Kristin L. Long

T-cell suppression by red blood cells is dependent on intact cells and is a consequence of blood bank processing.

Red blood cells (RBCs) suppress T‐cell responsiveness through a mechanism requiring cell–cell contact. Questions remain as to whether this effect is an allogeneic response, related to cell death, or dependent on particular components of the RBCs.

In vitro transfusion of red blood cells results in decreased cytokine production by human T cells.

BACKGROUND Transfusion-related immunomodulation consists of both proinflammatory and anti-inflammatory responses after transfusion of blood products. Stored red blood cells (RBCs) suppress human T-cell proliferation in vitro, but the mechanism remains unknown. We hypothesized that cytokine synthesis by T cells may be inhibited when stored RBCs are present and that suppression between fresh and stored RBCs would be different. METHODS Purified human T cells were stimulated to proliferate with anti-CD3/anti-CD28 and then exposed to stored or fresh RBCs. Cells were placed in culture for 5 days. Cell culture supernatants were analyzed for the production of typical T-cell cytokines using multianalyte ELISArray kits. RESULTS Stimulated T cells proliferated. RBC exposure markedly suppressed this proliferation. Interleukin 10, interleukin 17a, interferon &ggr;, tumor necrosis factor &agr;, and granulocyte macrophage colony-stimulating factor were increased in response to stimulation but depressed in the presence of stored RBCs. The use of fresh RBCs also resulted in depression of these cytokines when compared with stimulated T cells with no RBCs; however, this depression was less pronounced. CONCLUSION T-cell activation is associated with both proinflammatory and anti-inflammatory cytokine release, comparable with patterns seen in trauma and acute injury. All of these responses are depressed by an exposure to stored RBCs. Decreased levels of these cytokines after RBC transfusion represents a potential contributor to the immunosuppressive complications seen in trauma patients after transfusion. This provides insight for future mechanistic studies to delineate the role of RBC transfusion in transfusion-related immunomodulation.

Chondromyxoid fibroma of the second rib

Chondromyxoid fibromas are benign tumors which are found most frequently in the metaphyses of long bones. They comprise less than 1% of primary bone neoplasms and display a hypermetabolic appearance on PET imaging. Oftentimes, they are misdiagnosed as chondrosarcomas and are excised due to concern for malignancy. We present a case of a condromyxoid fibroma originating from the second rib of a 15-year-old girl.

Epithelioid hemangioendothelioma encasing the left brachiocephalic vein

Epithelioid hemangioendotheliomas are rare vascular tumors, often arising from medium to large veins in the extremities. Symptoms of these tumors vary depending upon location. Rarely, tumors may arise in chest and involve large vessels in the mediastinum. We present a case of a 17-year-old male presenting with compressive symptoms of the left upper extremity who was found to have a large epithelioid hemangioendothelioma encasing the left brachiocephalic vein.

Back so soon? Is early recurrence of papillary thyroid cancer really just persistent disease?

Background. Papillary thyroid carcinoma has excellent survival, yet recurrence remains a challenge. We sought to determine the proportion of reoperations performed for persistent, rather than truly recurrent, disease. Methods. We conducted a retrospective review of a prospectively maintained database. Patients with papillary thyroid carcinoma who underwent reoperation for disease from 2000–2016 were included. We defined recurrence as disease that developed after a patient had an undetectable thyroglobulin and a negative ultrasonography within 1 year of operation. Results. A total of 69 patients underwent 92 reoperations. On initial pathology, mean tumor size was 2.6 cm, 51% were multifocal, and 42% had extrathyroidal extension. Half (46%) of the patients underwent a central/lateral neck dissection at the initial operation, and 77% were treated with postoperative radioactive iodine. The median time to first reoperation was 21 months (range, 1–292), and 42% occurred within 1 year. Only 3 operations met criteria for true “recurrence,” while 71 operations were categorized as persistent disease. Conclusion. Many reoperations for papillary thyroid carcinoma are for management of persistent disease. More than half of the patients required reoperation within the first 2 years, which suggests strongly that improvements in the preoperative assessment and adequacy of initial operative therapy need to be made to improve the care of patients with thyroid cancer.

Cystic multiglandular maternal hyperparathyroidism diagnosed by neonatal hypocalcemic seizures.

A 7-day-old male infant born to a healthy 33-year-old female at 37 weeks of gestation was brought to the local emergency department (ED) with sudden-onset tonic–clonic seizures. Laboratory testing revealed extreme hypocalcemia (ionized calcium of 3.2 mg/dl) and undetectable parathyroid hormone (PTH <10 pg/ml). Concomitant evaluation of the mother revealed both elevated ionized calcium (5.9 mg/dl) and PTH (116 pg/ml). The mother underwent preoperative ultrasound localization and sestamibi scan, followed promptly by parathyroidectomy. Given the cystic appearance and presence of multiglandular disease, evaluation for familial cystic parathyroid adenomatosis (hyperparathyroidism-jaw bone-tumor syndrome) and MEN 1 were undertaken. The infant was stabilized and discharged home. He returned to the ED with seizures at 1 month of age. After increasing calcium supplementation appropriately, he was monitored with weekly office visits. This represents a unique case of undiagnosed maternal primary hyperparathyroidism manifesting with intrauterine parathyroid suppression and hypocalcemic seizures in the newborn.

