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Over the past 5 years, The University of Alabama at Birmingham (UAB) Department of Surgery has taken a keen interest in the practice of surgery in rural Alabama and has established the UAB surgery community network. Our goal is to improve the delivery of surgical care in rural areas through active recruitment of rural surgeons, the development of research around rural surgery practice, and the expansion of a surgery network throughout the state. Here, we will present the challenges faced by rural surgery, our early work to address these challenges, and offer a plan for moving forward.

The aim of this study is to examine the relationship between the sex pay gap in a large academic department of surgery and a recently instituted structured compensation plan.A recent large study found that after controlling for measures of academic and clinical productivity, male physicians earned nearly $20,000 more annually than female physicians. Increased salary transparency has been proposed as a method to reduce this disparity.A new structured compensation plan was developed to improve transparency of compensation and financial viability of each division. The total compensations of each faculty member before and after the new compensation plan were calculated. Salaries were compared with the Association of Academic Medical Colleges (AAMC) median value based on specialty, region, academic rank, stratified by sex and compared. Work relative value units (wRVUs) were calculated for each faculty member during the entire study period, stratified by sex and compared.Among 44 eligible surgeons (33 men and 11 women), a sex pay gap existed with male surgeon salaries significantly higher than female surgeon salaries [56% (8 to 213) vs 26% (1 to 64); P0.00001] despite similar RVU production (men 8725 ± 831 vs women 7818 ± 911, P = 0.454). The new compensation plan did not significantly change male surgeon salaries [56% (8 to 213) vs 58% (26 to 159); P = 0.552] but did significantly increase the salaries of female surgeons [26% (1 to 64) vs 42% (10 to 80); P = 0.026].A structured compensation plan can improve the sex pay gap in a short period of time. More transparency in surgical compensation plans is essential to understand the most equitable way to compensate all surgeons.

Background We investigated whether variation in post-acute care (PAC) services could be explained by surgeons discharging clinically similar patients to different PAC destinations, including home health (HH), skilled nursing facilities (SNF), and inpatient rehabilitation (IR). Methods We studied patients having colectomy, pancreatectomy or hepatectomy in the 2008–2011 Nationwide Inpatient Sample. We used propensity matching to determine: 1. Proportion of patients discharged to SNF/IR who could be matched to clinically similar patients discharged with HH. 2. Potential cost savings from greater use of HH. Results 30,843 patients were discharged with HH and 23,172 to SNF or IR. 14,163 (61%) SNF/IR patients could be matched to similar patients discharged with HH. Potential cost savings from increasing use of HH as an alternative to SNF/IR ranged from $2.5-$438 million annually. Conclusions There is considerable potential for reducing variation in PAC use and costs by better understanding how surgeons make decisions about PAC placement. Summary Many surgical patients discharged to inpatient rehabilitation or skilled nursing facilities have similar pre- and postoperative characteristics as individuals discharged home with home health. In order to reduce variation and deliver cost-effective care after discharge, it is important to understand how surgeons make decisions about post-acute care, and to develop processes to identify which type of post-acute care is best for each patient.

Surgical societies can provide many benefits to both the careers and personal lives of their members. Professionally, they serve to unite members through research and education. The American College of Surgeons (ACS), established in 1913 by Dr. Franklin Martin, is one of the largest professional societies in North America. Its aim is to “promote the highest standards of surgical care through education of, and advocacy for, its Fellows and their patients, and to safeguard standards of care in an optimal and ethical practice environment” [1]. While the ACS acts as a professional society for surgeons in various communities, others exist to connect surgeons in academia. For example, the Association for Academic Surgery (AAS) aims to inspire and develop young academic surgeons, and the Society of University Surgeons (SUS) seeks to support and advance leaders in academic surgery.

Aim: The purpose of this study was to determine threshold gamma probe counts to distinguish single adenoma (SA) from multigland disease (MGD) during radioguided parathyroidectomy. Methods: A retrospective analysis of 1656 patients was performed. Ex vivo counts of the first excised gland were taken and recorded as a percentage of background counts. Results: 69.4% of MGD patients had counts below the 50% threshold. The 50% threshold correctly grouped 72.8% of our cohort. Counts of more than 100% were accurate for grouping SA, with only 6.8% of patients with counts more than 100% having MGD. Conclusions: The gamma probe can aid surgeons in deciding to continue neck exploration if MGD is suspected or wait for labs to confirm cure if SA is suspected.

