Citations

A 62-year-old male presented with productive cough, weight loss, and night sweats. CXR revealed a right upper lobe cavitary lesion. Evaluation was negative forMycobacterium tuberculosis, and sputum revealedMycobacterium avium intracellulare(MAI). Since his clinical course was atypical for MAI, further investigations were pursued which identifiedMycobacterium interjectumin lung specimens, a very rarely described etiology of pulmonary disease. Appropriate therapy with rifampin, intravenous amikacin, trimethoprim/sulfamethoxazole (TMP/SMX), and ethambutol resulted in clinical and radiographic improvement. This is the third case described over a period of 20 years of destructive lung disease in an immunocompetent adult due toM. interjectum.

AbstractBackgroundBotulinum toxin A (BTX) confers flaccid paralysis and pain modulation when injected into a muscle. We hypothesized that long‐term paralysis of the abdominal wall musculature (i.e., chemical component paralysis, CCP) would benefit incisional hernia repair (IHR) by decreasing postoperative pain, the use of opioid analgesia, and thus opioid‐related side effects.MethodsAdult patients who underwent elective IHR with preoperative CCP (n = 22) were compared to concurrent matched controls (n = 66, 1:3 ratio) based on age (±5 years), sex, body mass index (±5 kg/m2), history of hernia recurrence (0 vs. ≥1), and type of repair (open vs. laparoscopic). BTX was injected under ultrasonographic guidance into the transversus abdominis and internal and external oblique muscles at three sites bilaterally (300 units total).ResultsPatients who underwent IHR with CCP used significantly less opioid analgesia (mean ± SD morphine equivalents) when compared to controls on hospital days (HDs) 2 and 5: HD2, 48 ± 27 versus 87 ± 41; HD5, 17 ± 16 versus 48 ± 45. Likewise, CCP patients reported significantly less pain (visual analogue scale 1–10) when compared to controls on HD2 (5.2 ± 1.5 vs. 6.8 ± 2) and HD4 (3.6 ± 1.2 vs. 5.2 ± 1.9): all p < 0.007 (Bonferroni adjusted). There was no difference in postoperative complications (surgical site, 9 vs. 14 %), opioid‐related adverse events (ileus 5 vs. 5 %), hospital stay (4 ± 3 vs. 3 ± 2 days), or hernia recurrence (18 months mean follow‐up: 9 vs. 9 %).ConclusionsDespite similar multimodality treatment of postoperative pain after IHR, patients who underwent CCP required significantly less opioid analgesia and reported less pain.

Laparoendoscopic single-site surgery (LESS) is a new minimally invasive surgical technique that presents physical and mental challenges to surgeons. Currently, LESS procedures are commonly performed using surgical instruments designed for traditional multi-incision laparoscopic surgery. A pilot study was conducted to determine which laparoscopic instruments were the most efficient for LESS procedures. In a LESS surgical trainer, 24 novice users completed a simple surgical task using standard (non-articulating) straight laparoscopic graspers and two different articulating instruments. Task performance was scored based on completion time and the number of errors. Analyses showed that the use of the simpler straight instruments produced significantly faster times (p = 0.004 and p = 0.014) and higher task scores (p = 0.005 and p = 0.021) than the articulating instruments. These results suggest that standard laparoscopic hand instruments enable better novice performance for a basic LESS task.

This session will focus on lessons learned when developing solutions for real world problems in healthcare. Human factors (HF) practitioners bring unique knowledge, methods, and perspectives to work with clinicians to address numerous defects in the worksystem but require problem-solving skills that focus on solutions. The HF contribution may be in the area of process improvement (e.g., prevention of patient falls), systems design (e.g., designing crashcart), or identification of design flaws so robust intervention may be deployed (e.g., glucose meters). Six human factors practitioners who work within healthcare systems will present real world challenges which were discovered by HF methods, or which have heavy HF implications, but where direct HF influence on design lead to the ultimate effective solution. The session will be designed to lead to a discussion about how HF methods were adapted to individual problems at hand and to focus on developing solutions.

The Institute of Medicine lists investigations of the comparative effectiveness for minimally invasive surgical procedures as a research priority. As new minimally invasive procedures are developed, comparisons of the resulting workload contribute valuable information about the impact of the new procedures. Recent reports suggest that surgeon workload can influence patient outcomes. Measurements of stress and fatigue for the surgical team participating in a randomized NIH supported trial of single incision versus traditional laparoscopic cholecystectomy were obtained. These stress measures showed that the SURG-TLX was sensitive to the difficulty of the surgery. The SURG-TLX and a surgical difficulty score was obtained from the surgical team for 16 laparoscopic surgeries by surgical approach (8 SILC and 8 4-port) showed that for this small sample size, there were no statistically significant differences in length of surgery, degree of difficulty, nor patient considerations such as post-operative pain scores. In addition, no statistically significant differences in the individual Surg-TLX subscale scores or Surg-TLX total for the surgical team overall or for the surgeon alone by surgical platform. This is likely due to the small sample size reducing the power of the tests.