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Background Lipomatous tumors of the vulva are exceedingly rare, particularly in adolescents. We describe the work-up and management of an adolescent girl who presented with a large, well-vascularized vulvar mass. Case A 14-year-old girl presented with a large vulvar mass of unclear etiology. Magnetic resonance imaging of this mass revealed an ill-defined, well-vascularized mass with fat signal characteristics suggestive of a lipomatous tumor that was concerning for malignancy. We performed complete resection of the mass, and histologic evaluation revealed a vulvar hibernoma. There have been no signs of recurrence 1 year later. Summary and Conclusion Although rare, a hibernoma of the vulvar region may present in adolescence and may be concerning for malignancy on imaging. Complete resection of these tumors is recommended for definitive diagnosis and treatment.

Objectives The purpose of this study was to measure faculty performance of simulated spinal manipulation on a mannequin to help identify teaching standards. Methods We measured 3-dimensional transmitted loads using a force plate mounted in the table. Thrusts were delivered through a compliant, jointed mannequin by faculty members along predefined “listings” as taught in lumbopelvic technique courses. Results Eleven chiropractic faculty members participated, delivering 9 thrusts at 3 loads (light, moderate, and heavy) along 9 different prone and side-posture listings, totaling 81 thrusts per participant. Single-hand Gonstead-style thrusts had variability in magnitude across participants and loads: light thrusts averaged 365 N (95% confidence interval [CI] 327-402), moderate thrusts 454 N (421-487), and heavy thrusts 682 N (623-740). All faculty members could easily distinguish the loads within their performances, but there was some crossover of load levels between participants. Thrust rates averaged 3.55 N/ms (95% CI 3.29-3.82). The dominant vector of prone thrusts was in the z direction (vertically downward), but side-to-side and inferior-to-superior vector components occurred. Conclusion Faculty member performance of simulated spinal manipulation indicated that they are able to control the thrust magnitude and rate as well as direction. In this sample, there was significant variability in peak loads between participants, which needs to be considered in student learning standards. These findings may be useful in translating the understanding of force characteristics to the technique teaching lab.

Adequate nutrition is essential for growth in children with cystic fibrosis (CF). The new CF Foundation Clinical Practice Guidelines bring attention to monitoring macronutrient intake as well as total energy.Dietary intake of 75 preschool children with CF and pancreatic insufficiency was examined and compared to the Clinical Practice Guidelines. Regression analyses examined relationships between macronutrient intake and growth.Approximately 45% of children met the 110% minimum recommended dietary allowance (RDA) recommendation. Children consumed 35.3% (6.1) of total daily energy intake from fat, 12.7% (1.7) from protein, and 52.0% (6.1) from carbohydrates. Percent energy from protein was associated with height growth.Many preschoolers with CF are not meeting nutrition benchmarks for total energy and fat. To optimize nutrition early, dietary monitoring with frequent individualized feedback is needed. Optimizing intake of macronutrients that promote growth, especially fat and protein, should be a primary clinical target.

Study Objective To confirm the safety and feasibility outcomes of robotic radical parametrectomy and pelvic lymphadenectomy and compare the clinicopathological features of women requiring adjuvant treatment with the historical literature. Design Retrospective cohort study and review of literature (Canadian Task Force classification II-2). Setting Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill. Patients All patients who underwent robotic radical parametrectomy with upper vaginectomy (RRPV), and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy at our institution between January 2007 and December 2015. Interventions RRPV and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy. We also performed a literature review of the literature on radical parametrectomy after occult cervical carcinoma. Measurements and Main Results Seventeen patients with invasive carcinoma of the cervix discovered after extrafascial hysterectomy underwent RRPV with bilateral pelvic lymphadenectomy. There were 2 intraoperative complications, including 1 bowel injury and 1 bladder injury. One patient required a blood transfusion of 2 units. Three patients underwent adjuvant treatment with chemoradiation with radiation-sensitizing cisplatin. One of these patients had residual carcinoma on the upper vagina, 1 patient had positive parametria and pelvic nodes, and 1 patient had positive pelvic lymph nodes. No patients experienced recurrence, and 1 patient died from unknown causes at 59.4 months after surgery. We analyzed 15 studies reported in the literature and found 238 women who underwent radical parametrectomy; however, no specific preoperative pathological features predicted outcomes, the need for adjuvant treatment, or parametrial involvement. Conclusion RRPV is a feasible and safe treatment option. As reflected in the literature, RRPV can help avoid empiric adjuvant chemoradiation; however, no pathological features predict the need for adjuvant treatment after surgery.

