Validation and educational impact study of the NANEP high-fidelity simulation model for open preperitoneal mesh repair of umbilical hernia.

OBJECTIVE: The aim of the study was to develop, validate and analyze the educational impact of a high-fidelity simulation model for open preperitoneal mesh repair of an umbilical hernia. The number of surgical simulators available for training residents is limited. Primary for ethical reasons and secondary for the emerging pay-per-quality policies, practicing-on simulators rather than patients is considered gold standard. Validated full-procedural surgical models will become more and more important in training residents. Such models may assure that evidence-based standards regarding technical aspects of the procedures become integral part of the curriculum. Furthermore, they can be employed as a quality control of residents' skills (Fonseca et al. in J Surg Educ 70:129-137, 2013). METHODS: In a repeated measures design, medical students, residents in their last year of training and attending surgeons performed an open preperitoneal mesh repair on the NANEP model [NANEP stands for the German acronym Nabelhernien-Netzimplatation-Präperitonal (English: Umbilical hernia mesh implantation preperitoneal)]. Subjects were categorized as "Beginners" (internship students) or "Experts" (residents and surgeons). Content validity was analyzed by criteria of subject-matter-experts. Blinded raters assessed surgical skills by means of the Competency Assessment Tool (CAT) using the online platform "CATLIVE". Differential validity was measured by group differences. Proficiency gain was analyzed by monitoring the learning curve (Gallagher et al. in Ann Surg 241:364-372, 2005). Post-operative examination of the simulators shed light on criterion validity. RESULTS: The NANEP model-proofed content and construct-valid significant Bonferroni-corrected differences were found between beginners and experts (p < 0.05). Beginners showed a significant learning increase from the first to the second surgery (p < 0.05). Post-operative examination data confirmed criterion validity. CONCLUSION: The NANEP model is an inexpensive, simple and efficient simulation model. It has highly realistic features, it has been shown to be of high-fidelity, full-procedural and benchtop-model. The NANEP model meets the main needs of surgical educational courses at the beginning of residency.

Incisional hernia repair in a high-fidelity silicone model for open retro-muscular mesh implantation with preparation of the fatty triangle: validation and educational impact study.

BACKGROUND: Incisional hernia repair requires detailed anatomic knowledge. Regarding median subxiphoidal hernias, the proper preparation of the fatty triangle is challenging. To foster proficiency-based training, a cost-efficient model for open median retromuscular mesh repair resembling the human body was developed, including the main anatomical structures related to the procedure. The aim is to create and validate a high-fidelity model on open retromuscular mesh repair suitable for "training before doing". MATERIALS AND METHODS: Different types of fabrics for imitation of connective tissue and 2-component silicones were used to construct the incisional hernia model. Sample size for validation of the model was determined by a triangular testing approach. Operations from six beginners and six experts were assessed by three blinded-raters. Reliability and construct-validity were evaluated on a behaviorally anchored rating scale (highest score: 4) for the criteria: "instrument use", "tissue handling", "near misses and errors", and "end-product quality". RESULTS: The model authentically mimicked an open median retromuscular mesh repair. Participants considered the procedure realistic. Reliability was excellent, ranging from 0.811 to 0.974 for "end-product quality", and "tissue handling" respectively. Construct-validity was confirmed with experts significantly outperforming beginners in the "use of instruments" (Mbeg. = 2.33, Mexp. = 3.94, p < 0.001), "tissue handling" (Mbeg. = 2.11, Mexp. = 3.72, p < 0.001), "near misses and errors" (Mbeg. = 2.67, Mexp. = 3.67, p < 0.001), and "end-product quality" (Mbeg. = 2.78, Mexp. = 3.72, p < 0.001). Criterion-validity revealed a paradox effect: beginners performed significantly better than experts (p < 0.05) when preparing the fatty triangle. CONCLUSIONS: The model covers all relevant aspects involved in median-open retromuscular incisional hernia mesh repair. Performance differences between beginners and experts confirm construct-validity and thereby realism of the model. It enables to efficiently improve and practice technical skills of the demanding surgery.

Predicting total dissolved solids release from central Appalachian coal mine spoils.

