33 So, what should be done, and how the graduates who will be the future health care provider of a nation should be prepared? The General Medical Council recommends that general clinical training is an integral part of basic medical education, the aim of which includes the development of competence in history taking, clinical examination, interpretation and selection of diagnostic tests, as well as diagnosis and decision making skills.31 The council also requires that doctors to be honest and

trustworthy, treat patients politely and considerately; listen to them, respect their dignity, privacy, and rights to be involved in clinical decision making process, Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical respect their spouses, and respect and protect confidential information. These are the core values

of clinical medicine.33 To overcome the problems that are encountered in bedside teaching one just need a sufficiently Selleckchem GDC0068 prepared careful planning. The planning should include the identification of the followings. 1) a description of the learner whether he (she) is a first or a fifth year student, a senior house officer in psychiatry or else, 2) a description of the behavior that the learner should Inhibitors,research,lifescience,medical demonstrate such as the ability to inform the patient, ability to examine or elicit, 3) a description of the condition in which the learner will demonstrate the learning such as the context for a follow up patient, a palliative setting, office setting, etc, Inhibitors,research,lifescience,medical 4) a description of the extent to which the learner can function in a responsive and honest manner.34

The implementation of an effective bedside teaching needs careful planning and coordination.35 Teachers and educational managers should be motivated and trained,34,36,37 to adopt the changing needs. The change in medical education is currently a worldwide phenomenon,38 and the changing the needs of teaching at the bedside must be adopted to prepare doctors Inhibitors,research,lifescience,medical who are able to fulfill the needs of the community. Below is a selection of some models that might help us to think about and structure bedside teaching. Three Domain-Model of Best Bedside Teaching Practices Janicik and Fletcher (2003),2 suggested a new three domains “Model of Best Bedside Teaching Practices,” which emphasizes on (1) attending to patient comfort, (2) focused teaching, and (3) group dynamics. Tolmetin Patients’ comfort can be achieved through established rules of conduct including asking the patient ahead of time, introducing all, providing a brief overview, avoiding technical language, teaching with data about the patient and providing a genuine encouraging closure. Focused teaching session should be relevant to an individual patient’s and learner’s needs. To make the teaching-focused, we have to diagnose the patient, diagnose the learner, target the teaching and provide constructive feedback privately.

Echocardiography is the choice investigation. Classically,

tricuspid valve leaflets and its subvalvular apparatus is thickened; excursion of the leaflets become retracted, fixed, and noncoapting, leading to the valve remaining in a semiopen position. A “dagger-shaped” continuous wave-doppler profile resulting from severe tricuspid regurgitation with elevated right atrial pressure (that causes early peak pressure and its rapid decline) is seen at continuous wave-doppler record.7) Because the blood cannot be adequately ejected through the pulmonary valve, the right ventricle work increases. The right Inhibitors,research,lifescience,medical atrium and ventricle are enlarged becomes volume overloaded. But, RV function seemingly remains intact until quite Inhibitors,research,lifescience,medical late in the disease course. The heart’s lesions may cause right-sided heart failure. Three-DE provided more detailed anatomic informations about the tricuspid valve. In addition, it seems to be more useful for the assessment of RV size and function in comparison to two-dimensional echocardiography because it is not based on geometrical assumptions. The systo-diastolic RV shape highlights the unhomogeneous RV contractility related to the degree of its dysfunction. RV volumes and RVEF% evaluated with 3-DE were significantly increased (volumes) and decreased (ejection fraction) respectively, in comparison to the normals,8) Inhibitors,research,lifescience,medical and are well correlated

with MRI estimated as reference method.9) 3DE slightly overestimated RV end diastolic and end systolic volumes, although

the degree of overestimation was not significant. On the contrary, Inhibitors,research,lifescience,medical RVEF was underestimated in respect to MRI. Possibile reasons for these differences between 3-DE and MRI include difficulties in defining the endocardial borders, artifacts induced by the respiration movements and some BMS-754807 purchase uncertainties in to precisely identify valvular planes. Conclusively, while 2-D echocardiography is the choice method for define the valvular involvements in carcinoid heart disease, the 3-D echocardiography seems able Inhibitors,research,lifescience,medical to provide more detailed and precise anatomic and hemodynamic informations about RV size and function and valvular anatomic and functional changes.10),11)
Cardiac calcified amorphous tumors (CATs) are extremely Parvulin rare cardiac masses which can arise in all four cardiac chambers.1),2) While several causes of cardiac CATs have been suggested, the true etiology is not still clear. Cardiac CATs are usually benign, but sometimes cause diverse symptoms due to obstruction or embolization.1),3) We recently encountered a patient with a cardiac CAT causing multiple, calcific, pulmonary emboli and right-sided heart failure. A cardiac CAT has not been reported previously in Korea. Case A 33-year-old man sought evaluation in our outpatient clinic for progressive pretibial pitting edema and shortness of breath on exertion.

