Changing climate, challenging choices: identifying and evaluating climate change adaptation options for protected areas management in Ontario, Canada.

Climate change will pose increasingly significant challenges to managers of parks and other forms of protected areas around the world. Over the past two decades, numerous scientific publications have identified potential adaptations, but their suitability from legal, policy, financial, internal capacity, and other management perspectives has not been evaluated for any protected area agency or organization. In this study, a panel of protected area experts applied a Policy Delphi methodology to identify and evaluate climate change adaptation options across the primary management areas of a protected area agency in Canada.

Outcome of critically ill patients with acute kidney injury using the Acute Kidney Injury Network criteria.

Objective: Acute kidney injury affects 5% to 7% of all hospitalized patients with a much higher incidence in the critically ill. The Acute Kidney Injury Network proposed a definition in which serum creatinine rises (>0.3 mg/dL) and/or oliguria (<0.

Medical management of postsurgical complications: the bariatric surgeon's perspective.

Bariatric surgery remains the only effective method to initiate and sustain massive weight loss in morbidly obese patients. Along with the advent of minimal access surgery, its popularity has not only resulted in an exponential increase in number of cases but also a subsequent increase in number of complications. Although most postsurgical bariatric complications are managed surgically, it is imperative that all physicians be aware of the unique potential complications to effectively communicate and optimize the medical management in this emergent set of patients.

Tissue compression analysis for magnetically anchored cautery dissector during single-site laparoscopic cholecystectomy.

Introduction: The purpose of this study was to evaluate the histological effects of dynamic abdominal wall compression using the magnetic anchoring and guidance system (MAGS) platform.

Methods: Cholecystectomy was performed in two nonsurvival and two survival pigs using a single-site laparoscopic (SSL) approach. A deployable MAGS cautery dissector was used to perform the entire dissection in conjunction with a laparoscope and other instruments.

Evaluation of digital PCR for absolute DNA quantification.

The emerging technique of microfluidic digital PCR (dPCR) offers a unique approach to real-time quantitative PCR for measuring nucleic acids that may be particularly suited for low-level detection. In this study, we evaluated the quantitative capabilities of dPCR when measuring small amounts (<200 copies) of DNA and investigated parameters influencing technical performance. We used various DNA templates, matrixes, and assays to evaluate the precision, sensitivity and reproducibility of dPCR, and demonstrate that this technique can be highly reproducible when performed at different times and when different primer sets are targeting the same molecule.

Early surgeon impressions and technical difficulty associated with laparoendoscopic single-site surgery: a Society of American Gastrointestinal and Endoscopic Surgeons Learning Center study.

Background: Interest in laparoendoscopic single-site surgery (LESS) is growing rapidly among surgeons. This study aimed to characterize current surgeon impressions about LESS and to determine the relative difficulty of performing a simulated LESS task using a multiport access device.

Methods: This study was conducted at the 2009 Society of Gastrointestinal Endoscopic Surgeons (SAGES) Learning Center.

New directions in simulation-based surgical education and training: validation and transfer of surgical skills, use of nonsurgeons as faculty, use of simulation to screen and select surgery residents, and long-term follow-up of learners.

The Consortium of American College of Surgeons-Accredited Education Institutes was created to explore new opportunities in simulation-based surgical education and training beyond the scope of individual accredited institutes. During the Third Annual Meeting of the Consortium of American College of Surgeons-Accredited Education Institutes Consortium, 4 work groups addressed the validation and transfer of surgical skills, the use of nonsurgeons as faculty, the use of simulation to screen and select surgery residents, and long-term follow-up of learners. The key elements from the deliberations and conclusions are summarized in this manuscript.

Robotic suturing on the FLS model possesses construct validity, is less physically demanding, and is favored by more surgeons compared with laparoscopy.

Background: The value of robotic assistance for intracorporeal suturing is not well defined. We compared robotic suturing with laparoscopic suturing on the FLS model with a large cohort of surgeons.

Methods: Attendees (n=117) at the SAGES 2006 Learning Center robotic station placed intracorporeal sutures on the FLS box-trainer model using conventional laparoscopic instruments and the da Vinci® robot.

Magnetic anchoring and guidance system instrumentation for laparo-endoscopic single-site surgery/natural orifice transluminal endoscopic surgery: lack of histologic damage after prolonged magnetic coupling across the abdominal wall.

Objectives: To study the potential pathologic effect of prolonged compression of abdominal wall between the components. Magnetic Anchoring and Guidance System (MAGS) instruments ameliorate some of the challenges in triangulation created by laparo-endoscopic single-site and natural orifice translumenal endoscopic surgery. They consist of an intracorporeal magnetic device coupled to an external hand-held magnet used to anchor and "steer" it around the peritoneal cavity.

Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a multicenter prospective randomized trial.

Background: Gastrointestinal (GI) bleeding and anastomotic stricture are frequent complications associated with the construction of the gastrojejunostomy during laparoscopic gastric bypass. Staplers with shorter staple height can reduce the rate of postoperative GI hemorrhage. The aim of the present study was to assess the outcomes of patients who had undergone gastric bypass with construction of the gastrojejunostomy using a 25-mm circular stapler with a 3.

Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance.

Background: The purpose of this study was to determine 2-year performance retention and certification exam pass rate after completion of a proficiency-based fundamental laparoscopic skills (FLS) curriculum and subsequent interval training.

Methods: Surgery residents (postgraduate year [PGY]1-5, n = 91) were enrolled in an Institutional Review Board approved protocol. All participants initially underwent proficiency-based training on all 5 FLS tasks.

Maximizing coupling strength of magnetically anchored surgical instruments: how thick can we go?

