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Despite the importance of simulation-based training for robotic surgery, there is no consensus about its training curricula. Recently, a virtual reality (VR) platform (SimNow, Intuitive, Inc) was introduced with 33 VR drills but without evidence of their validity. As part of our creating a new robotic VR curriculum, we assessed the drills' validity through content mapping and the alignment between learning goals and drill content.Three robotically trained surgeons content-mapped all 33 drills for how well the drills incorporated 15 surgery skills and also rated the drills' difficulty, usefulness, relevance, and uniqueness. Drills were added to the new curriculum based on consensus about ratings and historic learner data. The drills were grouped according to similar skill sets and arranged in order of complexity.The 33 drills were judged to have 12/15 surgery skills as primary goals and 13/15 as secondary goals. Twenty of the 33 drills were selected for inclusion in the new curriculum; these had 11/15 skills as primary goals and 11/15 as secondary goals. However, skills regarding energy sources, atraumatic handling, blunt dissection, fine dissection, and running suturing were poorly represented in the drills. Three previously validated inanimate drills were added to the curriculum to address lacking skill domains.We identified 20 of the 33 SimNow drills as a foundation for a robotic surgery curriculum based on content-oriented evidence. We added 3 other drills to address identified gaps in drill content.

Previous studies have reported healthcare disparities in the Texas-Mexico border population. Our aim was to evaluate treatment utilization and oncologic outcomes of colon cancer patients in this vulnerable population.Patients with localized and regional colon cancer (CC) were identified in the Texas Cancer Registry (1995-2016). Clinicopathological data, hospital factors, receipt of optimal treatment, and overall survival (OS) were compared between Texas-Mexico Border (TMB) and the Non-Texas-Mexico Border (NTMB) cohorts. Multivariable analysis was performed to identify risk factors associated with decreased survival.We identified 43,557 patients with localized/regional CC (9% TMB and 91% NTMB). TMB patients were more likely to be Hispanic (73% versus 13%), less likely to have private insurance (13% versus 21%), were more often treated at safety net hospitals (82% versus 22%) and less likely at ACS-CoC accredited hospitals (32% versus 57%). TMB patients were more likely to receive suboptimal treatment (21% versus 16%) and had a lower median OS for localized (8.58 versus 9.58 y) and regional colon cancer (5.75 versus 6.18 y, all P0.001). In multivariable analysis, TMB status was not associated with worse OS. Factors associated with worse survival included receipt of suboptimal treatment, Medicare/insured status, and treatment in safety net and non-accredited ACS-CoC hospitals (all P0.001) CONCLUSIONS: While TMB CC patients had worse OS, TMB status itself was not found to be a risk factor for decreased survival. This survival disparity is likely associated with higher rate of suboptimal treatment, Medicare/Uninsured status, and decreased access to ACS-CoC accredited hospitals.

We report long-term outcomes from our phase 1 dose-escalation study to determine the maximum tolerated dose of single-fraction liver SABR pooled with our subsequent single institutional experience with patients treated postprotocol at the highest dose level (40 Gy) established from the phase 1 study.Patients with liver metastases from solid tumors located outside of the central liver zone were treated with single-fraction SABR on a phase 1 dose escalation trial. At least 700 cc of normal liver had to receive9.1 Gy. Seven patients with 10 liver metastases received the initial prescription dose of 35 Gy, and dose was then escalated to 40 Gy for 7 more patients with 7 liver metastases. An additional 19 postprotocol patients with 22 liver metastases were treated to 40 Gy in a single fraction. Patients were followed for toxicity and underwent serial imaging to assess local control.Median imaging follow-up for the combined cohort (n = 33, 39 lesions) was 25.9 months; 38.9 months for protocol patients and 20.2 months for postprotocol patients. Median lesion size was 2.0 cm (range, 0.5-5.0 cm). There were no dose-limiting toxicities observed for protocol patients, and only 3 grade 2 toxicities were observed in the entire cohort, with no grade ≥3 toxicities attributable to treatment. Four-year actuarial local control of irradiated lesions in the entire cohort was 96.6%, 100% in the protocol group and 92.9% in the subsequent patients. Two-year overall survival for all treated patients was 82.0%.For selected patients with liver metastases, single-fraction SABR at doses of 35 and 40 Gy was safe and well-tolerated, and shows excellent local control with long-term follow-up; results in subsequent patients treated with single-fraction SABR doses of 40 Gy confirmed our earlier results.