Appalachian USA surface coal mines face public and regulatory pressure to reduce total dissolved solids (TDS) in discharge waters, primarily due to effects on sensitive macroinvertebrates. Specific conductance (SC) is an accurate surrogate for TDS and relatively low levels of SC (300-500 µS cm(-1)) have been proposed as regulatory benchmarks for instream water quality. Discharge levels of TDS from regional coal mines are frequently >1000 µS cm(-1). The primary objectives of this study were to (a) determine the effect of rock type and weathering status on SC leaching potentials for a wide range of regional mine spoils; (b) to relate leachate SC from laboratory columns to actual measured discharge SC from field sites; and (c) determine effective rapid lab analyses for SC prediction of overburden materials. We correlated laboratory unsaturated column leaching results for 39 overburden materials with a range of static lab parameters such as total-S, saturated paste SC, and neutralization potential. We also compared column data with available field leaching and valley fill discharge SC data. Leachate SC is strongly related to rock type and pre-disturbance weathering. Fine-textured and non-weathered strata generally produced higher SC and pose greater TDS risk. High-S black shales produced the highest leachate SC. Lab columns generated similar range and overall SC decay response to field observations within 5-10 leaching cycles, while actual reduction in SC in the field occurs over years to decades. Initial peak SC can be reliably predicted (R(2) > 0.850; p < 0.001) by simple lab saturated paste or 1:2 spoil:water SC procedures, but predictions of longer-term SC levels are less reliable and deserve further study. Overall TDS release risk can be accurately predicted by a combination of rock type + S content, weathering extent, and simple rapid SC lab measurements.

Forest restoration potentials of coal-mined lands in the eastern United States.

The Appalachian region in the eastern United Sates is home to the Earth's most extensive temperate deciduous forests, but coal mining has caused forest loss and fragmentation. More than 6000 km in Appalachia have been mined for coal since 1980 under the Surface Mining Control and Reclamation Act (SMCRA). We assessed Appalachian areas mined under SMCRA for forest restoration potentials. Our objectives were to characterize soils and vegetation, to compare soil properties with those of pre-SMCRA mined lands that were reforested successfully, and to determine the effects of site age on measured properties. Soils were sampled and dominant vegetation characterized at up to 10 points on each of 25 post-SMCRA mines. Herbaceous species were dominant on 56%, native trees on 24%, and invasive exotics on 16% of assessed areas. Mean values for soil pH (5.8), electrical conductivity (0.07 dS m(-1)), base saturation (89%), and coarse fragment content (50% by mass) were not significantly different from measured levels on the pre-SMCRA forested sites, but silt+clay soil fraction (61%) was higher, bicarbonate-extractable P (4 mg kg(-1)) was lower, and bulk density (1.20 g cm(-1)) was more variable and often unfavorable. Pedogenic N and bicarbonate-extractable P in surface soils increased with site age and with the presence of weathered rocks among coarse fragments. Our results indicate a potential for many of these soils to support productive forest vegetation if replanted and if cultural practices, including temporary control of existing vegetation, soil density mitigation, and fertilization, are applied to mitigate limitations and aid forest tree reestablishment and growth.

Land use influences and ecotoxicological ratings for upper clinch river tributaries in virginia.

The Clinch River system of southwestern Virginia and northeastern Tennessee is among the most biodiverse aquatic ecosystems of the United States, but its fauna are in decline. Unionidae (freshwater mussel) species are a major component of the Clinch's aquatic community, and their decline is well documented. Point-source discharges within the Clinch drainage are few, and primary stressors on the biota are believed to originate from non-point sources that are transported into the mainstem by tributaries. Currently, the relative influences of tributaries as stressors on aquatic biota are unclear. We studied 19 major tributaries of the free-flowing Upper Clinch River, developed an Ecotoxicological Rating (ETR) utilizing eight parameters, and assessed stream quality among land use categories using the ETR rating system. Biological, toxicological, habitat, and chemical variables were measured in each tributary, near its confluence with the Clinch. Geographic Information System software was used to quantify land use within each tributary watershed; all tributary watersheds are predominately forested, but agricultural, mining, and developed land uses (urban, transportation) are also present. ETRs indicated that the tributaries draining mining-influenced watersheds had greater potential impact on the mainstem than those draining agricultural or forested watersheds, because of poor benthic macroinvertebrate scores. ETRs ranged from 44 to 63, on a 100-point scale, for mining-influenced tributaries compared to agricultural (57-86) and forested tributaries (64-91). Mean ETRs for the mining-influenced tributaries (51) were significantly different than ETRs from agricultural and forested streams (75 and 80, respectively), and the presence of developed land uses had no significant relationship with ETRs.

