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Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010–2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9–3.1) to 4.1 (95% CI 3.5–4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6–3.1) to 9.9 (95% CI 4.9–14.9), while hospital volume increased from 3.5 (95% CI 2.3–4.6) to 15.4 (95% CI 6.9–24.0). Operative time was 34 (23–45) min faster in 2018–2019 compared with 2010–2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.

Although exposure to overweight and obesity at different ages is associated to a higher risk of type 2 diabetes, the effect of different patterns of exposure through life remains unclear. We aimed to characterize life-course trajectories of weight categories and estimate their impact on the incidence of type 2 diabetes. We categorized the weight of 7203 participants as lean, normal or overweight at five time-points from ages 7–55 using retrospective data. Participants were followed for an average of 19 years for the development of type 2 diabetes. We used latent class analysis to describe distinctive trajectories and estimated the risk ratio, absolute risk difference and population attributable fraction (PAF) associated to different trajectories using Poisson regression. We found five distinctive life-course trajectories. Using the stable-normal weight trajectory as reference, the stable overweight, lean increasing weight, overweight from early adulthood and overweight from late adulthood trajectories were associated to higher risk of type 2 diabetes. The estimated risk ratios and absolute risk differences were statistically significant for all trajectories, except for the risk ratio of the lean increasing trajectory group among men. Of the 981 incident cases of type 2 diabetes, 47.4% among women and 42.9% among men were attributable to exposure to any life-course trajectory different from stable normal weight. Most of the risk was attributable to trajectories including overweight or obesity at any point of life (36.8% of the cases among women and 36.7% among men). The overweight from early adulthood trajectory had the highest impact (PAF: 23.2% for woman and 28.5% for men). We described five distinctive life-course trajectories of weight that were associated to increased risk of type 2 diabetes over 19 years of follow-up. The variability of the effect of exposure to overweight and obesity on the risk of developing type 2 diabetes was largely explained by exposure to the different life-course trajectories of weight.

Tears in the annulus fibrosus (AF) of the intervertebral disk can result in disk herniation and progressive degeneration. Understanding AF failure mechanics is important as research moves toward developing biological repair strategies for herniated disks. Unfortunately, failure mechanics of fiber-reinforced tissues, particularly tissues with fibers oriented off-axis from the applied load, is not well understood, partly due to the high variability in reported mechanical properties and a lack of standard techniques ensuring repeatable failure behavior. Therefore, the objective of this study was to investigate the effectiveness of midlength (ML) notch geometries in producing repeatable and consistent tissue failure within the gauge region of AF mechanical test specimens. Finite element models (FEMs) representing several notch geometries were created to predict the location of bulk tissue failure using a local strain-based criterion. FEM results were validated by experimentally testing a subset of the modeled specimen geometries. Mechanical testing data agreed with model predictions (∼90% agreement), validating the model's predictive power. Two of the modified dog-bone geometries (“half” and “quarter”) effectively ensured tissue failure at the ML for specimens oriented along the circumferential-radial and circumferential-axial directions. The variance of measured mechanical properties was significantly lower for notched samples that failed at the ML, suggesting that ML notch geometries result in more consistent and reliable data. In addition, the approach developed in this study provides a framework for evaluating failure properties of other fiber-reinforced tissues, such as tendons and meniscus.

Background Breast-specific gamma imaging (BSGI) has brought scintimammography back to the forefront by using a dedicated small field-of-view system designed to detect and localize lesions down to 2 mm. Initial studies have reported sensitivity equaling that of magnetic resonance imaging, but with improved specificity. We reviewed our initial experience to evaluate the impact of this technology at our community breast center. Methods We performed a retrospective review of the initial 176 patients who underwent BSGI. Results A total of 128 patients underwent BSGI because of suspicious imaging, abnormal physical examination, or high risk with dense breasts. BSGI was positive in 12 of 107 patients with breast imaging reporting and data system (BI-RADS) 1, 2, or 3. Two of these were cancer. Of the 21 patients with BI-RADS 4, 18 were BSGI negative (11 with benign biopsy, 7 observed), and 3 were BSGI positive with 2 being cancer. Forty-eight patients with a new diagnosis of cancer obtained BSGI for further work-up. It was positive at a new location in 6 cases: 2 cases were new cancers in the contralateral breast, 1 was in the ipsilateral breast, and the remaining 3 had benign pathology. Of the 176 initial patients, clinical management was changed significantly in 14.2%, with another 6.3% in whom a negative BSGI could have prevented a biopsy. Conclusions BSGI has played an important role in our clinical management of breast patients with complex breast tissue. BSGI is also a good adjunctive imaging tool in the work-up of newly diagnosed breast cancer patients.

