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To make the most context-rich experiences possible and avoid a myriad of problems, designers must keep a user-centric focus. By viewing our educational products through the perspective of the user, we can devise more accessible, diverse, meaningful, and above all enjoyable experiences. Using simple tools such as problem statements, personas, user maps, story boarding, wireframes, low-definition prototypes, and high-definition prototypes, we can consult users first in design to inform us on how to proceed with decisions. Using the simple outlined in the Design Thinking process of empathizing, defining, ideating, prototyping, and testing, we can deliver the most user centric experience possible. The author will show how Design Thinking couples so well with User Experience (UX), walk through what a user study is, what to do with the feedback you get from users, and how to keep the user in mind from inception to launch. In this chapter, the author will discuss the basic framework of UX, where to apply the tools within the framework and why these tools are important when developing context-rich experiences.

The geographic distribution of brachiopod genus occurrences over the Phanerozoic shows that secular declines in origination and extinction rates were paralleled by increases in invasion and extirpation rates. Origination and extinction rates declined in two phases, the first from the Cambrian to latest Permian Periods and the second from the latest Permian Period to the present, which were accompanied by concomitant increases in invasion and extirpation rates. In addition to the temporal correlation, an inverse correlation was also weakly evident among time-averaged latitudinal gradients of rates. Compared with faunas at higher latitudes, low-latitude faunas experienced higher origination and extinction rates, and lower invasion and extirpation rates. We suggest that progressive increases in migration ability lowered origination and extinction rates because species that were better equipped to track a preferred habitat, for example, by the ability to disperse larvae over large distances, were less likely to evolve or become extinct in response to local environmental changes. The two phases were separated by the end-Permian mass extinction, which reset to high levels the origination and extinction rates of a taxonomically and ecologically altered global brachiopod fauna. Our data also allow us to quantify the relative contributions of origination, extinction, invasion, and extirpation to regional diversity (quantified as 10° latitudinal zones) more generally. Overall, invasion and extirpation explained slightly more variation in diversity than in situ origination and extinction. The four variables usually occurred in combinations that maintained rather than altered the shape of the latitudinal diversity gradient. For most of the Phanerozoic Eon, the gradient was not the product of continuous renewal, but rather existed as a holdover from a previous interval.

Anterior exposure for spinal surgery has expanded and is used for common spinal procedures, including anterior lumbar interbody fusion, disc replacement, and vertebral corpectomy. With this approach, vascular injuries have been reported ranging from 1% to 25%. The impact of resident participation on intraoperative and postoperative outcomes within an independent academic medical center has not been widely reported. The objective of this study was to determine the incidence of complications during anterior exposure spinal surgery at an independent academic medical center.After institutional review board approval, we conducted a retrospective review of medical records of patients who underwent elective anterior exposure for spinal surgery from 2000 through 2014.The study included 335 patients; 60.3% were female. Thirty-day postoperative complications included surgical site infection (4.2%), urinary tract infection (2.7%), need for blood transfusion (2.1%), retrograde ejaculation (1.2%), and deep vein thrombosis (0.9%). There were 12 vascular injuries overall (3.6%); 2.7% were major vascular injuries. Surgery residents participated in 34% of cases. Resident involvement increased over the course of the study. There was no difference in operative time or complications with resident involvement.The overall incidence of major vascular injury was 2.7%. Levels of exposure and blood loss were associated with vascular injury. Overall postoperative complication rates as well as major vascular injury rates compared favorably to published benchmarks. Complication rates were unaffected by surgical resident involvement.

Background As the incidence of pancreatic adenocarcinoma increases, so has the utilization of neoadjuvant therapy. The objective of this study was to evaluate outcomes in patients undergoing neoadjuvant therapy or surgery first for pancreatic adenocarcinoma. Methods The ACS-NSQIP 2014–2015 targeted pancreatectomy variables were queried for patients with pancreatic adenocarcinoma who underwent resection. Outcomes of those receiving neoadjuvant therapy were compared to surgery first using a multivariate, logistic regression model. Results 3408 patients underwent pancreatectomy; 2596 proximal pancreatectomies, 741 distal pancreatectomies, 64 total pancreatectomies and 7 other pancreatic procedures were performed. Of the 3408 patients identified, 934 (27.5%) received neoadjuvant therapy: 496 chemotherapy alone, 28 radiation alone, and 410 combined chemotherapy/radiation therapy. Overall morbidity and mortality were similar between patients receiving neoadjuvant therapy versus those who underwent surgery first. Neoadjuvant treatment was associated with lower rates of pancreatic fistulas (10.2% vs. 13.2%, P = 0.017), but higher intra/postoperative transfusion rates (27.4% vs. 20.3%, P Conclusions Neoadjuvant therapy appeared to be safe prior to operative intervention as no difference in overall postoperative morbidity or mortality rates were identified. There were increased intra/postoperative transfusions in the neoadjuvant therapy group, but neoadjuvant therapy was associated with lower rates of pancreatic fistulas.

