Low-Grade Appendiceal Mucinous Neoplasm Involving the Endometrium and Presenting with Mucinous Vaginal Discharge.

Primary appendiceal mucinous lesions are uncommon and represent a spectrum from nonneoplastic mucous retention cysts to invasive adenocarcinoma. Low-grade appendiceal mucinous neoplasms (LAMNs) represent an intermediate category on this spectrum and can be classified according to whether or not they are confined to the appendix. Although LAMNs are frequently confined to the appendix, they can also spread to the peritoneum and clinically progress as pseudomyxoma peritonei (i.e., mucinous ascites). Thus, the appropriate classification of appendiceal primary neoplasia is essential for prognosis and influences clinical management. In addition, the precise classification, management, and clinical outcome of patients with disseminated peritoneal disease remain controversial. Here, we report an unusual case of LAMN with pseudomyxoma peritonei that initially presented with mucinous and bloody vaginal discharge. Pathological evaluation revealed low-grade appendiceal mucinous neoplasm with secondary involvement of the peritoneum, ovaries, and endometrial surface. Therefore, LAMN should be considered in the differential diagnosis of mucinous vaginal discharge

Virtual reality suturing task as an objective test for robotic experience assessment

BackgroundWe performed a pilot study using a single virtual-simulation suturing module as an objective measurement to determine functional use of the robotic system. This study will assist in designing a study for an objective, adjunctive test for use by a surgical proctor.MethodsAfter IRB approval, subjects were recruited at a robotic renal surgery course to perform two attempts of the "Tubes" module without warm-up using the Da Vinci® Surgical Skills Simulator™. The overall MScore (%) from the simulator was compared among various skill levels to provide construct validity. Correlation with MScore and number of robotic cases was performed and pre-determined skill groups were tested. Nine metrics that make up the overall score were also tested via paired t test and subsequent logistic regression to determine which skills differed among experienced and novice robotic surgeons.ResultsWe enrolled 38 subjects with experience ranging from 0- < 200 robotic cases. Median time to complete both tasks was less than 10 min. The MScore on the first attempt was correlated to the number of previous robotic cases (R(2) = 0.465; p = 0.003). MScore was different between novice and more experienced robotic surgeons on the first (44.7 vs. 63.9; p = 0.005) and second attempt (56.0 vs. 69.9; p = 0.037).ConclusionA single virtual simulator exercise can provide objective information in determining proficient use of the robotic surgical system

Are self-identified "disadvantaged" students less likely to enter surgical residencies? A single-institution study.

BackgroundGiven more emphasis on training primary care physicians for underserved areas, we hypothesized that students self-identifying as "disadvantaged" would be less likely to pursue surgical training.MethodsWe retrospectively reviewed medical school data on students graduating 2005-2014. Students were stratified into "disadvantaged" and "nondisadvantaged". Data were recorded on age, grade point average, Medical College Admission Test (MCAT), gender, surgery grade, United States Medical Licensing Examination step 1 score, and residency match into a surgical field. A comparison of the proportion of students matching into a surgical field was assessed with chi-square test. Multivariate logistic regression was performed to assess the factors that predict the choice of general surgery versus another surgical field.ResultsOf the 1140 students who graduated during the study period, 219 (19.2%) students self-identified as "disadvantaged". Of all students, 158 (13.9%) chose a surgical field. The disadvantaged group was older at entry and had lower grade point average and total MCAT scores. Twenty-seven (12.3%) disadvantaged students chose a surgical residency versus 130 (14.1%) nondisadvantaged students (P = 0.56). On multivariate logistic regression, female gender (odds ratio [OR] = 3.9; 95% confidence interval = [1.9-8.3], P < 0.01), disadvantaged status (OR = 2.8 [1.1-7.1], P = 0.03), and United States Medical Licensing Examination step 1 score ≥ 227 (OR = 0.43 [0.21-0.88], P = 0.02) were significantly associated with matching into general surgery versus another surgical specialty.DiscussionAlthough the disadvantaged cohort was older and had lower undergraduate GPAs and MCAT scores, the proportion of disadvantaged students matching into a surgical residency was not statistically different. To address the future shortage of general surgeons in underserved areas, increasing enrollment of "disadvantaged" students may alleviate the "surgical desert"

High-resolution natural recording systems: intercomparisons of the response to interannual climatic variability [abstract]