Pringle maneuver (PM) is used for inflow vascular control during hepatectomy, but its use remains controversial. We aimed to report its pattern of use and association with postoperative outcomes.We identified hepatectomy patients using the liver-targeted National Surgical Quality Improvement Program database (2014-2016). Associations between PM and posthepatectomy liver failure (PHLF), receipt of blood transfusion, and total hospital length of stay (LOS) were evaluated.We identified 7870 patients (74.9%) with no Pringle maneuver and 2632 (25.1%) with PM. PM patients were older (median age 61 versus 60 y, P = 0.002) and had higher ASA scores (76.1% versus 71.4% were ASA 3-4, P 0.001). PM had more malignancy (83.0% versus 73.0%, P 0.001), neoadjuvant therapy (37.7% versus 28.8%, P 0.001), total lobectomy (30.6% versus 23.2%, P 0.001), open resection (90.8% versus 74.9%, P 0.001), and longer operations (246 min versus 212 min, P 0.001). PM was associated with longer LOS (0.36 d, 95% confidence interval [CI] 0.11-0.60) and increased risk of PHLF (odds ratio [OR] 1.36, 95% CI 1.11-1.66), although not clinically significant grade B/C PHLF (OR 0.82, 95% CI 0.57-1.19), but was not associated with receipt of perioperative blood transfusions (OR 1.00, 95% CI 0.69-1.64).PM is associated with similar clinically significant PHLF and transfusion requirements but longer LOS compared with no Pringle maneuver.

Predictive models for nonhome discharge (NHD) have been proposed in major surgical specialties. The rates and risk factors associated with NHD and prolonged length of stay (PLOS) after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) have not been evaluated. The aim of this study is to identify risk factors for NHD and PLOS after CRS/HIPEC in a national cohort of patients.CRS/HIPEC cases were identified from the National Surgical Quality Improvement Program 2011-2012 data set. Patients with an NHD or PLOS (30 d) were compared with a group of patients discharged to home within 30 d. Univariate analysis was used to compare patient characteristics, operative variables, and postoperative complications among both groups. Multivariate regression analysis was used to identify independent predictors of NHD and PLOS.Five hundred fifty-six patients undergoing CRS/HIPEC were identified, of which 44 (7.9%) were not discharged to home within 30 d. The rate of NHD and PLOS in this cohort was 4.1% and 3.7%, respectively. Multivariate analysis identified age ≥65 y, pre-op albumin3.0 g/dL, and having a multivisceral resection as independent predictors of NHD/PLOS. If all three predictors are met preoperatively, the probability of NHD/PLOS was calculated to be 30.2%.The main risk factors for NHD/PLOS after CRS/HIPEC were advanced age, hypoalbuminemia, and multivisceral resection. Adequate identification of these risk factors may facilitate preoperative discussion with patients, and improve discharge planning and resource utilization.