Background: The Magnetic Anchoring and Guidance System (MAGS) includes an external magnet that controls intra-abdominal surgical instruments via magnetic attraction forces. We have performed NOTES (Natural Orifice Transluminal Endoscopic Surgery) and LESS (Laparoendoscopic Single Site) procedures using MAGS instruments in porcine models with up to 2.5-cm-thick abdominal walls, but this distance may not be sufficient in some humans.

Video. Modified single-incision laparoscopic adjustable gastric band.

Introduction: This video describes a modified single-incision laparoscopic approach for adjustable gastric band placement.

Method: The patient was a 28-year-old female with a BMI of 48.75 with no prior surgery but with numerous comorbidities.

Proficiency-based Fundamentals of Laparoscopic Surgery skills training results in durable performance improvement and a uniform certification pass rate.

Background: The authors have previously documented a 100% certification pass rate immediately after a proficiency-based skills training curriculum for the Fundamentals of Laparoscopic Surgery (FLS) program. This study aimed to determine the durability of skills acquired after initial training.

Methods: For this study, 21 novice medical students were enrolled in institutional review board (IRB)-approved protocols at two institutions.

Initial laparoscopic basic skills training shortens the learning curve of laparoscopic suturing and is cost-effective.

Background: Laparoscopic suturing is an advanced skill that is difficult to acquire. Simulator-based skills curricula have been developed that have been shown to transfer to the operating room. Currently available skills curricula need to be optimized.

Preparing medical students to enter surgery residencies.

Background: This study was designed to develop and evaluate an integrated cognitive and proficiency-based skills curriculum based on American College of Surgeons Graduate Medical Education Committee (ACGME) competencies to prepare students for surgery internships.

Methods: Course content included cadaver dissections, didactic sessions, team training, and training in clinical and technical skills. Using previously validated skills curricula (12 open and 5 Fundamental Laparoscopic Surgery [FLS] tasks), trainees underwent pretest, self-practice to proficiency, and post-test.

Pretraining on Southwestern stations decreases training time and cost for proficiency-based fundamentals of laparoscopic surgery training.

Background: We previously reported a proficiency-based Fundamentals of Laparoscopic Surgery (FLS) curriculum that uniformly resulted in passing the technical skills certification criteria. We hypothesized that pretraining using the Southwestern (SW) videotrainer stations would decrease costs and training time and maintain benefits.

Study Design: Group I (2nd-year medical student, n = 10) underwent FLS pretesting (Pretest 1), SW station proficiency-based training, repeat FLS testing (Pretest 2), FLS proficiency-based training, and final FLS testing (Posttest).

Maintaining proficiency after fundamentals of laparoscopic surgery training: a 1-year analysis of skill retention for surgery residents.

Background: The purpose of this study was to determine performance retention after initial and ongoing Fundamentals of Laparoscopic Surgery (FLS) skills training.

Methods: Surgery residents (postgraduate year [PGY] 1-5; n = 91) initially underwent proficiency-based training during a 2-month period for all 5 FLS tasks. Subsequently, available residents (PGY 2-5; n = 44) were enrolled in a follow-up curriculum for Tasks 4 and 5, with retention testing at 6.

Management of transmesenteric tunnel jejunal strictures with endoscopic dilation by using achalasia balloons (with videos).

Background: Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Transmesenteric tunnel (TMT) or mesocolic jejunal stricture is an unusual postoperative complication that requires another operation. We hypothesize that endoscopic dilation by using achalasia dilatation balloons can be used to treat some TMT jejunal strictures.

Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload.

Background: Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room.

Methods: Medical students (n = 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol.

Endotherapy for a 5-cm mid-esophageal perforation with tandem stenting above the lower esophageal sphincter (with videos).

Background: Esophageal perforation, whether spontaneous or more commonly as a result of instrumentation, is a life-threatening condition and carries high mortality despite recent advances. Outcome is dependent on etiology, location of injury, and interval between perforation and initiation of therapy. Successful management of esophageal perforation entails combination of: (1) control of the leakage site either surgically or endoscopically to prevent further contamination, (2) drainage of contamination, and (3) appropriate antibiotics along with nutritional support.

Do metrics matter? Time versus motion tracking for performance assessment of proficiency-based laparoscopic skills training.

Introduction: The purpose of this study was to compare the added value of motion metrics in determining training completion during a proficiency-based simulator curriculum compared with traditional metrics (time).

Methods: Novices (n=16) practiced on a basic laparoscopic task of a hybrid simulator until expert-derived proficiency levels for time, path length, and smoothness were achieved on two consecutive attempts. The order by which proficiency in each metric was achieved was recorded and correlated to baseline characteristics.

Modeling the primary hormone-binding site of RXFP1 and RXFP2.

The primary binding sites of the relaxin and insulin-like peptide 3 (INSL3) receptors, RXFP1 and RXFP2, are found within the leucine-rich repeats (LRRs) of the ectodomains. Specific B-chain residues in the peptides interact with residues in the inner beta-sheets of the LRRs of the receptors. Relaxin binds to RXFP2 with high affinity, although INSL3 has a very poor affinity for RXFP1.

Resolving the unconventional mechanisms underlying RXFP1 and RXFP2 receptor function.

The receptors for relaxin and insulin-like peptide 3 (INSL3) are now well-characterized as the relaxin family peptide (RXFP) receptors RXFP1 and RXFP2, respectively. They are G-protein-coupled receptors (GPCRs) with closest similarity to the glycoprotein hormone receptors, with both containing large ectodomains with 10 leucine-rich repeats (LRRs). Additionally, RXFP1 and RXFP2 are unique in the LGR family in that they contain a low-density lipoprotein class A (LDL-A) module at their N-terminus.