Intrahepatic cholangiocarcinoma: current management and emerging therapies.

Intrahepatic cholangiocarcinoma (iCCA) is a malignancy with an increasing incidence and a high-case fatality. While surgery offers the best hope at long-term survival, only one-third of tumors are amenable to surgical resection at the time of the diagnosis. Unfortunately, conventional chemotherapy offers limited survival benefit in the management of unresectable or metastatic disease.

Regular Formal Evaluation Sessions are Effective as Frame-of-Reference Training for Faculty Evaluators of Clerkship Medical Students.

Background: Face-to-face formal evaluation sessions between clerkship directors and faculty can facilitate the collection of trainee performance data and provide frame-of-reference training for faculty.

Objective: We hypothesized that ambulatory faculty who attended evaluation sessions at least once in an academic year (attendees) would use the Reporter-Interpreter-Manager/Educator (RIME) terminology more appropriately than faculty who did not attend evaluation sessions (non-attendees).

Design: Investigators conducted a retrospective cohort study using the narrative assessments of ambulatory internal medicine clerkship students during the 2008-2009 academic year.

Clinical relevance of mold culture positivity with and without recurrent wound necrosis following combat-related injuries.

Background: Invasive fungal wound infections (IFIs) are a recognized threat for personnel who sustain combat-related blast trauma in Afghanistan. Blast trauma, particularly when dismounted, has wounds contaminated with organic debris and potential for mold infection. Trauma-associated IFI is characterized by recurrent wound necrosis on serial debridement with histologic evidence of invasive molds and/or fungal culture growth.

Effect of early screening for invasive fungal infections in U.S. service members with explosive blast injuries.

Background: An outbreak of invasive fungal infections (IFI) began in 2009 among United States servicemen who sustained blast injuries in Afghanistan. In response, the military trauma community sought a uniform approach to early diagnosis and treatment. Toward this goal, a local clinical practice guideline (CPG) was implemented at Landstuhl Regional Medical Center (LRMC) in early 2011 to screen for IFI in high-risk patients using tissue histopathology and fungal cultures.

Risk factors associated with invasive fungal infections in combat trauma.

Background: In recent years, invasive fungal infections (IFI) have complicated the clinical course of patients with combat-related injuries. Commonalities in injury patterns and characteristics among patients with IFI led to the development of a Joint Trauma System (JTS) clinical practice guideline (CPG) for IFI management. We performed a case-control study to confirm and further delineate risk factors associated with IFI development in combat casualties with the objective of generating data to refine the CPG and promote timelier initiation of treatment.

Prospective evaluation of the clinical utility of 18-fluorodeoxyglucose PET CT scanning in patients with von hippel-lindau-associated pancreatic lesions.

Background: The natural history of pancreatic neuroendocrine neoplasms (PNENs) in patients with Von Hippel-Lindau (VHL) disease is poorly defined. Management of patients with PNENs is challenging because there are no reliable preoperative criteria to detect malignant lesions, and the majority of resected tumors are found to be benign. The aim of this study was to determine whether 18-fluorodeoxyglucose-positron emission tomography ((18)FDG-PET) uptake predicts growth and detects malignant VHL-associated PNENs.

Patient specific tumor growth prediction using multimodal images.

Personalized tumor growth model is valuable in tumor staging and therapy planning. In this paper, we present a patient specific tumor growth model based on longitudinal multimodal imaging data including dual-phase CT and FDG-PET. The proposed Reaction-Advection-Diffusion model is capable of integrating cancerous cell proliferation, infiltration, metabolic rate and extracellular matrix biomechanical response.

Multimodal image driven patient specific tumor growth modeling.

Personalized tumor growth model using clinical imaging data is valuable in tumor staging and therapy planning. In this paper, we build a patient specific tumor growth model based on longitudinal dual phase CT and FDG-PET. We propose a reaction-advection-diffusion model integrating cancerous cell proliferation, infiltration, metabolic rate and extracellular matrix biomechanical response.

Assessment of tumor growth in pancreatic neuroendocrine tumors in von Hippel Lindau syndrome.

Background: The incidence of pancreatic neuroendocrine tumors (PNETs) is increasing, but only a subset of these heterogeneous tumors will progress to malignant disease, which is associated with a poor prognosis. Currently, there are limited data on the natural history of these tumors and it is difficult to determine which patients require surgical intervention because the risk of metastatic disease cannot be accurately determined.