64,65 One approach to inhibition of GSK-3 that has been used in these studies is lithium. Lithium results in developmental abnormalities in experimental models that, mimic a signal transduction cascade known as Wingless (wnt in mammals). Wingless or wnt signaling results in GSK-3 inhibition, and this led Klein and Melton to hypothesize and then demonstrate that lithium mimics Wingless signal by inhibiting GSK-3.66 In nonneuronal cells, in neurons, and in animals, lithium has

now been shown to reduce tau phosphorylation as would be expected if GSK-3 is a predominant taukinase.67-72 This inhibition of GSK-3 alters the properties of tau in neurons and in living nonneuronal cells, Inhibitors,research,lifescience,medical and does so within the therapeutic range of lithium. This

body of work Inhibitors,research,lifescience,medical does raise the interesting question as to whether GSK-3 is the target of lithium in the therapy of affective disorders, especially as another agent used in bipolar disorder, sodium valproate, also inhibits GSK-3.73 Attention has recently turned to a pathway that interacts with Wingless signaling – the Notch pathway. Notch is a transmembrane protein essential for neurogenesis, but also present, and presumably therefore active, in adult brain.74-76 Activation of Notch involves cleavage within the membrane domain, very reminiscent of the y-secretase cleavage of APP.77 A role for presenilins in Notch activity was first suggested by homology as the equivalent Inhibitors,research,lifescience,medical of presenilins in Caenorhabditis elegatis, SEL12, is associated with LIN12, the C elegans equivalent of Notch. Human presenilins are able to compensate for loss of SEL12, but mutated human presenilins lose Inhibitors,research,lifescience,medical this ability.78,79 In a number of

different mammalian model experiments, the presenilin protein has now been shown to activate Notch.79-84 The evidence that presenilins are involved in Notch signaling is now compelling, and this is intriguing, as Notch signaling and Wingless signaling interact.85-87 In the Wingless signal cascade, inhibition of GSK-3 results in accumulation of a protein called β-catenin, and, to add to the complexity Inhibitors,research,lifescience,medical of this area, presenilins bind to catenins and affect β-catenin signaling.88-92 Much needs to be done to untangle this complicated set of observations, not all of which are consistent. However, it Montelukast Sodium does appear to be the case that Wingless and Notch signaling interact, and that, in doing so, GSK-3 activity is regulated, and that the presenilins are involved – certainly with Notch signaling, and possibly with Wingless signaling. In addition to Wingless/wnt signaling, GSK-3 is inhibited by insulin signaling through protein kinase B (PKB) and PT3-kinase. As predicted, insulin not only reduces tau phosphorylation in neurons, but, also increases taumicrotubulc interactions.93 Just, as GSK-3 might be the missing link between Selleck VX 809 amyloid and tau, so too might GSK-3 be the missing link between an important, finding from epidemiology and etiopathogenesis.

The Ibn Sina (Avicenna, c. 980–1037)) statue (C,D) (http://www.muslimphilosophy.com) may have served … However, the sculptured face bears remarkable resemblance to the great physician and philosopher Ibn Sina (Avicenna, 980–1037) (Figure 11) whose sculpture was based on an accurate reconstruction of his skull. Evidently, all artists look for inspiration and historical, tangible references and often resort to using archetypical faces collectively believed to characterize distinguished ancient scholars/physicians/philosophers not necessarily Jews. WHAT IS THE

SIGNIFICANCE OF Inhibitors,research,lifescience,medical HIS UNIQUE TURBAN AND RICHLY DECORATED CLOTHES? Whether the artist has chosen a garment and decorations based on historical factoids or was simply influenced by stereotypes and existing living models is undetermined. The end result might be coincidental, but some symbolic hints warrant further reflection. Egyptians and Orientals, including local Jews, have indeed worn typical turbans for many centuries. A typical turban known Inhibitors,research,lifescience,medical as the Moock’leh resembles the one in the Maimonides portrait.15 In certain periods of history, different colored turbans were mandated by law according to one’s religion. There were also identifiable differences in the manner of wrapping them. Nicolas Inhibitors,research,lifescience,medical de Nicolay who returned from

Istanbul in 1552 reported that Jewish turbans were yellow/orange, Inhibitors,research,lifescience,medical a color that matches the one in the Maimonides portrait. His published original engravings and observations of the Orient16 include a famous impression of a Merchant Jew considered a trustworthy representation of the turban and clothes worn by rich eminent Jews. The decorated clothes may also allude to the usage of amulets or talismans. Maimonides himself Inhibitors,research,lifescience,medical disrespected and even preached strongly against the

protective and healing powers of amulets or blessed objects. Nevertheless at the time when the Maimonides portrait was published most people of all religions, including Jews, believed in those powers, and the artist may have drawn the “medal” or engraved coin accordingly. Alternatively, this may simply represent a generally accepted trade-mark of ancient physicians, almost like wearing a stethoscope nowadays is considered a trade-mark of modern physicians. Furthermore the artist may have alluded to an honorary ranking symbol given to Maimonides as head physician of first Salah-a-Din, the Sultan of Egypt. The embroidery and what appears like gold braid with 12 colored gemstones might even be the artist’s interpretation of the Hoshen, the sacred breastplate worn by the High Priest for the Israelites. In the selleckchem biblical account, the breastplate is termed the breastplate of judgment, because the Urim and Thummim (four rows of three engraved gems), which were used in divination, were placed within it.

