The evolutionary history of the goby Elacatinus puncticulatus in the tropical eastern pacific: Effects of habitat discontinuities and local environmental variability.

Habitat discontinuities, temperature gradients, upwelling systems, and ocean currents, gyres and fronts, can affect distributions of species with narrow environmental tolerance or motility and influence the dispersal of pelagic larvae, with effects ranging from the isolation of adjacent populations to connections between them. The coast of the Tropical Eastern Pacific (TEP) is a highly dynamic environment, with various large gyres and upwelling systems, alternating currents and large rocky-habitat discontinuities, which may greatly influence the genetic connectivity of populations in different parts of the coast. Elacatinus puncticulatus is a cryptic, shallow-living goby that is distributed along the continental shore of virtually the entire TEP, which makes it a good model for testing the influence of these environmental characteristics in the molecular evolution of widespread species in this region. A multilocus phylogeny was used to evaluate the influence of habitat gaps, and oceanographic processes in the evolutionary history of E. puncticulatus throughout its geographical range in the TEP. Two well-supported allopatric clades (one with two allopatric subclades) were recovered, the geographic distribution of which does not correspond to any previously proposed major biogeographic provinces. These populations show strong genetic structure and substantial genetic distances between clades and sub-clades (cytb 0.8-7.3%), with divergence times between them ranging from 0.53 to 4.88 Mya, and recent population expansions dated at 170-130 Kya. The ancestral area of all populations appears to be the Gulf of Panama, while several isolation events have formed the phylogeographic patterns evident in this species. Local and regional oceanographic processes as well as habitat discontinuities have shaped the distribution patterns of the genetic lineages along the continental TEP. Large genetic distances, high genetic differentiation, and the results of species-tree and phylogenetic analyses indicate that E. puncticulatus comprises a complex of three allopatric species with an unusual geographic arrangement.

Into the void: a review of postoperative urinary retention after minimally invasive gynecologic surgery.

PURPOSE OF REVIEW: Postoperative urinary retention (POUR) is a common occurrence after minimally invasive gynecologic surgery (MIGS). This review discusses the definition, incidence, evaluation, diagnosis, and treatment of POUR after MIGS. RECENT FINDINGS: Reported incidence of POUR after MIGS ranges from 0.5 to 21%. Active void trials or awaiting spontaneous void after surgery are both viable options for diagnosing POUR, but active void trials appear to be more accurate, quicker, and preferred by patients. The use of enhanced recovery after surgery pathways and minimizing postoperative opioids can help reduce POUR. SUMMARY: It is important to evaluate postoperative patients for POUR after MIGS. Standard guidelines are lacking for the evaluation and treatment of patients with POUR.

Vascular training in Scotland and Northern Ireland: The trainee perspective prior to introduction of the new vascular curriculum.

BACKGROUND: The last decade has seen the evolution of vascular surgery from a sub-specialty of general surgery to that of an independent, stand-alone specialty. The introduction of a vascular-only curriculum is anticipated to require significant change from the current provision for vascular surgical training to allow vascular trainees to acquire the specialist skills in elective, emergency, and endovascular surgery to provide endovascular services in the future. AIM: To provide an insight into current vascular training in Scotland and Northern Ireland. METHOD: Specialty trainees in general surgery, with a sub-specialty interest in vascular in Scotland and Northern Ireland were asked to carry out a voluntary online survey between May 2012 and July 2012. RESULTS: 22 specialty trainees/specialist registrars who have declared a sub-specialty interest in vascular surgery were identified and polled. 20 trainees completed the survey. 13 trainees still participated in general surgical on-call rotas. Formal teaching opportunities were readily available but only 10 trainees could attend regularly. All trainees worked in units offering endovascular treatment for aneurysm and occlusive disease, but few had dedicated training sessions in endovascular skills. All endovascular simulation-based training was industry sponsored. The majority of trainees report a good overall training experience and are keen to see the implementation of a vascular-specific curriculum. 15 trainees had undertaken a dedicated period of research towards a higher degree, with only 50% based on a vascular topic. CONCLUSION: The majority of trainees reported a positive training experience with Scotland and Northern Ireland having great potential as vascular training deaneries. The survey identifies specific areas that could be improved by the development of the new curriculum in vascular surgery to provide excellent vascular training in Scotland and Northern Ireland.