Background The prognostic influence of lateral neck nodal metastases present at the time of diagnosis of papillary thyroid cancer (PTC) remains controversial. This study aims to document disease outcomes and nodal recurrence rates in such patients. Methods Patients with PTC and lateral neck nodal metastases who underwent concurrent total thyroidectomy, central and lateral compartment neck dissection between 2000 and 2010 were identified from the prospectively maintained surgical databases of The University of Sydney and University of Wisconsin Endocrine Surgical Units. Disease outcomes and nodal recurrence rates were compared at 12 months post-operatively and in longer-term follow-up. Results During this 11-year period, 121 patients were identified. Mean age was 45 years; 58% were female and 98% underwent post-operative radioactive iodine ablation. At a median follow-up of 31 months (range 12–140), there were no disease-specific deaths and disease-free survival (defined by stimulated serum thyroglobulin (Tg) 30% were significantly associated with an increased risk of lateral neck nodal recurrence. Conclusion With total thyroidectomy, formal compartmental neck dissection and radioactive iodine treatment, disease-free survival can be achieved in the majority of patients with PTC and synchronous lateral neck nodal metastases. A persistently elevated Tg post-operatively and a high ratio of metastatic nodes identify patients at increased risk of locoregional recurrence.

Background Current literature is controversial regarding the importance of obese BMI classifications as a risk factor for pulmonary complications after outpatient surgery. The objective of the current investigation was to evaluate predictors of pulmonary outcomes after outpatient surgery and to assess the importance of BMI weight classifications in risk assessment. Study Design Patients with "outpatient" recorded as their inpatient/outpatient status in the 2012 to 2013 NSQIP database were included. The primary outcome of interest was the occurrence of a new pulmonary complication (eg pneumonia, pulmonary embolism, unplanned intubation, or ventilator-assisted respiration for greater than 48 hours) within 30 days of surgery. Results There were 444,532 cases included in the final analysis. There were 996 (0.22%; 99% CI 0.21% to 0.24%) all-cause pulmonary complications. Binary logistic regression identified BMI as an independent predictor of a pulmonary complication, unadjusted odds ratio 1.091 (99.75% CI 1.026 to 1.160) per 5 kg/m 2 change in BMI, p 2 was 1.44 (99.75% CI 1.01 to 2.06; p = 0.002) and with a BMI of 40 to 49.99 kg/m 2 was 1.68 (99.75% CI 1.13 to 2.50; p 2 . Conclusions Obese classes II and III were associated with an independent risk of a pulmonary complication. The risk associated with obesity was low compared with the risk associated with advanced age, prolonged surgical duration, and the risk of comorbidities including congestive heart failure, COPD, and renal failure.

Lessons Learned Pancreatic neuroendocrine tumors versus carcinoid tumors should be examined separately in clinical trials. Progression-free survival is more clinically relevant as the primary endpoint (rather than response rate) in phase II trials for low-grade neuroendocrine tumors. Background. The most common subtypes of neuroendocrine tumors (NETs) are pancreatic islet cell tumors and carcinoids, which represent only 2% of all gastrointestinal malignancies. Histone deacetylase (HDAC) inhibitors have already been shown to suppress tumor growth and induce apoptosis in various malignancies. In NET cells, HDAC inhibitors have resulted in increased Notch1 expression and subsequent inhibition of growth. We present here a phase II study of the novel HDAC inhibitor panobinostat in patients with low-grade NET. Methods. Adult patients with histologically confirmed, metastatic, low-grade NETs and an Eastern Cooperative Oncology Group (ECOG) performance status of ≤2 were treated with oral panobinostat 20 mg once daily three times per week. Treatment was continued until patients experienced unacceptable toxicities or disease progression. The study was stopped at planned interim analysis based on a Simon two-stage design. Results. Fifteen patients were accrued, and 13 were evaluable for response. No responses were seen, but the stable disease rate was 100%. The median progression-free survival (PFS) was 9.9 months, and the median overall survival was 47.3 months. Fatigue (27%), thrombocytopenia (20%), diarrhea (13%), and nausea (13%) were the most common related grade 3 toxicities. There was one grade 4 thrombocytopenia (7%). These results did not meet the prespecified criteria to open the study to full accrual. Conclusion. The HDAC inhibitor panobinostat has a high stable disease rate and reasonable PFS in low-grade NET, but has a low response rate.