The goal of this work is to examine the properties of recording mechanisms which are common to continuously recording high-resolution natural systems in which climatic signals are imprinted and preserved as proxy records. These systems produce seasonal structures as an indirect response to climatic variability over the annual cycle. We compare the proxy records from four different high-resolution systems: the Quelccaya ice cap of the Peruvian Andes; composite tree ring growth from southern California and the southwestern United States; and the marine varve sedimentation systems in the Santa Barbara basin (off California, United States) and in the Gulf of California, Mexico. An important focus of this work is to indicate how the interannual climatic signal is recorded in a variety of different natural systems with vastly different recording mechanisms and widely separated in space. These high-resolution records are the products of natural processes which should be comparable, to some degree, to human-engineered systems developed to transmit and record physical quantities. We therefore present a simple analogy of a data recording system as a heuristic model to provide some unifying concepts with which we may better understand the formation of the records. This analogy assumes special significance when we consider that natural proxy records are the principal means to extend our knowledge of climatic variability into the past, beyond the limits of instrumentally recorded data

Robustness of antiadhesion between nanofibers and surfaces covered with nanoripples of varying spatial period

Since nanofibers have a high surface-to-volume ratio, van der Waals forces render them attracted to virtually any surface. The high ratio provides significant advantages for applications in drug delivery, wound healing, tissue regeneration, and filtration. Cribellate spiders integrate thousands of nanofibers into their capture threads as an adhesive to immobilize their prey. These spiders have antiadhesive nanoripples on the calamistrum, a comb-like structure on their hindmost legs, and are thus an ideal model for investigating how nanofiber adhesion can be reduced. We found that these nanoripples had similar spacing in the cribellate species Uloborus plumipes, Amaurobius similis, and Menneus superciliosus, independent of phylogenetic relation and size. Ripple spacing on other body parts (i.e., cuticle, claws, and spinnerets), however, was less homogeneous. To investigate whether a specific distance between the ripples determines antiadhesion, we fabricated nanorippled foils by nanosecond UV laser processing. We varied the spatial periods of the nanoripples in the range ~ 203–613 nm. Using two different pulse numbers resulted in ripples of different heights. The antiadhesion was measured for all surfaces, showing that the effect is robust against alterations across the whole range of spatial periods tested. Motivated by these results, we fabricated irregular surface nanoripples with spacing in the range ~ 130–480 nm, which showed the same antiadhesive behavior. The tested surfaces may be useful in tools for handling nanofibers such as spoolers for single nanofibers, conveyor belts for producing endless nanofiber nonwoven, and cylindrical tools for fabricating tubular nanofiber nonwoven. Engineered fibers such as carbon nanotubes represent a further candidate application area

A Novel Tool for Predicting Major Complications After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

ABSTRACT Background. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has an emerging role in the treatment of peritoneal malignancies. The CRS-HIPEC approach has known treatment-related toxicities. This study sought to determine the predictors of major postoperative complications after CRS-HIPEC in a high-volume center. Methods. From a single-institution database, this study investigated complications experienced by patients undergoing CRS-HIPEC. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day Clavien grade 3 and greater (major) complications by logistic regression. A predictive model was created from preoperative factors using multivariate logistic regression. The model was tested by Akaike's information criterion, the Hosmer and Lemeshow Goodness-of-Fit Test, the receiver operating characteristic, and the Youden Index. Results. The study evaluated 247 patients undergoing CRS-HIPEC. The primary tumor site was the appendix in 166 cases (67.2 %), the colorectal area in 51 cases (20.6 %), the peritoneum (mesothelioma) in 22 cases (8.9 %), the ovary in 5 cases (2 %), and the small bowel in 3 cases Patients with peritoneal metastases have historically been considered as having incurable disease. In select patients, the peritoneum may represent the sole site of metastatic disease, prompting the use of cytoreductive surgery (CRS) and regional chemotherapy in the form of hyperthermic intraperitoneal chemotherapy (HIPEC). Mounting evidence points to the efficacy of CRS-HIPEC in the treatment of select patients with peritoneal metastases from cancers of the appendix, 1-3 colon and rectum, 4-6 small bowel, 7,8 ovary, 9 and peritoneum (mesothelioma). 10,11 Whereas the magnitude of the benefit from CRS-HIPEC for peritoneal metastases is being better defined, treatmentrelated toxicities are well-known. Large series in the modern era have found a major morbidity rate of 24-34 % and a mortality rate of 2-4 % after CRS-HIPEC