431) or the 5-FU-treated group (overall log rank P=0.112) (data not shown). For each patient, the ratio of Bax/Bcl2 expression was determined and correlated with patient

survival separately for each treatment category. The ratio of Bax/Bcl2 expression was not correlated with patient survival in surgery alone category (Fig 3C). In contrast, the ratio of Bax/Bcl2 expression significantly correlated with patient survival, indicating that those patients with a high Bax/Bcl2 ratio value would not benefit from 5-FU treatment; however, those patients with low Bax/Bcl2 ratios were more OSI-906 in vivo likely to have better survival when treated with Inhibitors,research,lifescience,medical 5-FU based therapies (Fig 3D). Analysis of nuclear accumulation Inhibitors,research,lifescience,medical of p53 Expression of p53nac was generally homogenous; however, p53 staining was observed in the cytoplasm of malignant cells in 7% of cases (8 of 112) (Fig 2G-I). The cytoplasmic staining was not further analyzed. High levels of p53nac were found in tumors of 59% of patients (33 5-FU-treated and 32 surgery-alone). For both categories of patients, there were no significant differences in the incidence of deaths due to CRCs (Table 1), in the median survival (Table 3), or survival rates (data not shown) in relation to p53nac (Table 1). Multivariate survival analyses As determined by multivariate analyses of Cox proportional hazards, surgery-alone patients with low Bax expression had 5.33 Inhibitors,research,lifescience,medical times Inhibitors,research,lifescience,medical higher mortality compared to those with

high Bax expression (HR: 5.33; CI: 1.78-15.94) when adjusted for demographic and clinicopathological variables and for expression Bcl-2, the Bax/Bcl2 ratio, and p53nac (Table 4). 5-FU treated patients with low Bax/Bcl2 ratios had 21.55 times higher mortality compared to those with high Bax/Bcl2 ratios (HR: 21.55; CI: 1.46-31.00), when adjusted for other variables (Table 4). Bcl-2 and p53nac, however, were not independent prognostic indicators of survival in either group of patients (Table 4). Table 4 Multivariate Cox regression analyses Inhibitors,research,lifescience,medical to assess the prognostic

significance of clinicopathological and molecular features based on treatment status on overall survival Discussion The current study, we analyzed the predictive value of Bax, Bcl-2, and p53nac and determined their isothipendyl association with survival in CRC patients who received 5-FU-based adjuvant treatment after surgery and in CRC patients matched for age, gender, ethnicity, tumor stage, tumor location, and tumor differentiation who underwent surgery alone with curative or palliative intent. These analyses demonstrate a better survival of patients who received chemotherapy when their CRCs lacked Bax expression. In contrast, patients with CRCs that exhibited high Bax expression had worse survival when they received 5-FU-based adjuvant chemotherapy. Furthermore, multivariate Cox regression analysis showed that surgically treated patients with low levels (or lack) of Bax expression had 5.

We tried to avoid the spreading of drugs to other regions of the hippocampus by restricting the volume of microinjections to 0.2 μL. Considering this, our findings suggest that the severity of convulsive reactions induced by peripheral treatment with PTZ, rather than cholinergic mechanisms of the dH, may also be mediated by other areas of the CNS, for example, the entorhinal cortex (Stringer 1996), amygdaloid complex (Galvis-Alonso et al. 2004; Foresti et al. 2008), other structures Inhibitors,research,lifescience,medical of the hippocampal formation (Rodrigues et al. 2004; Lan et al. 2007),

and the corpora quadrigemina (Garcia-Cairasco 2002; Doretto et al. 2009). Additionally, the severity of convulsive reactions may possibly be modulated by the substantia nigra, pars reticulata, and inhibitory pathways that modulate Inhibitors,research,lifescience,medical aversive stimulus-induced defensive responses