The prognostic influence of lateral neck nodal metastases present at the time of diagnosis of papillary thyroid cancer (PTC) remains controversial. This study aims to document disease outcomes and nodal recurrence rates in such patients.Patients with PTC and lateral neck nodal metastases who underwent concurrent total thyroidectomy, central and lateral compartment neck dissection between 2000 and 2010 were identified from the prospectively maintained surgical databases of The University of Sydney and University of Wisconsin Endocrine Surgical Units. Disease outcomes and nodal recurrence rates were compared at 12 months post-operatively and in longer-term follow-up.During this 11-year period, 121 patients were identified. Mean age was 45 years; 58% were female and 98% underwent post-operative radioactive iodine ablation. At a median follow-up of 31 months (range 12-140), there were no disease-specific deaths and disease-free survival (defined by stimulated serum thyroglobulin (Tg)2.0 μg/L, negative clinical and radiological examination) was 66%. Of the 50 patients with persistently elevated Tg measured 12 months post-operatively, 15 developed clinical lateral neck nodal recurrence. All have undergone re-operative surgery. Elevated stimulated Tg at 12 months post-operatively and a nodal ratio of30% were significantly associated with an increased risk of lateral neck nodal recurrence.With total thyroidectomy, formal compartmental neck dissection and radioactive iodine treatment, disease-free survival can be achieved in the majority of patients with PTC and synchronous lateral neck nodal metastases. A persistently elevated Tg post-operatively and a high ratio of metastatic nodes identify patients at increased risk of locoregional recurrence.

Author(s): Hodin, Richard; Angelos, Peter; Carty, Sally; Chen, Herb; Clark, Orlo; Doherty, Gerard; Duh, Quan-Yang; Evans, Douglas B; Heller, Keith; Inabnet, William; Kebebew, Electron; Pasieka, Janice; Perrier, Nancy; Sturgeon, Cord

A reliability test of the Novacor N100PC left ventricular assist system (LVAS) with valved conduits, including a pump/drive unit with compact controller and LVAS monitor was performed. The initial test objective was to demonstrate sufficient reliability for clinical use as a long-term circulatory support system. The subsequent objective, a test to failure, was intended to provide an assessment of the durability of the design and to determine the LVAS wearout modes. Testing began in April 1993 and was performed with 12 systems on gravity-feed mock circulatory loops. The pump/ drive units were submersed in body temperature saline for the duration of the test. Each of the LVAS units was operated at nominal afterloads of 75, 90, and 105 mm Hg, with test conditions varied to yield nominal pump outputs of 5.6, 7.1, and 8.3 L/min. Failure was defined as the inability of the LVAS to maintain an average pump output of 4 L/min or an average output pressure of 60 mm Hg. After 3 years, all systems remained on test, with durations of 2.3 to 3.0 years. Analysis of the testing to that date, using a constant hazard rate model, indicated a minimum demonstrated reliability of 94% at a 60% confidence level, or 86% at a 90% confidence level, for a 2 year mission time. This greatly surpasses the reliability level included in the STS-ASAIO Long-Term Mechanical Circulatory Support System Reliability Recommendation (80% reliability, 60% confidence level for a 1 year mission time). In the subsequent test-to-failure protocol, all systems ran failure-free for at least 3 years. System failures occurring at longer durations were caused by a single common cause: wear of the energy converter's armature support bearings and shafts. The wearout mode was gradual and could be diagnosed noninvasively before failure. An analysis using a Weibull model was performed, using the test durations of those devices that failed, those that were electively removed from test for analysis of the wear mode, and those that continued on test. As of April 1998, the test results showed a reliability, at a 60% confidence level, of >99.9% for a 1 year mission time, 99.5% for a 2 year mission, and 92.0% for a 3 year mission (>99.9%, 98.3%, and 85.9% for equivalent mission times, at a 90% confidence level). Systems continue on test after as long as 4.9 years.