Nutrients have traditionally been viewed as a means to provide basic calories to sustain homeostasis. However, critically ill, surgical, and trauma patients are in a constant dynamic state between systemic inflammatory response (SIRS) and compensatory anti-inflammatory response (CARS). Results from ongoing research strongly support the use of specific nutrients to modulate the immune and/or metabolic response. These agents can now be considered therapeutic tools in the management of complex hypermetabolic diseases. The principle of using nutrients as a therapeutic strategy rather than just as "nutritional support" requires a shift in the current dogma. The most common nutrients found in currently available enteral immune-modulating formulas are omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid), antioxidants, nucleotides, glutamine, and arginine. Multiple individual reports and at least five meta-analyses using combinations of immune-modulating nutrients have reported almost uniform beneficial results. However, certain conflicting hypotheses continue to revolve around the use of arginine in septic patients.

The use of photography and video recording is common place in healthcare. Before and after photos are necessities and required in plastic surgery, intraoperative videos of laparoscopic procedures are routinely used for teaching and seminars, families often record the birth of a child.

BACKGROUND: Breast-specific gamma imaging (BSGI) is a functional imaging modality that has comparable sensitivity but superior specificity compared with magnetic resonance imaging, yielding fewer false-positive results and thereby improving clinical management of the newly diagnosed breast cancer patient. METHODS: A retrospective review was performed from 2 community-based breast imaging centers of newly diagnosed breast cancer patients in whom BSGI was performed as part of the imaging work-up. RESULTS: A total of 138 patients (69 invasive ductal carcinoma, 20 invasive lobular carcinoma, 32 ductal carcinoma in situ, and 17 mixtures of invasive ductal carcinoma, invasive lobular carcinoma, or ductal carcinoma in situ and other) were reviewed. Twenty-five patients (18.1%) had a positive BSGI study at a site remote from their known cancer or more extensive disease than detected from previous imaging. Fifteen patients (10.9%) were positive for a synchronous or more extensive malignancy in the same or contralateral breast. Five patients had benign findings on pathology, 5 benign on ultrasound follow-up (false-positive rate, 7.2%). Findings converted 7 patients to mastectomy, 1 patient to neoadjuvant chemotherapy, and 7 patients were found to have previously undetected contralateral cancer. The positive predictive value for BSGI was 92.9%. CONCLUSIONS: BSGI detected additional or more extensive malignancy in the same or contralateral breast in 10.9% of newly diagnosed breast cancer patients. Only 7.2% incurred an additional work-up. BSGI provides accurate evaluation of remaining breast tissue in newly diagnosed breast cancer patients with few false-positive readings.

Spontaneous infection with Clostridium septicum (C. septicum) is rare, but when isolated it is commonly associated with malignancy. We report a case of a 47-year-old man with infected pancreatic necrosis involving greater than 80% of the pancreas, transmural gastric necrosis, and liquefaction necrosis of the spleen. Initial cultures revealed C. septicum infection. He was managed with prompt aggressive surgical debridement, resection, appropriate broad spectrum antibiotics, and early enteral nutrition.

Arginine is a nonessential amino acid in the normal physiological state that becomes conditionally essential during periods of hypermetabolic stress. Recent literature supports the hypothesis that arginine plays an important role in the intermediary metabolism of the critically ill patient. Current critical care literature is conflicting on arginine use in the clinical setting, with some proposing it as a panacea, whereas others report it as poison. Multiple individual reports and at least 5 major meta-analyses using combinations of immune-modulating nutrients have reported mostly beneficial results, but few have evaluated the effects of arginine when given as a single supplemental nutrient. This review attempts to objectively analyze the literature and evaluate the potential role of arginine in the critical care setting.