Recent Publications by CFE Educators

Without haptic feedback, robotic surgeons rely on visual processing to interpret the operative field. To provide guidance for teaching in this environment, we analyzed intracorporeal actions and behaviors of a robotic surgeon. Six hours of video were captured by the intracorporeal camera during a robot-assisted lower anterior resection. After complete review, authors reduced the video to a consecutive 35 min of highly focused robotic activity and finally, a 2-min clip was subjected to microanalysis. The clip was replayed multiple times (capturing 1, 2, 10, 60 and 120 s intervals) and activities were identified, such as right and left hand motion, tissue handling and camera adjustments recorded using a software program. Activity patterns were categorized into two main themes: change in operative focus occurs when there is an inability to obtain adequate tension, and observation of robot-assisted surgery is based on an incomplete visual framework. The surgeon manipulated tissue predominantly using blunt adjustments and rarely grasped it, likely as a way to avoid tissue trauma. A magnified operative field required precise dissection, which occurs robotically with movement of a single instrument against a static field (motionless second robotic arm). This meticulous technique is unlike the bimodal manipulation often used for laparoscopic dissection. Since residents have limited active participation in robotic cases, and therefore, rely heavily on the captured image for skill acquisition, we recommend surgeons to use focus shifts as an opportunity to describe their operative decision-making and highlight instrument manipulations specific to operating with robotic technology.

BACKGROUND

In the 1980s, a small research group began identifying variables affecting applicant success on the American Board of Surgery (ABS) Certifying Examination (CE). We now report success and trends as we complete 25 years. We had multiple challenges as identified through faculty focus groups and participant feedback that needed to be addressed: increase the national optics of the program, integrate new innovative experiences, maintain the integrity of the collected data on excel files, incorporate national trends in surgery, attract experienced clinical volunteer faculty and staff, security of capital, and schedule management.

METHOD

The primary purpose of the program is to define the root cause interfering with success on the ABS CE. All of the listed changes in course design (2012-2016) were entered into excel files along with participants demographics, including results of the pretesting modules, the communication inventory, all self-reported stressors, and interview results to track the effect of faculty interventions, trends and ABS outcomes.

RESULTS

The profiles of the participants have changed over time, including: marital status, presence of DSM-5 stressors, gender, fellowship training, study habits, financial burdens, and international graduate status. International graduates demonstrated communication issues that were present, though rarely addressed, during residency training. The gradual absorption of junior faculty allowed a seamless transition over time as part of the succession plan. Although the national success rates on the CE were 72% to 80%, this program's success rate still remained in the 90 percentile (94%-97%) for those who followed their education improvement plan. Deidentified excel files will be converted to REDCap for preservation and analysis.

DISCUSSION

The small course design has continued to be effective at identifying variables that interfere with success on the CE examination. The inclusion of additional PhD education scientists facilitated focused individual interventions. A pilot program for international graduate status residents is in development.

PURPOSE

To demonstrate feasibility of endothelial cell (EC) biopsy from dialysis arteriovenous fistulas (AVFs) with the use of guidewires and to characterize gene expression differences between ECs from stenotic and nonstenotic outflow vein segments.

MATERIALS AND METHODS

Nine consecutive patients undergoing fistulography for AVF dysfunction from June to August 2016 were enrolled. ECs were biopsied with the use of guidewires from venous outflow stenoses and control outflow veins central to the stenoses. ECs were sorted with the use of flow cytometry, and the Fluidigm Biomark HD system was used for single-cell quantitative polymerase chain reaction (qPCR) analysis of gene expression. Forty-eight genes were assessed and were selected based on different cellular functions and previous literature. Linear mixed models (LMMs) were used to identify differential gene expression between the groups, and self-organizing maps (SOMs) were used to identify cell clusters based on gene coexpression profiles.

RESULTS

A total of 219 and 213 ECs were sampled from venous outflow stenoses and control vein segments, respectively. There were no immediate biopsy-related complications. Forty-eight cells per patient were sorted for qPCR analysis. LMM identified 7 genes with different levels of expression at stenotic segments (P .05), including AGTR-2, HMOX-2, MTHFR, SERPINC-1, SERPINE-1, SMAD-4, and VWF. SOM analysis identified 4 cell clusters with unique gene expression profiles, each containing stenotic and control ECs.