Development of a non-heart-beating donor program and results after the first year.

Our lung transplant unit began activity in October 2008. We have performed 37 lung transplants with a hospital mortality of 2.7% (n = 1). The need for a greater number of donors and the presence of an already existent non-heart-beating donor (NHBD) program for abdominal grafts and tissues encouraged us to consider assessing lung grafts from these donors. It was necessary to develop a new multiorgan preservation methodology, "bithermia preservation." The clinical experience with which during the first year June 2010 to July 2011, including 15 NHBDs is presented herein. The chest x-ray was normal in 6 donors (40%) and 7 had pulmonary infiltrates. Bronchoscopy was normal in 8 donors (53%) but 3 had abundant bleeding airway secretions and signs of bronchoaspiration. Preservation procedures were performed in 6 donors. Pulmonary functional evaluation in 4 donors showed gas measurements to be adequate in 75% of cases. Three double-lung grafts were judged to be valid for implantation, among which we performed 3 lung transplantations, 1 bilateral and 2 unilaterals, while 2 grafts were offered to the National Transplant Organization for other units. No transplant suffered primary graft dysfunction; all 3 showed excellent function allowing early extubation in 2 cases. There was no in-hospital mortality. All 3 patients are alive and leading normal lives; none has bronchiolitis obliterans syndrome. In conclusion, the "bithermia preservation" methodology achieved adequate lung preservation in NHBDs, allowing liver, kidneys, and lungs to be obtained from the same donor.

Improving the future of surgical training and education: consensus recommendations from the Association of Surgeons in Training.

In the past decade surgical training in the United Kingdom (UK) has seen radical overhaul with the introduction of formal training curricula, competency based assessment, and a new Core Surgical Training programme. Despite this, and in common with many other countries, numerous threats remain to sustaining high-quality surgical training and education in the modern working environment. These include service delivery pressures and the reduction in working hours. There are numerous areas for potential improvement and dissemination of best training practice, from incentivising training within the National Health Service (NHS) through top-down government initiatives, to individualised information and feedback for trainees at the front-line. This document sets out the current structure of surgical training in the UK, and describes the contribution to the current debate by the Association of Surgeons in Training. Highlighting areas for improvement at national, regional, local and individual levels, the Association proposes 34 action points to enhance surgical training and education. Adoption of these will ensure future practice continues to improve on, and learn from, the longstanding history of training provided under the guidance of the Royal Surgical Colleges.

[Effectiveness and complications of video-assisted surgery for primary spontaneous pneumothorax]. / Eficacia y morbilidad del tratamiento con cirugía videoasistida del neumotórax espontáneo primario.

OBJECTIVE: To assess the effectiveness and describe the complications of video-assisted thoracoscopic surgery (VATS) for the treatment of primary spontaneous pneumothorax. PATIENTS AND METHODS: Between May 1997 and September 2003, our department scheduled 147 VATS procedures for spontaneous pneumothorax in 127 patients (102 men [80.5%]). The mean (SD) age for the series was 28.3 (11.6) years. Bullae and blebs were resected by endostapler and vigorous pleural abrasion was carried out. Vanderschueren staging was as follows: stage I, 10 (6.8%); stage II, 22 (15%); stage III, 71 (48.3%); and stage IV, 44 (29.9%). The procedure was indicated for the following reasons: third episode, 56 (38.1%); persistent air leak, 47 (32%); elective, 16 (10.9%); simultaneous bilateral pneumothorax, 28 (19%). VATS was performed on the right side only in 85 patients (57.8%), on the left in 62 (42.2%), and on both sides in 16 (11.6%). RESULTS: A total of 137 of the 147 VATS procedures scheduled (93.2%) were performed, and there were no deaths. The rate of conversion to thoracotomy was 6.8%, and the overall rate of complications was 13.7%. Postoperative complications were due to bleeding in 5 cases (3.6%), air leak (>5 days) in 10 (7.2%), wound infection in 2 (1.4%), residual pneumothorax in 4 (2.9%), need to insert a new pleural drain in 3 (2.1%), and pleural empyema in 1 (0.7%). Two patients took oral analgesics for more than 30 days after the procedure. Pneumothorax recurred during follow-up in 7 patients (5.1%). No significant correlation was found between recurrence of pneumothorax after VATS and Vandeschueren stage, age, bilaterality of the procedure, indication, or days of postoperative drainage (P>.05). CONCLUSIONS: VATS for resection of pleural lesions plus pleural abrasion is an efficacious and simple treatment for primary spontaneous pneumothorax regardless of intraoperative findings.