Highlights • TP53 mutations are common in serous endometrial tumors. • Endometrial tumors with micro and macrometastasis are more likely than tumors with ITC only to have LVSI. • No patient with ITC only disease had a recurrence in the study time frame., Objectives Lymph node (LN) metastasis and genomic profiles are important prognostic factors in endometrial cancer (EMCA). However, the prognostic significance of low volume metastasis found in sentinel lymph nodes (SLN) is unknown. We sought to determine if genomic mutations were associated with metastatic volume. Methods Surgically staged women with EC who were enrolled in both a SLN clinical trial and tumor sequencing protocol were eligible. Relevant targets were enriched by a custom designed Agilent SureSelect hybrid capture enrichment library using standard protocols. Three specific gene mutations were evaluated, TP53, PTEN and PIK3CA in the primary tumor of patients with LN negative, LN positive and ITC disease. Results 42 patients were eligible; of these, 7 (16.7%) had ITC only and 7 (16.7%) had micrometastatic or macrometastatic (LN positive) disease. No differences were seen in TP53, PIK3CA or PTEN between groups. All ITC patients with TP53 mutations were of non-endometrioid histology (2/7). Deeper myometrial invasion and lymph vascular space invasion were more likely to occur in the LN positive group (p

Highlights • Spontaneous bladder ruptures have only been reported intraperitoneally, and years after the cessation of therapy. • Extraperitoneal bladder rupture can occur with radiation therapy in treatment of cervical cancer. • Improved reporting of toxicity is needed to identify types of genitourinary toxicity seen with modern chemoradiation., The standard of care for locally advanced cervical cancer is pelvic radiotherapy with sensitizing cisplatin, and intracavitary brachytherapy. This standard of care treatment paradigm has best survival outcomes, however is associated with genitourinary toxicities. Spontaneous bladder rupture (SBR) is a rare complication of chemoradiation that has only been reported in literature as an intraperitoneal rupture occurring years after the cessation of treatment. We herein present a novel case of extraperitoneal SBR in a 27-year-old female with FIGO Stage IIIC cervical cancer and no prior surgical history who was undergoing chemoradiation with sensitizing cisplatin. During her final planned brachytherapy treatment upon instilling the bladder under ultrasound guidance, an anterior midline extraperitoneal rupture was noted. She was managed conservatively for several weeks and during this time was ultimately able to complete her external beam therapy and last cycle of cisplatin. After approximately ten weeks of conservative management, imaging demonstrated complete resolution of the rupture. A review of the literature suggests this complication tends to occur as an intraperitoneal rupture years after the cessation of therapy. Late genitourinary complications and types of complications are rarely reported in clinical trials, so it is difficult to determine the true incidence of rare complications and identify patients that may be at risk.

The ability to develop nanofibers containing whey proteins presents a unique opportunity to exploit the inherent benefits of whey protein with that of the desirable attributes of nanofibers. In this study, aqueous whey protein solutions, both whey protein isolate (WPI) and one of its major components beta-lactoglobulin (BLG), are electrospun into nanofibers in conjunction with a spinnable polymer, poly(ethylene oxide) (PEO). WP:PEO solution composition as high as 3:1 and with average fiber diameters ranging from 312 to 690 nm are produced depending on polymer composition and concentration. WP/PEO solutions are also successfully electrospun at acidic pH (2 ≤ pH ≤ 3), which could improve shelf life. FTIR analysis of WP/PEO fiber mat indicates some variation in WP secondary structure with varying WPI concentration (as WPI increases, % α-helix increases and β-turn decreases) and pH (as pH decreases from neutral (7.5) to acidic (2), % β-sheet decreases and α-helix increases). XPS also confirms the presence of WP on the surface of the blend fibers, augmenting the FTIR analysis. Interestingly, WP/PEO composite nanofibers maintain its fibrous morphology at temperatures as high as 100 °C, above the 60 °C PEO melting point. In addition, the mats swell in water and retain a fibrous quality which makes them desirable for application in regenerative medicine. Finally, we incorporate a small hydrophobic molecule Rhodamine B (RhB) as a model flavonoid into WP/PEO nanofiber mats. The BLG:PEO nanofibers qualitatively exhibit improved fiber quality and RhB distribution compared to PEO nanofibers; however, no effect on the release profile is observed.