Herbaceous vegetation productivity, persistence, and metals uptake on a biosolids-amended mine soil.

The selection of plant species is critical for the successful establishment and long-term maintenance of vegetation on reclaimed surface mined soils. A study was conducted to assess the capability of 16 forage grass and legume species in monocultures and mixes to establish and thrive on a reclaimed Appalachian surface mine amended with biosolids. The 0.15-ha coarse-textured, rocky, non-acid forming mined site was prepared for planting by grading to a 2% slope and amending sandstone overburden materials with a mixture of composted and dewatered, anaerobically digested biosolids at a rate of 368 Mg ha(-1) (dry weight). Tall fescue (Festuca arundinacea Schreb.), orchardgrass (Dactylis glomerata L.), switchgrass (Panicum virgatum L.), caucasian bluestem (Bothriochloa caucasia L.), reed canarygrass (Phalaris arundinacea L.), ladino clover (Trifolium repens L.), birdsfoot trefoil (Lotus corniculatus L.), crownvetch (Coronilla varia L.), alfalfa (Medicago sativa L.), common sericea lespedeza and AULotan sericea lespedeza (Lespedeza cuneata L.), tall fescue-ladino clover, tall fescue-alfalfa, orchardgrass-birdsfoot trefoil, switchgrass-AULotan, and an herbaceous species mix intended for planting on reforested sites consisting of foxtail millet [Setaria italica (L.) Beauv.], perennial ryegrass (Lolium perenne L.), redtop (Agrostis alba L.), kobe lespedeza (Kummerowia striata L.), appalow lespedeza (Lespedeza cuneata L.), and birdsfoot trefoil were established between spring 1990 and 1991. Vegetative biomass and/or persistence were assessed in 1996, 1997, 1998, 2000, 2001, and 2002. The high rate of biosolids applied provided favorable soil chemical properties but could not overcome physical property limitations due to shallow undeveloped soil perched atop a compacted soil layer at 25 cm depth. The plant species whose persistence and biomass production were the greatest after a decade or more of establishment (i.e., switchgrass, sericea lespedeza, reed canarygrass, tall fescue, and crownvetch) shared the physiological and reproductive characteristics of low fertility requirements, drought and moisture tolerance, and propagation by rhizome and/or stolons. Of these five species, two (tall fescue and sericea lespedeza) are or have been seeded commonly on Appalachian coal surface mines, and often dominate abandoned pasture sites. Despite the high rates of heavy metal-bearing biosolids applied to the soil, plant uptake of Cd, Cu, Ni, and Zn were well within critical concentrations more than a decade after establishment of the vegetation.

Evaluation of ionic contribution to the toxicity of a coal-mine effluent using Ceriodaphnia dubia.

The United States Environmental Protection Agency has defined national in-stream water-quality criteria (WQC) for 157 pollutants. No WQC to protect aquatic life exist for total dissolved solids (TDS). Some water-treatment processes (e.g., pH modifications) discharge wastewaters of potentially adverse TDS into freshwater systems. Strong correlations between specific conductivity, a TDS surrogate, and several biotic indices in a previous study suggested that TDS caused by a coal-mine effluent was the primary stressor. Further acute and chronic testing in the current study with Ceriodaphnia dubia in laboratory-manipulated media indicated that the majority of the effluent toxicity could be attributed to the most abundant ions in the discharge, sodium (1952 mg/L) and/or sulfate (3672 mg/L), although the hardness of the effluent (792 +/- 43 mg/L as CaCO3) ameliorated some toxicity. Based on laboratory testing of several effluent-mimicking media, sodium- and sulfate-dominated TDS was acutely toxic at approximately 7000 microS/cm (5143 mg TDS/L), and chronic toxicity occurred at approximately 3200 microS/cm (2331 mg TDS/L). At a lower hardness (88 mg/L as CaCO3), acute and chronic toxicity end-points were decreased to approximately 5000 microS/cm (3663 mg TDS/L) and approximately 2000 microS/cm (1443 mg TDS/L), respectively. Point-source discharges causing in-stream TDS concentrations to exceed these levels may risk impairment to aquatic life.

Impaired Acroneuria sp. (Plecoptera, Perlidae) populations associated with aluminum contamination in neutral pH surface waters.