Introduction. Neuroendocrine (NE) tumors such as carcinoids are highly metastatic neoplasms that produce numerous bioactive hormones resulting in significant symptomatology. We have previously demonstrated that activation of the raf-1/MEK/ERK signaling pathway can suppress cellular growth and hormone production in NE tumor cells in vitro. Thus, we were interested in developing pharmacologic methods to activate the raf-1 signaling pathway. In this study, we investigated a novel therapy for NE tumors based on pharmacologic raf-1 activation using the compound ZM336372. Methods. Pulmonary carcinoid H727 tumor cells were treated with ZM336372 (20–100 μM) or carrier (DMSO). Raf-1/MEK/ERK pathway activation, cellular bioactive hormone production, and levels of cell-cycle inhibitors were determined by Western Blot for phosphorylated MEK1/2, chromogranin A (CgA), and p21, and INK4c, respectively. Cellular growth was assessed by MTT assay. Results. H727 cells did not have any detectable phosphorylated MEK1/2 at baseline. Escalating doses of ZM336372 in H727 cells resulted in increasing raf-1 activation as measured by phosphorylation of MEK1/2. Importantly, treatment of H727 cells with ZM336372 led to a marked suppression of cellular proliferation and induction of the cell-cycle inhibitors p21 and INK4c. Furthermore, treatment with ZM336372 resulted in a progressive reduction of bioactive hormone production (CgA) by the tumor cells. Conclusions. ZM336372 is an effective pharmacologic activator of raf-1/MEK/ERK signaling in carcinoid tumor cells. Raf-1 pathway induction in NE tumor cells by ZM336372 suppressed cellular proliferation and reduced bioactive hormone production. Therefore, this novel signaling-based therapy may be a viable therapeutic and palliative treatment for patients with NE tumors.

Introduction: The Notch1 pathway regulates the endocrine phenotype in differentiating NE cells. During development, Notch1 silences NE markers by increasing the levels of HES1 and suppressing hASH1 (human achaete-scute homolog-1, a NE transcription factor). GI NE tumors cells express high levels of hASH1 but lack Notch1. We hypothesized that stable expression of Notch1 in NE tumor cells could lead to decrease in NE marker production and growth inhibition through suppression of hASH1. Methods: BON cells were stably transduced with an estrogen inducible Notch1 construct to create BON-NIER cells. BON and BON-NIER cells were treated with either control (C) or 1μM estradiol (E2) for 4 days and were analyzed using western blot for the expression of hASH1, HES1, and the NE marker, chromogranin A. Protein levels were standardized to GAPDH. Cellular growth was analyzed by standard cell counts in triplicate. Results: Notch1 activation by E2 treatment resulted in a 47% reduction in chromogranin A and 14% reduction in hASH1. Importantly, Notch1 activation also led to an increase in HES1 levels. Growth curves and showed a marginal reduction in cell number in the estradiol treated BON-NIER cells. Conclusions: The Notch1 signaling pathway, which regulates NE during development, can control hormone production and growth of GI NE tumor cells. This pathway could be exploited in the treatment of these tumors. TABLE—ABSTRACT 84 . Relative protein levels & cell number BON C BON E2 BON-NIER C BON-NIER E2 Chromogranin A 100% 100% 100% 53% hASH1 100% 93% 100% 86% HES1 100% 72% 100% 530% Cell growth 6.8 × 10 5 6.6 × 10 5 6.8 × 10 5 5 × 10 5

Somatostatin analogs are the mainstay treatment for controlling tumor proliferation and hormone secretion in carcinoid patients. The new somatostatin analog Pasireotide (SOM230) may be more effective than others in its class, given its broader receptor spectrum and elevated binding affinity. Recent data suggest that ERK1/2 phosphorylation may potentiate the anti-tumor effects of somatostatin analogs in carcinoids. Additionally, ERK1/2 phosphorylation by Raf-1 activating agents has been shown to suppress biomarker expression in carcinoids. Thus, drugs that activate the Raf-1/MEK/ERK1/2 pathway may be synergistic with somatostatin analogs such as SOM230. Here, we investigate the effects of SOM230 in combination with Teriflunomide (TFN), a Raf-1 activator, in a human carcinoid cell line. Introduction