5586Background: Lymph node (LN) metastasis and genomic profiles are important prognostic factors in endometrial cancer (EC). However, the prognostic significance of the volume of metastatic disease...

Collagen, the most abundant protein on Earth, is used as a platform for studying three major hurdles of nanotechnology: (1) What is the aggregation limit in self-assembling systems? (2) What is the smallest scale at which matter can be reliably and repeatedly organized? (3) Where do the natural boundaries lie in what is achievable via directed manipulation at the nanoscale? Through work involving a mechanics-based model for predicting the radial aggregation limit of collagen fibrils using translation length, axial and torsional stiffness of the tropocollagen model, and specific binding sites, the 20–500 nm diameter distribution of collagen is explored, verifying previous atomic force microscopy data. Preliminary micromanipulation of collagen fibers with the Zyvex S100 also implicate the necessary steps to be taken in proposed nanomanipulation experiments. Results presented implicate: (1) That the aggregation limit of collagen fibrils and perhaps other structural proteins may be predicted by the mechanical properties of its molecular subunits wherein the outer portions of the fibril are in tension balanced by compressive stresses within the inner portions, (2) That currently the top-down style of nanomanipulation must be improved via advances in computational imaging if it is to keep pace with advancements which have been made at the microscale, and (3) That there exist tightly constrained paths which must be followed in order to create beneficial mutations at the molecular level.

To determine if preoperative hypoalbuminemia is associated with postoperative wound complications among patients with vulvar cancer.The National Surgical Quality Improvement Program database was queried for cases of vulvar cancer undergoing vulvectomy with or without lymphadenectomy (LND) from 2008 to 2013. Primary outcome was major wound complication. Secondary outcome was minor wound complication. Hypoalbuminemia was defined as albumin3.5g/dL. Descriptive statistics and multivariable logistic regression were used for analysis.Of 777 vulvar cancer patients, 514 (66.2%) had vulvar surgery alone and 263 (30.3%) had a LND. Median age was 66 (range 20-90) and median BMI was 28.9kg/m(2) (range 14.3-65.5). The incidence of wound complication was 10.4% (81/777) with 48 minor and 39 major complications. There was no difference in major wound complications when a LND was performed (p=1.0). Preoperative albumin was recorded in 429 patients (55.2%). Patients with hypoalbuminemia were more likely to have a major wound complication (OR 2.9 95% CI 1.1-7.3, p=0.02), even after adjusting for BMI, age, preoperative hematocrit, and diabetes (aOR 2.7 95% CI 1.1-7.1, p=0.04). In bivariable analysis, age, diabetes, and BMI were not associated with wound complication. Patients with a wound infection had 10 times the odds of being readmitted within 30days (OR 9.5, 95% CI 4.9-18.4, p0.01).Low preoperative albumin is associated with major postoperative wound complications in women undergoing surgery for vulvar cancer. When obtaining informed consent, patients with low albumin should be counseled regarding higher risks of postoperative wound complication.

OBJECTIVE: Robotic gynecological surgery is feasible in obese patients, but there remain concerns about the safety of this approach because the positioning required for pelvic surgery can exacerbate obesity-related changes in respiratory physiology. The objective of our study was to evaluate pulmonary and all-cause complication rates in obese women undergoing robotic gynecological surgery and to assess variables that may be associated with complications. STUDY DESIGN:A retrospective chart review was performed on obese patients (body mass index of � 30 kg/m 2 ) who underwent robotic gynecological surgery at 2 academic institutions between 2006 and 2012. The primary outcome was pulmonary complications and the secondary outcome was all-cause complications. Univariate and multivariate logistic regression analyses were used to determine the associations between patient baseline variables, operative variables, ventilator parameters, and complications. RESULTS:Of1032patients,146patients(14%)hadanycomplication, whereas only 33 patients (3%) had a pulmonary complication. Median body mass index was 37 kg/m 2 . Only age was significantly associated with a higher risk of pulmonary complications (P ¼ .01). Older age, higher estimated blood loss, and longer case length were associated with a higher rate of all-cause complications (P ¼ .0001, P < .0001, and P ¼ .004, respectively). No other covariates were strongly associated with complications. CONCLUSION: The vast majority of obese patients can successfully tolerate robotic gynecological surgery and have overall low complications rates and even lower rates of pulmonary complications. The degree of obesity was not predictive of successful robotic surgery and subsequent complications.