Our aim was to quantify impairment to invertebrate predator populations, particularly to Acroneuria sp. (Plecoptera, Perlidae), downstream of an acid mine drainage-impacted tributary to the North Fork of the Powell River, southwestern Virginia. Predatory insects comprised 9.0 +/- 1.3% of the total abundance at the three stations upstream of the impacted tributary, but were significantly reduced (p = 0.0039) downstream (3.9 +/- 0.6%). Acroneuria sp. populations followed the same trend, with the upstream average (2.3 and 2.8%) being significantly higher (p < 0.05) than the downstream averages (0.2 and 0%) during 1999 and 2000, respectively. Using correlation analysis, we evaluated the relationship between the percent abundance of Acroneuria sp. throughout this reach and metal concentrations in water, sediment, and biological tissues (invertebrate predators and primary consumers). Water column aluminum (Al) concentration was the only parameter that was significantly correlated with percent Acroneuria sp. abundance, with correlation coefficients of -0.845 and -0.873 during 1999 and 2000, respectively. While this correlation exists, it may not indicate a causal relationship, and experiments should be conducted to determine the long-term toxicity of various Al species to perlid stoneflies.

Factors affecting alkalinity generation by successive alkalinity-producing systems: regression analysis.

Use of successive alkalinity-producing systems (SAPS) for treatment of acidic mine drainage (AMD) has grown in recent years. However, inconsistent performance has hampered widespread acceptance of this technology. This research was conducted to determine the influence of system design and influent AMD chemistry on net alkalinity generation by SAPS. Monthly observations were obtained from eight SAPS cells in southern West Virginia and southwestern Virginia. Analysis of these data revealed strong, positive correlations between net alkalinity generation and three variables: the natural log of limestone residence time, influent dissolved Fe concentration, and influent non-Mn acidity. A statistical model was constructed to describe SAPS performance. Subsequent analysis of data obtained from five systems in western Pennsylvania (calibration data set) was used to reevaluate the model form, and the statistical model was adjusted using the combined data sets. Limestone residence time exhibited a strong, positive logarithmic correlation with net alkalinity generation, indicating net alkalinity generation occurs most rapidly within the first few hours of AMD-limestone contact and additional residence time yields diminishing gains in treatment. Influent Fe and non-Mn acidity concentrations both show strong positive linear relationships with net alkalinity generation, reflecting the increased solubility of limestone under acidic conditions. These relationships were present in the original and the calibration data sets, separately, and in the statistical model derived from the combined data set. In the combined data set, these three factors accounted for 68% of the variability in SAPS systems performance.

Fate of the herbicides mecoprop, dichlorprop, and 2,4-D in aerobic and anaerobic sewage sludge as determined by laboratory batch studies and enantiomer-specific analysis.

Aerobic degradation experiments with the racemic mixtures of mecoprop and dichlorprop revealed that activated sludge collected from the aeration tank of a municipal waste water treatment plant degraded both enantiomers of mecoprop and dichlorprop within 7 days, albeit in an enantioselective manner; the (S) enantiomers were preferentially degraded. Mecoprop, dichlorprop, and 2,4-D were completely metabolized under aerobic conditions, as shown by the 86-98% elimination of dissolved organic carbon. Under anaerobic conditions, the concentration of 2,4-D decreased exponentially with a first-order reaction rate constant of 0.24 per day and without a lag-phase. After an incubation time of 17 days, 2,4-D was completely removed. 2,4-Dichlorophenol was the main metabolite of anaerobic 2,4-D degradation; only traces of 4-chlorophenol were detected. In contrast, the chiral phenoxypropionic acid herbicides mecoprop and dichlorprop persisted under anaerobic conditions during 49 days of incubation.

Enantioselective uptake and degradation of the chiral herbicide dichlorprop [(RS)-2-(2,4-dichlorophenoxy)propanoic acid] by Sphingomonas herbicidovorans MH.