Eficacia y morbilidad del tratamiento con cirugía videoasistida del neumotórax espontáneo primario / Effectiveness and complications of video-assisted surgery for primary spontaneous pneumothorax

Objetivo: Evaluar y describir la eficacia y la morbilidad de la VATS (video assisted toracic surgery [cirugía torácica videoasistida]) en el tratamiento del neumotórax espontáneo primario (NEP). Pacientes y métodos: Entre mayo de 1997 y septiembre de 2003 se programaron en nuestro servicio 147 intervenciones por NEP para VATS en 127 pacientes. Las lesiones bullosas se resecaron mediante endograpadoras. Posteriormente se realizó pleuroabrasión vigorosa. La estadificación según Vanderschueren resultó: estadio I, 10 (6,8%); II, 22 (15%); III, 71 (48,3%), y IV, 44 (29,9%). Se intervino a 102 (80,5%) hombres y 25 (19,5%) mujeres. La media de edad fue de 28,3 ± 11,6 años. Las indicaciones fueron: tercer episodio, 56 (38,1%); fuga aérea persistente, 47 (32%); cirugía electiva, 16 (10,9%); neumotórax bilateral sincrónico, 28 (19%). Se realizó VATS en el lado derecho en 85 pacientes (57,8%) y en el izquierdo en 62 (42,2%). Se realizó intervención bilateral en 16 (11,6%). Resultados: Se realizaron 137 VATS (93,2%). No hubo mortalidad y la tasa de reconversión fue del 6,8%. La incidencia de complicaciones fue del 13,7%. La morbilidad post-operatoria fue: sangrado en 5 pacientes (3,6%); fuga aérea (> 5 días) en 10 (7,2%); infección de herida en 2 (1,4%); neumotórax residual en 4 (2,9%); nuevo drenaje torácico en 3 (2,1%), y empiema pleural en 1 (0,7%). Dos pacientes tomaron analgésicos orales durante más de 30 días después del procedimiento. La recurrencia en seguimiento fue de 7 (5,1%). Se analizó el índice de recurrencia post VATS en relación al estadio Vandeschueren, la edad, el carácter bilateral del neumotórax, la indicación o los días de drenaje post-operatorio y no se encontraron diferencias significativas (p > 0,05). Conclusiones: La VATS con resección de lesiones y pleuroabrasión es un método eficaz y sencillo independiente de los hallazgos intraoperatorios para el tratamiento del NPE