Percutaneous cholecystostomy tube (PCT) placement serves as a treatment option for acute cholecystitis in elderly and critically ill patients. The objective of this study was to compare PCT and cholecystectomy outcomes over time.PCTs placed from April 1, 1998, to December 31, 2009 (time period 2) were retrospectively reviewed. Patients who underwent cholecystectomies served as matched controls. Institutional data from March 1, 1989, to March 31, 1998 (time period 1) were reviewed to compare trends.A total of 143 patients successfully underwent PCT placement in time period 2. When compared with patients undergoing cholecystectomy, PCT patients had a higher rate of cardiovascular disease (66% vs 26%, P = 0.001), diabetes (27% vs 13%, P = 0.001), and a higher mean Charlson comorbidity index (3.27 vs 1.07, P = 0.001). Compared with the first time period, patients undergoing PCT in the second time period had lower American Society of Anesthesiologist's classifications (American Society of Anesthesiologist's class I, II: 0% vs 18%, P = 0.001). Thirty-day mortality decreased from 36% to 12% in patients undergoing PCT (P = 0.001).Among patients with acute cholecystitis, percutaneous cholecystostomy tubes were placed in older patients with increased comorbidities compared to cholecystectomy. Mortality rates after PCT decreased over time.

Surgical resection offers the only treatment associated with long-term survival for colorectal cancer (CRC) with hepatic metastasis. Imaging studies are paramount for the identification of potential surgical candidates. Synchronous hepatic disease is identified at presentation in 20–30 % of patients and ultimately, hepatic metastases occur in over 50 % of patients diagnosed with CRC. Computed tomography (CT) has been the imaging standard to identify patients with hepatic metastasis, but the array of preoperative imaging has expanded over the past several years. Currently, ultrasound, CT, magnetic resonance imaging, and positron emission tomography all play a vital role in the management and treatment of stage IV CRC. In addition, patient characteristics such as steatosis and treatment such as neoadjuvant chemotherapy affect imaging of hepatic metastases. The goal of this review is to discuss the current standing of imaging modalities used in the perioperative care of patients with colorectal liver metastasis.

Background and Objectives Patient-centered care is recommended by the Institute of Medicine to build a better healthcare system. The aim of this study was to audit patient-centered quality measures (QM) to create a breast center report card that could be provided to patients for education and informed consent. Methods An IRB approved retrospective review of 695 patients undergoing sentinel lymph node biopsy for breast cancer was conducted to audit the components of one step surgery and other QM. Results The intraoperative sensitivity to detect node positive patients was 25% (2/8), 27% (9/34), and 87% (68/78) for pN0(i+), pN1mi, pN1 patients, respectively. The re-excision lumpectomy rate was 15% (72/471) and the one step surgery success rate, which included lumpectomy and mastectomy patients, was 86% (598/695). Patient self-assessment of “very good to excellent” cosmesis and pain control were 77% (103/134) and 83% (60/72). Local recurrence rate was 2% (12/695) at a mean 3.1-year follow-up. Conclusions The components of care that contribute to a patient-centered assessment of breast cancer surgery are measurable. “Bundling” of QM creates a perioperative report card that aids patients' informed consent and provides a framework for future comparative effectiveness studies. J. Surg. Oncol. J. Surg. Oncol. 2010;102:34–38. © 2010 Wiley-Liss, Inc.

Aneurysmal disease in the venous system is uncommon. The majority of venous aneurysms occur in peripheral vessels. Visceral venous aneurysms (VVA) are rare, the most common being portal mesenteric vein aneurysms. Because of their rare nature, limited information concerning the natural history, presentation, and management of VVA is known. Many VVA are asymptomatic; others cause mass effect or other complications. Rupture is a rare complication, occurring in only 2.2% of VVA. To date, only 17 descriptions of superior mesenteric vein (SMV) aneurysms have been reported. We report the first case of a ruptured SMV aneurysm.