Study Design: We conducted a prospective study of 87 patients with von Hippel Lindau syndrome-associated solid pancreatic lesions to determine the natural history of these tumors with biochemical testing, follow-up anatomic and functional imaging, and advanced imaging analysis, with a median follow-up of 4 years.

Utility of intraoperative parathyroid hormone monitoring in patients with multiple endocrine neoplasia type 1-associated primary hyperparathyroidism undergoing initial parathyroidectomy.

Background: Intraoperative parathyroid hormone monitoring (IOPTH) is a widely used adjunct for primary hyperparathyroidism (pHPT). However, the benefit of IOPTH in familial pHPT, such as in multiple endocrine neoplasia type I (MEN1), remains unclear.

Methods: We performed a retrospective analysis of 52 patients with MEN1-associated pHPT undergoing initial parathyroidectomy with IOPTH monitoring at our institution.

Altered PTEN, ATRX, CHGA, CHGB, and TP53 expression are associated with aggressive VHL-associated pancreatic neuroendocrine tumors.

Von Hippel-Lindau (VHL) syndrome is an inherited cancer syndrome in which 8-17 % of germline mutation carriers develop pancreatic neuroendocrine tumors (PNETs). There is limited data on prognostic markers for PNETs other than Ki-67, which is included in the World Health Organization classification system. Recently, specific genes and pathways have been identified by whole exome sequencing which may be involved in the tumorigenesis of PNETs and may be markers of disease aggressiveness.

Long-term outcomes of combat casualties sustaining penetrating traumatic brain injury.

Background: Previous studies have documented short-term functional outcomes for patients sustaining penetrating brain injuries (PBIs). However, little is known regarding the long-term functional outcome in this patient population. Therefore, we sought to describe the long-term functional outcomes of combat casualties sustaining PBI.

Association of type-O blood with neuroendocrine tumors in multiple endocrine neoplasia type 1.

Context: The ABO blood type system describes the expression of human blood group antigens found on both erythrocytes and normal tissue throughout the body. We recently reported an association between O blood type and the manifestation of pancreatic neuroendocrine tumors in a cohort of patients with Von Hippel-Lindau syndrome.

Objective: The aim of the study was to determine whether there is an association of ABO blood type with the development of neuroendocrine tumors in patients with multiple endocrine neoplasia, type 1 (MEN-1).

Adrenal histologic findings show no difference in clinical presentation and outcome in primary hyperaldosteronism.

Background: Primary hyperaldosteronism is most commonly due to a solitary cortical adenoma. Thus, some surgeons have suggested a subtotal adrenalectomy is a reasonable approach when a mass can be identified. On the other hand, adrenal vein sampling (AVS) is being used more frequently to distinguish patients with unilateral disease for adrenalectomy, even if a discrete mass is not identified on axial imaging.

Association of type O blood with pancreatic neuroendocrine tumors in Von Hippel-Lindau syndrome.

Background: ABO blood type antigens are expressed not only on human red blood cells, but also throughout the gastrointestinal tract and in normal pancreatic tissue. Previous studies have identified an association between ABO blood type and various malignancies. We analyzed the association of ABO blood type with pancreatic neuroendocrine tumors (PNETs) in a high-risk cohort of patients with Von Hippel-Lindau (VHL) syndrome.

Clinical utility of functional imaging with ¹⁸F-FDOPA in Von Hippel-Lindau syndrome.

Context: Von Hippel-Lindau (VHL) syndrome is an inherited cancer syndrome in which patients are at risk of developing multiple tumors in different organs. 6-L-¹⁸F-fluorodihydroxyphenylalanine (¹⁸F-FDOPA) positron emission tomography (PET) is a relatively new metabolic imaging tracer proposed for the use of localizing sites of neuroendocrine tumors. There are limited data on the clinical utility of using ¹⁸F-FDOPA PET for identifying neuroendocrine tumors in a high-risk population such as VHL.

Emergent management of postpartum hemorrhage for the general and acute care surgeon.

Background: Postpartum hemorrhage is one of the rare occasions when a general or acute care surgeon may be emergently called to labor and delivery, a situation in which time is limited and the stakes high. Unfortunately, there is generally a paucity of exposure and information available to surgeons regarding this topic: obstetric training is rarely found in contemporary surgical residency curricula and is omitted nearly completely from general and acute care surgery literature and continuing medical education.

Methods: The purpose of this manuscript is to serve as a topic specific review for surgeons and to present a surgeon oriented management algorithm.