Objective: To assess the effectiveness and describe the complications of video-assisted thoracoscopic surgery (VATS) for the treatment of primary spontaneous pneumothorax. Patients and methods: Between May 1997 and September 2003, our department scheduled 147 VATS procedures for spontaneous pneumothorax in 127 patients (102 men [80.5%]). The mean (SD) age for the series was 28.3 (11.6) years. Bullae and blebs were resected by endostapler and vigorous pleural abrasion was carried out. Vanderschueren staging was as follows: stage I, 10 (6.8%); stage II, 22 (15%); stage III, 71 (48.3%); and stage IV, 44 (29.9%). The procedure was indicated for the following reasons: third episode, 56 (38.1%); persistent air leak, 47 (32%); elective, 16 (10.9%); simultaneous bilateral pneumothorax, 28 (19%). VATS was performed on the right side only in 85 patients (57.8%), on the left in 62 (42.2%), and on both sides in 16 (11.6%). Results: A total of 137 of the 147 VATS procedures scheduled (93.2%) were performed, and there were no deaths. The rate of conversion to thoracotomy was 6.8%, and the overall rate of complications was 13.7%. Postoperative complications were due to bleeding in 5 cases (3.6%), air leak (>5 days) in 10 (7.2%), wound infection in 2 (1.4%), residual pneumothorax in 4 (2.9%), need to insert a new pleural drain in 3 (2.1%), and pleural empyema in 1 (0.7%). Two patients took oral analgesics for more than 30 days after the procedure. Pneumothorax recurred during follow-up in 7 patients (5.1%). No significant correlation was found between recurrence of pneumothorax after VATS and Vandeschueren stage, age, bilaterality of the procedure, indication, or days of postoperative drainage (P>.05). Conclusions: VATS for resection of pleural lesions plus pleural abrasion is an efficacious and simple treatment for primary spontaneous pneumothorax regardless of intraoperative findings

C5 complement inhibition attenuates shock and acute lung injury in an experimental model of ruptured abdominal aortic aneurysm.

BACKGROUND: Ruptured abdominal aortic aneurysm (RAAA) is associated with a systemic inflammatory response syndrome and multiple organ dysfunction. The potential role of a novel C5 complement inhibitor in attenuation of pathological complement activation and tissue injury was explored in a model of RAAA. METHODS: Anaesthetized rats were randomized to sham (control) or shock and clamp (SC) groups. Animals in the SC group underwent 1 h of haemorrhagic shock (mean arterial pressure 50 mmHg or less), 45 min of supramesenteric aortic clamping and 2 h of reperfusion. They were randomized to receive an intravenous bolus of a functionally blocking anti-C5 monoclonal antibody (C5 inhibitor), at a dose of 20 mg/kg, or saline. Lung injury was assessed by permeability to 125I-labelled albumin, tissue myeloperoxidase (MPO) activity, and semiquantitative reverse transcriptase-polymerase chain reaction (RT-PCR) for mRNAs encoding tumour necrosis factor (TNF) alpha and interleukin (IL) 6. RESULTS: The lung permeability index was significantly increased in the SC compared with the sham group (P = 0.032); this was prevented by the C5 inhibitor (P = 0.015). Lung MPO activity was significantly increased in the SC compared with the sham group (P < 0.001), and this increase was attenuated by treatment with the C5 inhibitor (P < 0.001). Semiquantitative RT-PCR in SC group demonstrated downregulation of TNF-alpha mRNA (P = 0.050) and upregulation of IL-6 mRNA (P < 0.001), which were both prevented by the C5 inhibitor (P = 0.014 and P < 0.001 respectively). CONCLUSION: These results indicated that C5 complement inhibition can reduce shock and acute lung injury in an experimental model of RAAA.

Amyand's hernia causing necrotising fasciitis of the anterior abdominal wall.

The finding of appendicitis within an inguinal hernia is a recognized phenomenon: Amyand's hernia. The development of necrotising soft tissue infection-necrotising fasciitis-is associated with high morbidity and mortality. We present a case of Amyand's hernia resulting in a severe, life-threatening necrotising soft tissue infection, which is previously unreported in English literature. We outline features relating to the diagnosis of this rare condition, and improve awareness among clinicians of the possibility of appendicitis within a direct inguinal hernia, and highlight the importance of appropriate initial surgical intervention for necrotising soft tissue infection to improve survival for these patients.

Fine needle aspiration biopsy (FNAB) for lesions of the salivary glands.

We examined 112 fine needle aspiration biopsy (FNAB) specimens of salivary glands (80 parotid and 32 submaxillary) taken between January 1989 and December 1995. Cytologic diagnoses were compared with the final histological diagnoses of the surgical specimens. The sensitivity and specificity were 84.8% and 93.7% respectively, and the accuracy was 91.1%. We conclude that FNAB by itself does not provide total security because of the high percentage of false-negatives. It is nevertheless useful when combined with an adequate clinical history, examination and radiological tests.

