were telephoned monthly to answer questions related to their medications. Patients served as their own controls to show comparison between pre- and postintervention adherence rates calculated according to proportion of days covered over the previous 6 months. Mean medication adherences before and after intervention were assessed via paired t test. Linear regression was used to analyze predictors of average medication adherence. The Charlson Comorbidity Index was used to measure the impact of comorbid conditions on medication adherence. RESULTS: Fifty-six of 354 patients met inclusion criteria, consented, and completed the study. The percentage of patients achieving an adherence rate of 80% or more increased from 9% initially to 59% at study completion. Each medication class showed improvement in adherence rates: diabetes from 66.24% to 80.06% (P = 0.0153), hypertension from 72.33% to 81.34% (P = 0.0192), and hyperlipidemia from 64.45% to 74.66% (P = 0.0103). Overall, average medication adherence increased by 11% (P < 0.0001). The top patient-reported barrier to adherence was convenience/forgetfulness (46.43%). CONCLUSION: Pharmacist-led counseling sessions with the use of the 3 prime questions showed short-term improvement in adherence rates among patients participating in a medication adherence program. Future studies should assess if improved adherence is sustained long-term following active intervention.

Implementation of a pharmacist-driven immunization program designed to improve overall vaccination rates in indigent and uninsured patients.

OBJECTIVE: To demonstrate the results of a pharmacist-driven immunization program designed to increase overall vaccination rates among the low-income, uninsured patients in a free clinic. SETTING: Cape Fear Clinic, a free clinic located in Wilmington, North Carolina. PRACTICE DESCRIPTION: Cape Fear Clinic provides medical, pharmacy, mental health, and dental services to adults in 4 eastern North Carolina counties who are uninsured and have incomes of no more than 200% of Federal Poverty Guidelines. PRACTICE INNOVATION: A pharmacist-driven immunization program consisting of a comprehensive chart review of every active clinic patient in order to improve the vaccination status of the clinic's patients at no cost to the patient. INTERVENTIONS: Student pharmacists completed a comprehensive chart review of every active clinic patient to identify patients eligible for immunizations according to the Advisory Committee on Immunization Practices guidelines. EVALUATION: More than 500 patients eligible for immunizations were notified of their immunization status and educated about indicated vaccinations. Patients willing to receive indicated vaccinations would present to the pharmacy and a pharmacist or student pharmacist administered the necessary doses. RESULTS: The vaccine initiative was introduced January 1, 2015 and has since delivered 1878 doses of vaccines as of June 30, 2016. CONCLUSION: The immunization program implemented by pharmacists and student pharmacists at Cape Fear Clinic has been successful in increasing awareness of vaccine preventable diseases as well as increasing rates of vaccination among eligible clinic patients.

A novel collaborative practice model for treatment of mental illness in indigent and uninsured patients.

PURPOSE: The implementation and evaluation of a collaborative practice model (CPM) of mental health care at a free clinic are described. SUMMARY: Since 2004, the mental health clinic of the Cape Fear Clinic in Wilmington, NC, has provided pharmacotherapy and psychotherapy services to a mostly female population of poor and uninsured patients (average age, about 45 years) under a CPM that includes a state-licensed Clinical Pharmacist Practitioner with prescribing privileges. Spanish is the primary language of about 28% of the clinic's patients. At patient intake and (when possible) six months later, three measures of physical and mental health are administered: the Short-Form Health Survey (SF-12), the physical and mental component summaries of the Patient Health Questionnaire for depression (PHQ-9), and the Alcohol Use Disorders Identification Test (AUDIT); psychological counseling, psychotropic medications, and laboratory monitoring are provided as appropriate. In 2009, the clinic's volunteer health care providers served 56 patients (a total of 316 office visits), providing about 165 hours of free clinical services valued at more than $15,000 and free prescription medications valued at about $123,000. Although the clinic's experience has demonstrated the feasibility of CPM-based mental health care for the indigent and uninsured, a comparison of pretest and posttest data on a sample of clinic patients did not show significant changes from mean baseline SF-12, PHQ-9, and AUDIT scores, possibly due in large part to sampling challenges resulting from the loss of many clinic patients to follow-up. CONCLUSION: A CPM that includes a pharmacist with prescribing authority and psychologists was implemented to provide care for a low-income, uninsured, partly Spanish-speaking patient population.

Two years of wait and 7000 miles of journey: the tale of a gossypiboma.

Postoperative retention of a foreign body is an infrequent but well-recognized complication. A case of a retained swab in the abdominal cavity ("gossypiboma") has been reported. In view of the high morbidity (50%) and mortality (10%) that may result from potential complications, as well as underlying medico-legal implications, it is important to ensure that every effort is made to prevent such occurrences. Presentation of gossypiboma may vary and can be caused by pseudotumoral, occlusive, or septic syndrome. Ultrasonography that shows a "hyper-reflective mass with hypoechoic rim along with a strong posterior shadow" and computed tomography that reveals "a whirl-like spongiform pattern in a hypodense mass with a thick peripheral rim" are considered the mainstay of investigations. These findings, along with a high index of suspicion, can help make a preoperative diagnosis.