Sphingomonas herbicidovorans MH was able to completely degrade both enantiomers of the chiral herbicide dichlorprop [(RS)-2-(2,4-dichlorophenoxy)propanoic acid], with preferential degradation of the (S) enantiomer over the (R) enantiomer. These results are in agreement with the recently reported enantioselective degradation of mecoprop [(RS)-2-(4-chloro-2-methylphenoxy)propanoic acid] by this bacterium (C. Zipper, K. Nickel, W. Angst, and H.-P. E. Kohler, Appl. Environ. Microbiol. 62:4318-4322, 1996). Uptake of (R)-dichlorprop, (S)-dichlorporp, and 2,4-D (2,4-dichlorophenoxyacetic acid) was inducible. Initial uptake rates of cells grown on the respective substrate showed substrate saturation kinetics with apparent affinity constants (Kt) of 108, 93, and 117 microM and maximal velocities (Vmax) of 19, 10, and 21 nmol min-1 mg of protein-1 for (R)-dichlorprop, (S)-dichlorprop, and 2,4-D, respectively. Transport of (R)-dichlorprop, (S)-dichlorprop, and 2,4-D was completely inhibited by various uncouplers and by nigericin but was only marginally inhibited by valinomycin and by the ATPase inhibitor N,N'-dicyclohexylcarbodiimine. Experiments on the substrate specificity of the putative transport systems revealed that (R)-dichlorprop uptake was inhibited by (R)-mecoprop but not by (S)-mecoprop, (S)-dichlorprop, or 2,4-D. On the other hand, the (S)-dichlorprop transport was inhibited by (S)-mecoprop but not by (R)-mecoprop, (R)-dichlorprop, or 2,4-D. These results provide evidence that the first step in the degradation of dichlorprop, mecoprop, and 2,4-D by S. herbicidovorans is active transport and that three inducible, proton gradient-driven uptake systems exist: one for (R)-dichlorprop and (R)-mecoprop, another for (S)-dichlorprop and (S)-mecoprop, and a third for 2,4-D.

Complete microbial degradation of both enantiomers of the chiral herbicide mecoprop [(RS)-2-(4-chloro-2-methylphenoxy)propionic acid] in an enantioselective manner by Sphingomonas herbicidovorans sp. nov.

Sphingomonas herbicidovorans MH (previously designated Flavobacterium sp. strain MH) was able to utilize the chiral herbicide (RS)-2-(4-chloro-2-methylphenoxy)propionic acid (mecoprop) as the sole carbon and energy source. When strain MH was offered racemic mecoprop as the growth substrate, it could degrade both the (R) and the (S) enantiomer to completion, as shown by biomass formation, substrate consumption, and stoichiometric chloride release. However, the (S) enantiomer disappeared much faster from the culture medium than the (R) enantiomer. These results suggest the involvement of specific enzymes for the degradation of each enantiomer. This view was substantiated by the fact that resting cells of strain MH grown on (S)-mecoprop were able to degrade the (S) but not the (R) enantiomer of mecoprop. Accordingly, resting cells of strain MH grown on (R)-mecoprop preferentially metabolized the (R) enantiomer. Nevertheless, such cells could transform (S)-mecoprop at low rates. Oxygen uptake rates with resting cells confirmed the above view, as oxygen consumption was strongly dependent on the growth substrate. Cells grown on (R)-mecoprop showed oxygen uptake rates more than two times higher upon incubation with the (R) than upon incubation with the (S) enantiomer and vice versa.

Enantioselective Metabolism of Chiral 3-Phenylbutyric Acid, an Intermediate of Linear Alkylbenzene Degradation, by Rhodococcus rhodochrous PB1.

Rhodococcus rhodochrous PB1 was isolated from compost soil by selective culture with racemic 3-phenylbutyric acid as the sole carbon and energy source. Growth experiments with the single pure enantiomers as well as with the racemate showed that only one of the two enantiomers, (R)-3-phenylbutyric acid, supported growth of strain PB1. Nevertheless, (S)-3-phenylbutyric acid was cometabolically transformed to, presumably, (S)-3-(2,3-dihydroxyphenyl)butyric acid (the absolute configuration at the C-3 atom is not known yet) by (R)-3-phenylbutyric acid-grown cells of strain PB1, as shown by (sup1)H nuclear magnetic resonance spectroscopy of the partially purified compound and gas chromatography-mass spectrometry analysis of the trimethylsilyl derivative. Oxygen uptake rates suggest that either 3-phenylpropionic acid or cinnamic acid (trans-3-phenyl-2-propenoic acid) is the substrate for aromatic ring hydroxylation. This view is substantiated by the fact that 3-(2,3-dihydroxyphenyl)propionic acid was a substrate for meta cleavage in cell extracts of (R)-3-phenylbutyric acid-grown cells of strain PB1. Gas chromatography-mass spectrometry analysis of trimethylsilane-treated ethyl acetate extracts of incubation mixtures showed that both the meta-cleavage product, 2-hydroxy-6-oxo-2,4-nonadiene-1,9-dicarboxylic acid, and succinate, a hydrolysis product thereof, were formed during such incubations.