Improving surgical outreach in Palestine: assessing goals of local and visiting surgeons

BACKGROUND Short-term surgical outreach is often criticized for lack of sustainability and partnership with local collaborators. As global surgical capability increases, there is increased focus on educating local providers. We sought to assess and compare the educational goals of local surgeons in the Palestinian territories with goals of visiting volunteer providers. METHODS Electronic surveys were sent to Palestinian surgeons and compared with evaluation data collected from Palestine Childrens Relief Fund volunteer providers. RESULTS The response rate was 52% from Palestinian surgeons and 100% from volunteer providers, giving a combined response rate of 83%. Ninety-two percent of Palestinian surgeons desired protected time during each mission trip for formal didactic teaching and 92% learn new techniques best by performing skills on patients with expert surgeons observing and providing feedback. Most respondents requested the addition of case reviews or debriefing sessions after completion of surgical cases. Volunteer providers indicate that 86% of prior mission trips involved training of local surgeons and 100% plan to volunteer with the organization again in the future. CONCLUSIONS Surgical education is a vital component of any successful outreach program. Adult learning theory emphasizes the necessity of understanding the specific educational needs of participants to foster the most successful learning environment. This survey highlights the value of tailoring surgical specialty outreach to the explicit needs of local providers and patient populations, while also clearly demonstrating the importance of collaboration, feedback, and protected educational didactics as a critical focus of future surgical humanitarian endeavors.

Operative Treatment of Recurrent or Metastatic Disease

Well-differentiated thyroid cancer may recur in approximately 30% of patients. Recurrences may involve vital structures, such as the recurrent laryngeal nerve, trachea, and esophagus, or they may present as distant metastatic disease. Careful multidisciplinary evaluation is necessary to determine appropriate treatment of recurrent disease. Surgical treatment is often necessary, but timing and extent of operation should be thoroughly discussed among members of a treatment team.

Doing More with Less: Performance Improvement in Humanitarian Endocrine Surgery

Appreciating the luxury of our modern operating rooms and arsenal of surgical instruments never seemed easier than when forced to operate in a very low-resource setting. As we have both experienced during short-term humanitarian surgical mission trips to Africa, performing specialized endocrine surgical procedures in resource-limited settings can make technically difficult cases seem all the more challenging. The article by O Donohoe et al. highlights a collection of key points regarding endocrine surgery in Sub-Saharan Africa [1]. First and foremost, continued development of the surgical workforce in Sub-Saharan Africa is of paramount importance. Local surgeons are often required to perform procedures that are frequently funneled to fellowshiptrained subspecialists in developed countries. Mission surgical specialists can provide invaluable onsite, personalized, one-on-one committed teaching and consultation to these surgeons. The experienced, sage surgeon comfortable with complex endocrine procedures is poised to do this and could increase the chances of excellent outcomes—a necessity with limited care [2]. Improved training of local non-specialist African surgeons is undoubtedly one of the most effective methods to establish sustainability and reliable endocrine surgical care in areas such as these. For decades, humanitarian surgical efforts have often focused on short-term surgical excursions, where teams of specialists and equipment fly in, operate around the clock, and fly out like a whirlwind. While compassion and care was clearly extended to the local patient population during the short visit, minimal emphasis was placed on long-term results and little or no patient follow-up occurred. Today, increasing emphasis is placed on patient outcomes, and humanitarian surgery is no different. Papers from McClenaghan and colleagues and Grimes et al., strongly support tracking outcomes and improving patient follow-up for surgical interventions in low-resource settings [3, 4]. Finally, tracking outcomes in a prospective manner for thyroid resections performed in resource-poor settings allows surgeons to better delineate local guidelines and standards of care as well as identifying specific areas for performance and quality improvement. In short, ‘‘A prospective analysis of thyroidectomy outcomes in a resource-limited setting’’ serves as an important example of the beginnings of quality and outcomes research in areas of the world crippled by endemic disease with significant disparities in available surgical care. This paper can easily serve as an inspiration and valuable reference for endocrine surgeons interested in effective and sustainable humanitarian surgical efforts.

When Operating on Dead People Saves Lives: Benefits of Surgical Organ Donor Intensivists.

Solid organ transplantation has emerged as a life-saving treatment for many patients suffering from end-stage organ failure. Organs have been successfully recovered after a variety of aggressive interventions. We propose that decompressive laparotomy, when clinically indicated, should be considered in the aggressive resuscitation of potential organ donors. A thorough literature review examining aggressive interventions on potential organ donors was conducted after experience with a unique case at this institution. Articles were reviewed for the types of interventions performed as well as the time frame in relation to organ donation. In our case, several ethical issues were raised when considering decompressive laparotomy in a patient pronounced dead by neurologic criteria. We propose that having a surgical intensivist involved in the management of potential donors will further increase the salvage rate, as more invasive resuscitation options are possible.