The potential benefits of SILS include superior cosmesis and possibly shorter operative time, lower costs, and a shortened time to full physical recovery. Careful case selection and a low threshold of conversion to conventional laparoscopic surgery are essential. Multicenter, randomized, prospective studies are needed to compare short- and long-term outcome measures against those of conventional laparoscopic surgery.

Horizontal gene transfer threatens the therapeutic success of antibiotics by facilitating the rapid dissemination of resistance alleles among bacterial species. The conjugative mobile element Tn916 provides an excellent context for examining the role of adaptive parasexuality as it carries the tetracycline-resistance allele tetM and has been identified in a wide range of pathogens. We have used a combination of experimental evolution and allelic frequency measurements to gain insights into the adaptive trajectories leading to tigecycline resistance in a hospital strain of Enterococcus faecalis and predict what mechanisms of resistance are most likely to appear in the clinical setting. Here, we show that antibiotic selection led to the near fixation of adaptive alleles that simultaneously altered TetM expression and produced remarkably increased levels of Tn916 horizontal gene transfer. In the absence of drug, approximately 1 in 120,000 of the nonadapted E. faecalis S613 cells had an excised copy of Tn916, whereas nearly 1 in 50 cells had an excised copy of Tn916 upon selection for resistance resulting in a more than 1,000-fold increase in conjugation rates. We also show that tigecycline, a translation inhibitor, selected for a mutation in the ribosomal S10 protein. Our results show the first example of mutations that concurrently confer resistance to an antibiotic and lead to constitutive conjugal-transfer of the resistance allele. Selection created a highly parasexual phenotype and high frequency of Tn916 jumping demonstrating how the use of antibiotics can lead directly to the proliferation of resistance in, and potentially among, pathogens.

Categories of facial asymmetry perception establish a framework to counsel patients with facial asymmetries, and are a valuable adjunct to clinical judgment in the management of static and dynamic facial deformities.

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Evolving professional, social and political pressures highlight the importance of lifelong learning for clinicians. Continuing medical education (CME) facilitates lifelong learning and is a fundamental factor in the maintenance of certification. The type of CME differs between surgical and non-surgical specialties. CME methods of teaching include lectures, workshops, conferences and simulation training. Interventions involving several modalities, instructional techniques and multiple exposures are more effective. The beneficial effects of CME can be maintained in the long term and can improve clinical outcome. However, quantitative evidence on validity, reliability, efficacy and cost-effectiveness of various methods is lacking. This is especially evident in urology. The effectiveness of CME interventions on maintenance of certification is also unknown. Currently, many specialists fulfil mandatory CME credit requirements opportunistically, therefore erroneously equating number of hours accumulated with competence. New CME interventions must emphasize actual performance and should correlate with clinical outcomes. Improved CME practice must in turn lead to continuing critical reflection, practice modification and implementation with a focus towards excellent patient care.

Study Type – Therapy (systematic review) Level of Evidence 1a What's known on the subject? and What does the study add? Research on the subject has shown that robotic surgery is more costly than both laparoscopic and open approaches due to the initial cost of purchase, annual maintenance and disposable instruments. However, both robotic and laparoscopic approaches have reduced blood loss and hospital stay and robotic procedures have better short term post‐operative outcomes such as continence and sexual function. Some studies indicate that the robotic approach may have a shorter learning curve. However, factors such as reduced learning curve, shorter hospital stay and reduced length of surgery are currently unable to compensate for the excess costs of robotic surgery. This review concludes that robotic surgery should be targeted for cost efficiency in order to fully reap the benefits of this advanced technology. The excess cost of robotic surgery may be compensated by improved training of surgeons and therefore a shorter learning curve; and minimising costs of initial purchase and maintenance. The review finds that only a few studies gave an itemised breakdown of costs for each procedure, making accurate comparison of costs difficult. Furthermore, there is a lack of long term follow up of clinical outcomes, making it difficult to accurately assess long term post‐operative outcomes. A breakdown of costs and studies of long term outcomes are needed to accurately assess the effectiveness of robotic surgery in urology. OBJECTIVES Although robotic technology is becoming increasingly popular for urological procedures, barriers to its widespread dissemination include cost and the lack of long term outcomes. This systematic review analyzed studies comparing the use of robotic with laparoscopic and open urological surgery. These three procedures were assessed for cost efficiency in the form of direct as well as indirect costs that could arise from length of surgery, hospital stay, complications, learning curve and postoperative outcomes. METHODS A systematic review was performed searching Medline, Embase and Web of Science databases. Two reviewers identified abstracts using online databases and independently reviewed full length papers suitable for inclusion in the study. RESULTS Laparoscopic and robot assisted radical prostatectomy are superior with respect to reduced hospital stay (range 1–1.76 days and 1–5.5 days, respectively) and blood loss (range 482–780 mL and 227–234 mL, respectively) when compared with the open approach (range 2–8 days and 1015 mL). Robot assisted radical prostatectomy remains more expensive (total cost ranging from US $2000–$39 215) than both laparoscopic (range US $740–$29 771) and open radical prostatectomy (range US $1870–$31 518). This difference is due to the cost of robot purchase, maintenance and instruments. The reduced length of stay in hospital (range 1–1.5 days) and length of surgery (range 102–360 min) are unable to compensate for the excess costs. Robotic surgery may require a ...

The details of the total synthesis of viridicatumtoxin B (1) are described. Initial synthetic strategies toward this intriguing tetracycline antibiotic resulted in the development of key alkylation and Lewis acid-mediated spirocyclization reactions to form the hindered EF spirojunction, as well as Michael–Dieckmann reactions to set the A and C rings. The use of an aromatic A-ring substrate, however, was found to be unsuitable for the introduction of the requisite hydroxyl groups at carbons 4a and 12a. Applying these previous tactics, we developed stepwise approaches to oxidize carbons 12a and 4a based on enol- and enolate-based oxidations, respectively, the latter of which was accomplished after systematic investigations that revealed critical reactivity patterns. The herein described synthetic strategy resulted in the total synthesis of viridicatumtoxin B (1), which, in turn, formed the basis for the revision of its originally assigned structure. The developed chemistry facilitated the synthesis of a series of viridicatumtoxin analogues, which were evaluated against Gram-positive and Gram-negative bacterial strains, including drug-resistant pathogens, revealing the first structure–activity relationships within this structural type.