Stereologic estimates of volume-weighted mean nuclear volume in aspiration smears of ductal breast carcinoma. Correlation with cytologic grade, tumor size and lymph node status.

OBJECTIVE: To estimate cytologic volume-weighted mean nuclear volume and correlate it with other prognostic factors, such as tumor diameter and cytologic grading in relation to nodal infiltration. STUDY DESIGN: The relationships between nodal status and nuclear VV, tumor diameter and cytologic grading, according to the modified Black nuclear grading system, were analyzed on fine needle aspirates of 49 cases of breast cancer by univariate and multivariate logistic regression. RESULTS: Volume-weighted mean nuclear volume (nuclear VV) estimated on fine needle aspiration smears showed a significant correlation with grade of tumor differentiation. CONCLUSION: Stereologic evaluation of nuclear size by nuclear VV is an objective method for the cytologic grading of ductal carcinoma of the breast and has independent prognostic value in relation to nodal status higher than those of tumor diameter and cytologic grade.

Bronchoalveolar lavage cell composition in allogeneic bone marrow transplant patients without symptomatic lung complications.

The purpose of this study was to assess the cytological composition of bronchoalveolar lavage (BAL) fluid in allogeneic BMT patients without lung complications and compare it with that obtained from healthy volunteers. During the first 6 months post-BMT we studied the differential cell counts of 98 BALs from 56 patients as well as the total cell count of 44 BALs from 27 patients. The BAL cellular composition in BMT patients was clearly different from that of healthy subjects: there was a marked increase in alveolar neutrophils (in 82% of the patients when sequential BALs were performed) and an increase in lymphocytes, with a lower percentage of macrophages and similar numbers of eosinophils. A greater variation in cellular populations was found without an evident cause. The total number of cells per ml of fluid recovered appeared similar to that of healthy volunteers. A high frequency of neutrophilic alveolitis was found in patients with asymptomatic CMV on BAL. Owing to the variability of BAL cellular composition in asymptomatic BMT patients and its difference from that in healthy volunteers, great caution should be taken when interpreting the BAL composition data from patients with lung complications. In order to avoid drawing wrong conclusions these data should be compared with those obtained from a control group of BMT patients without lung complications and not from healthy volunteers.

Endoscopic biopsy and cytology in the diagnosis of malignant gastric ulcers.

Endoscopy significantly improves the diagnosis of tumors of the stomach; however, its value may be limited in differentiating benign from malignant gastric ulcers (MGUs). The accuracy of endoscopy was compared in 20 patients with MGU studied by endoscopy, biopsy, and cytology. Endoscopy correctly diagnosed 13 cases (65%), with endoscopic signs being benign or indeterminate in the remaining seven. However, all 20 MGUs were accurately diagnosed since biopsy and cytology increased the diagnostic accuracy of endoscopy in the remaining seven patients. The combination of biopsy and cytology yielded a positive diagnosis in 19 patients (95%); the remaining patient was operated on with only the endoscopic diagnosis of MGU. The complementarity of these three techniques was highlighted in five cases where only one of the procedures unequivocally diagnosed malignancy. It is concluded that biopsy and cytology are useful complementary techniques and should always be performed together in categorizing the nature of all gastric ulcers despite a benign macroscopic appearance at endoscopy.

Correlations between ldh isoenzyme patterns and brushing cytology in ulcerative colitis.

Forty-one rectal samples from 22 patients with ulcerative colitis and eight rectal samples from normal controls were studied cytologically, histologically and histochemically (LDH isoenzyme pattern). The cytological specimens from patients were classified into three groups (A, B and C) and the degree of cellular atypia was compared with the modifications of LDH isoenzymogram. The differences between the polypeptide M levels of the group A, B and C were statistically significant, as well as those between groups B and C versus the normal controls. The highest percentages of M were observed in group C and correlate with the presence of large single or double nucleoli. These results most likely represent active cellular regeneration, and further investigations are needed to elucidate whether the histochemical alterations could be useful to detect precocious malignant changes in patients with long-standing ulcerative colitis.