Coleoids are the most diverse group of cephalopod mollusks. While their origin is date during the Mesozoic, the diversification pattern is unknown. However, two hypotheses have been proposed. The first suggests an increasing diversification rate after the Cretaceous–Paleogene extinction event (K–Pg) as consequence of empty habitats left by the ammonites and belemnites. The second hypothesis proposes a mid-Cenozoic increase in diversification rate related to distributional changes during ice ages and biotic interactions. To test these hypotheses, we estimated a lineage through time (LTT) and the gamma-statistic along with model-based diversification rates. These analyses were conducted on a dated molecular phylogeny for coleoids that we reconstructed using five molecular markers (cytochrome b, 16S rRNA, cytochrome oxidase I, rhodopsin, and PAX-6). Our divergence time estimation suggests that coleoids originated in the Mesozoic Era (Middle Triassic) and that both main clades (Decapodiformes and Octopodiformes) diverged in the Cretaceous/Jurassic Period. The LTT, gamma statistic, and diversification rates inferred with the Bayesian Analysis of Macro-evolutionary Mixtures (BAMM), indicate an acceleration in diversification rate over time since the origin of coleoids. Additionally, BAMM allowed us to detect abrupt increases in diversification rate before and after the K-Pg boundary. Our results partially support both hypotheses as all analyses indicate that the coleoid diversification rate was increasing during the Cenozoic. However, our results also indicate increasing diversification rates before the K-Pg boundary. We propose that the radiation of coleoids has been shaped by an acceleration in diversification rate over time, including exceptional episodes of abrupt increases before and after the K-Pg boundary.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) can significantly improve the survival in selected patients with peritoneal carcinomatosis. This study aims to identify perioperative patient characteristics predictive of failure to rescue (FTR), mortality following postoperative complications from CRS/HIPEC.Patients suffering a complication following CRS/HIPEC between 2005 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program data set. FTR was defined as 30-d mortality in the setting of a complication. Patients who suffered FTR were compared against those who survived a complication (non-FTR). Predictors of FTR were identified using a multivariable logistic regression model.A total of 915 eligible CRS/HIPEC cases were identified. In all, 382 patients (42%) developed ≥1 postoperative complication, and 88 patients (10%) suffered ≥1 major complication. Seventeen patients died following a complication, amounting to an FTR rate of 4%. FTR patients were more likely than non-FTR patients to have dependent functional status (18% versus 2%, P = 0.01), have American Society of Anesthesiologists (ASA) class 4 status (29% versus 8%, P = 0.01), develop ≥3 complications (65% versus 24%, P 0.01), and suffer a major complication (94% versus 20%, P 0.01). The following were independently associated with FTR: ASA class 4 (odds ratio [OR]: 13.4, 95% confidence interval [CI], 1.2-146.8) and major complications (OR: 66.0, 95% CI, 8.4-516.6).ASA class 4, major morbidity, and likely dependent functional status are independent predictors of FTR following CRS/HIPEC to treat peritoneal carcinomatosis. Therefore, ASA class 4 and dependent functional status should be considered as contraindications for CRS/HIPEC and only offered in highly selective cases.

BackgroundRobotic distal pancreatectomy (RDP) is performed increasingly, but knowledge of the number of cases required to attain procedural proficiency is lacking. The aim of this study was to identify the learning curve associated with RDP at a high‐volume pancreatic centre.MethodsMetrics of perioperative safety and efficiency for all consecutive RDPs were evaluated. Outcomes were followed to 90 days. Cumulative sum (CUSUM) analysis was used to identify inflexion points corresponding to the learning curve.ResultsBetween 2008 and 2013, 100 patients underwent RDP. There was no 90‐day mortality. In two patients (2.0%), surgery was converted to laparotomy. Thirty procedures were performed for pancreatic adenocarcinoma. Precipitous operative time reductions from an initial operative time of 331 min were observed after the first 20 and 40 cases to 266 min and 210 min, respectively (P

ResumenEl objetivo de este trabajo es describir dos eventos producidos en la provincia de Buenos Aires en los cuales Neospora caninum estuvo asociado a la ocurrencia de abortos en bovinos de cría para carne. En uno de ellos se registraron 11 abortos en 57 vaquillonas durante 45 días, en este evento fue 5 veces más probable que una vaquillona que sufrió un aborto fuera seropositiva a N. caninum que una que no lo sufrió (odds ratio [OR] = 4,9 IC 1,2–19,9) (p0,05). Se analizaron dos fetos de cada evento: estos resultaron negativos a otros patógenos de la reproducción, aunque presentaron anticuerpos específicos y lesiones histopatológicas compatibles con infecciones por N. caninum. Estos resultados sugieren dos posibles modalidades de presentación de abortos en bovinos causados por N. caninum: una epidémica, como la del primer evento aquí referido, y una endémica, como la del segundo.AbstractThe aim of this study was to describe two events in which Neospora caninum was involved in bovine abortions in beef cattle. In the first event, 11 abortions in 57 heifers were recorded in 45 days. One aborted heifer was 5 times more likely to be seropositive than a non-aborted heifer (OR=4.9; IC 1.2–19.9) (p0.05). Neither antibodies nor isolation of other pathogens were achieved in any case. On the contrary, antibodies and pathognomonic histopathological lesions were observed in the four fetuses from both cases. Interestingly, the findings in the first event suggest the epidemic behavior of the disease. In contrast, in the second event it appears that few abortions were due to N. caninum, suggesting the presence of endemic neosporosis.