CONCLUSIONS

EC biopsy from dialysis AVFs with the use of guidewires is feasible. Gene expression data suggest that genes involved in multiple cellular functions are dysregulated in stenotic areas. SOMs identified 4 unique clusters of cells, indicating EC phenotypic heterogeneity in outflow veins.

Yafi et al. have conducted a study that will be of great interest to the lay community and also of import to practicing urologists who routinely encounter patients with concerns about the appearance of their phallus [1]. In one study 14% of men expressed dissatisfaction with their genitals with flaccid penile length being the most common source of dissatisfaction [2]. The concerns of such men tend to be the perception that their penis is small, or at least smaller than the penises of other men.

OBJECTIVES

Ulcerative laryngitis (UL) is challenging in terms of treatment and patient counseling, with few reports in the literature. This study describes UL patients and their clinical course including detailed voice and stroboscopic outcomes after treatment which have not been described in previous literature.

METHODS

Single-institution, retrospective review of 23 UL patients. Demographics, historical factors, disease course, treatment, and outcomes are presented. Treatment results were compared to prior studies.

RESULTS

Seventy four percent had inflammatory/infectious precipitating event. Average presenting Voice-Handicap-Index-10 (VHI-10) was 25 (range: 6-38) and average final VHI-10 was 9 (range: 0-26). Ninty five percent had improvement in VHI-10 (average decrease of 15). Only 50% had final VHI-10 within "normal" limits. Treatment comprised reflux medications (85%), antibiotics (22%), antifungals (39%), antivirals (52%) steroids (52%), and/or voice rest (65%). Average symptom duration before evaluation was 42 days; average follow-up was 6.8 months. Final laryngovideostroboscopy revealed no ulcers in 78%, but 65% had persistently decreased mucosal wave vibration. Average time to ulcer resolution was 2.25 months but resolution or plateau of voice symptoms occurred later, average 2.7 months. Multiple regression analyses revealed that younger age, shorter symptom duration, and antireflux treatment were significant predictors of decrease in VHI-10 (P 0.05).

CONCLUSIONS

Most patients have good voice outcomes following resolution of UL, although vocal fold mucosal wave abnormalities may persist. This study provides the most detailed report of UL, disease course and treatment outcomes to date. Additionally, this study is also the first to suggest that earlier initiation of treatment may improve voice outcome after UL.

The adoption of enterprise digital imaging, along with the development of quantitative imaging methods and the re-emergence of statistical learning, has opened the opportunity for more personalized cancer treatments through transformative data science research. In the last 5 years, accumulating evidence has indicated that noninvasive advanced imaging analytics (i.e., radiomics) can reveal key components of tumor phenotype for multiple lesions at multiple time points over the course of treatment. Many groups using homegrown software have extracted engineered and deep quantitative features on 3-dimensional medical images for better spatial and longitudinal understanding of tumor biology and for the prediction of diverse outcomes. These developments could augment patient stratification and prognostication, buttressing emerging targeted therapeutic approaches. Unfortunately, the rapid growth in popularity of this immature scientific discipline has resulted in many early publications that miss key information or use underpowered patient data sets, without production of generalizable results. Quantitative imaging research is complex, and key principles should be followed to realize its full potential. The fields of quantitative imaging and radiomics in particular require a renewed focus on optimal study design and reporting practices, standardization, interpretability, data sharing, and clinical trials. Standardization of image acquisition, feature calculation, and statistical analysis (i.e., machine learning) are required for the field to move forward. A new data-sharing paradigm enacted among open and diverse participants (medical institutions, vendors and associations) should be embraced for faster development and comprehensive clinical validation of imaging biomarkers. In this review and critique of the field, we propose working principles and fundamental changes to the current scientific approach, with the goal of high-impact research and development of actionable prediction models that will yield more meaningful applications of precision cancer medicine.