Outcomes After Repeat Transsphenoidal Surgery for Recurrent Cushing Disease: Updated

BACKGROUND Transspheniodal surgery (TSS) for Cushing disease (CD) is considered the first-line treatment; however, reported recurrence rates are high. OBJECTIVE To systemically review indications and outcomes for repeat TSS in recurrent CD. METHODS Retrospective review of patients undergoing TSS from 2008 to 2018 was performed. Patients undergoing repeat TSS for clinical and/or biochemically recurrent CD with follow-up at least 12 mo postoperatively were included. These data were analyzed in our “current cohort” and combined with our previously published data in a “combined cohort.” RESULTS The current cohort of patients undergoing operations from 2008 to 2018 with repeat surgery following a prior operation included 15 patients. Pathology at the time of first operation was positive for adrenocortiotrophic hormone (ACTH) adenoma in 13/15 (86.7%) and 9/15 (60%) had evidence of recurrence after a previous surgical procedure on preoperative magnetic resonance imaging (MRI). Remission was achieved immediately postoperatively in 13/15 (86.7%). Over an average follow-up of 34.7 mo (range: 12-116), 11/15 (68.8%) achieved persistent remission. When combined with the historical cohort that underwent an operation during 1992−2006, 44/51 (86.3%) patients had a prior operation demonstrating ACTH adenoma and 35/51 (68.6%) had evidence of recurrent disease on preoperative MRI. Thirty-five (68.6%) patients went into remission immediately postoperatively. Thirty one (60.8%) had continued remission at most recent reported follow-up. CONCLUSION Recurrent CD can be a therapeutic challenge; however, these data demonstrate that in many patients repeat surgery can be an effective and safe next step prior to radiation or medical therapy.

Science with the Murchison Widefield Array: Phase I results and Phase II opportunities

The Murchison Widefield Array (MWA) is an open access telescope dedicated to studying the low-frequency (80–300 MHz) southern sky. Since beginning operations in mid-2013, the MWA has opened a new observational window in the southern hemisphere enabling many science areas. The driving science objectives of the original design were to observe 21 cm radiation from the Epoch of Reionisation (EoR), explore the radio time domain, perform Galactic and extragalactic surveys, and monitor solar, heliospheric, and ionospheric phenomena. All together $60+$ programs recorded 20 000 h producing 146 papers to date. In 2016, the telescope underwent a major upgrade resulting in alternating compact and extended configurations. Other upgrades, including digital back-ends and a rapid-response triggering system, have been developed since the original array was commissioned. In this paper, we review the major results from the prior operation of the MWA and then discuss the new science paths enabled by the improved capabilities. We group these science opportunities by the four original science themes but also include ideas for directions outside these categories.

Research on Cost Control of Infrastructure Project with Prior Operation Function in Design Phase

Along with the acceleration of market-oriented economy, a number of large infrastructure projects are exposed with some obvious drawbacks. The main reason for the problems mentioned above is that traditional mode of construction and operation, especially in the design phase of the project only focus on investment control, however, ignoring the operational functions. Given the situation that design phase is the key stage to control the cost and functional design, this paper mainly focuses on cost control of infrastructure project with prior operation function in design phase, which is designed to achieve the best match of function and cost in order to improve project value as well as promote sustainable development of infrastructure projects from the perspective through construction investment control organizational model, and value engineering methods.

The Effect of ACGME Duty Hour Restrictions on Operative Continuity of Care

Resident work restrictions limit participation in operations that address problems created by a prior operation, because complications occur at any time. We compared resident and attending surgeon staffing of operative complications. We reviewed all complications that required a second operation reported at our Morbidity and Mortality Conference over 1 year, noting surgeons present, their postgraduate year level, and call shift. Comparisons were done using χ2. Of 142 cases, 39 involved a second operation. The same attending surgeon was present for both in 79 per cent of cases, whereas the same resident was present in only 44 per cent ( P = 0.002). Postgraduate year 4 to 5 were less likely to be present for second operations than attendings (48% vs 87%, P = 0.011). Resident shift (day, night float, and weekend) was known in 32 cases. When the first operation occurred during day hours, attendings and residents were equally likely to be present at the second (55% and 45%, P = 0.16). When original operations took place during night float or weekend shifts, residents were less likely to be present (33%) than attendings (83%) at second operations ( P = 0.036). Duty hour restrictions interfere with operative continuity of care. Reoperations should be exempted from duty hour restrictions.

Posterior subscapular approach to the brachial plexus

✓ A 15-year operative experience with 105 posterior subscapular approaches to the brachial plexus in 102 patients is presented. The procedure is indicated in carefully selected cases, especially where the proximal portions of lower spinal nerves are involved. Its main advantage is proximal exposure of the plexus spinal nerves, particularly at an intraforaminal level. The indications in this series were thoracic outlet syndrome (TOS) in 51 carefully selected procedures, brachial plexus tumor involving proximal roots in 22 patients, post-irradiation brachial plexopathy in 14 cases, and proximal traumatic brachial plexus palsy in 18 patients. Thoracic outlet syndrome associated with neurological loss, recurrent TOS after a prior operation, or proximal brachial plexus surgical lesions involving the spinal nerve(s), especially at an intraforaminal level, can be approached advantageously by such a posterior subscapular approach. The technique should also be considered when prior operation, trauma, or irradiation to the neck or anterior chest wall make a posterior exploration of the plexus easier than an anterior one. Anterior exposure of the plexus is the preferable approach for the majority of lesions needing an operation, but the posterior subscapular procedure can be useful in well-selected cases.