(Coimbra and Brandão 1993; Eichenberger et al. 2002; Ribeiro et al. 2005; Castellan-Baldan et al. 2006), as well as epileptogenic activity (Rodrigues et al. 2004; Rossetti et al. 2011, 2012). In conclusion, the neuroanatomical substrates identified Inhibitors,research,lifescience,medical in the present work reinforce the involvement of the pain inhibitory system in pain control and suggest that the nuclei connected to the dH are critically involved in the elaboration of postictal antinociception. A reduction in dH activity, caused by blocking local synapses with cobalt chloride, decreased postictal analgesia, confirming dH involvement in the elaboration of antinociception induced by tonic-clonic seizures. Furthermore, our findings suggest that the muscarinic and nicotinic cholinergic pathways from the dH exert Inhibitors,research,lifescience,medical an important role in the organization of postictal antinociception, possibly modulated by input to the dH from both prosencephalic areas and from the endogenous pain inhibitory Inhibitors,research,lifescience,medical system. Elucidation of the neurochemistry

of the antinociceptive process evoked by convulsive seizures may represent an important step toward understanding the NVP-BKM120 neural basis of the control of pain. Acknowledgments This work was supported by FAPESP (proc. 96/08574-9, 02/01496-5, and 07/01174-1), CAPES (AUX-PE-PNPD either 2400/2009, proc. 23038.027801/2009-37), and FAEPA (proc. 537/1995 and 70/2002). L. I. Bolognesi was the recipient of a Scientific Initiation scholarship sponsored by FAPESP (08/03402-4). A. Twardowschy was a Doctorate (Sc.D.; process 2008/00531-8) student and a Post-Doctoral (process 2011/20381-3) researcher supported by FAPESP. R. L. de Freitas was the recipient of a Scientific Initiation scholarship (process 01/03752-6), a Magister Scientiae (M.Sc.) fellowship (process 03/05256-1) sponsored by FAPESP, a Scientiae Doctor (Sc.D.). Fellowship sponsored by CAPES and is a Post-Doctorate researcher supported by FAPESP (process 2009/17258-5). N. C.

52 In living subjects, kidney mass is obtainable by weighing the donor kidney prior to transplantation and has proven to have clinical relevance (vide infra). Kidney Volume Kidney volume can be readily measured by ultrasound. Spencer et al. found relatively lower kidney volumes in LBW Australian Aboriginal children aged 5–18 when adjusted for body size.60 In contrast, Rakow et al. did not find a significant difference between kidney volumes of individuals who had been term AGA, term SGA, or preterm, when adjusting for body surface Inhibitors,research,lifescience,medical area (BSA), gender, and age.61 Kidney

size is dependent on nephron number and the degree of nephron hypertrophy and is strongly correlated

with current body size.15 In fetuses and at birth, kidney volume is proportional to nephron number; however, subsequently, normal kidney growth (impacted Inhibitors,research,lifescience,medical by BSA, age, and gender), glomerulomegaly (hypertrophy due to low nephron number, obesity, etc.), and nephron loss through injury are likely to affect kidney volume disproportionately, Inhibitors,research,lifescience,medical making a direct relationship less clear.60 Among young adults born prematurely (either AGA or SGA) compared with term age-matched controls, prematurity was associated with smaller kidneys at age 20 years, whereas IUGR had only a small, non-significant effect.62 Kidney volume may

therefore not be ideally reliable as a surrogate for nephron endowment. CLINICAL CONSEQUENCES OF IMPAIRED DEVELOPMENTAL PROGRAMMING IN THE KIDNEY Nephron Number, Size, and Blood Pressure In adult animals, surgical removal of one kidney under varying circumstances and in different Inhibitors,research,lifescience,medical species does not always result in spontaneous hypertension Inhibitors,research,lifescience,medical and renal disease.63 In contrast, however, NSC 683864 solubility dmso uni-nephrectomy on postnatal day 1 in rats, or fetal uni-nephrectomy in sheep, i.e. loss of nephrons at a time when nephrogenesis is still on-going, does lead to adult hypertension prior to any evidence of renal injury.64–66 These data support the possibility that intrauterine or many congenital reduction in nephron number may elicit different compensatory responses compared to later nephron loss, augmenting the risk of hypertension. Consistent with this view, kidneys from rats that underwent uni-nephrectomy at day 3 of age had similar total number but a greater proportion of immature glomeruli in adulthood, compared with those who underwent nephrectomy at day 120 of age.67 In addition, mean glomerular volume in neonatally nephrectomized rats was increased by 59% compared with 20% in adult nephrectomized rats, suggesting a greater degree of compensatory hypertrophy and hyperfunction in response to neonatal nephrectomy.

MRS studies using animal models of human diseases facilitate biomarker identification and drug development because they allow delineation of the pathological correlates of biomarkers and screening of potential drugs in preclinical trials. As such, these animal studies enhance human applications of MRS, however, the interpretation and translation of animal data to human applications need additional considerations. First, the regional differences

and developmental changes in metabolite levels120 need to be taken into account when designing studies. Of note, the neurochemical profile of the rodent and human brain is very similar, with only few differences, Inhibitors,research,lifescience,medical such as very high taurine levels in the rodent brain (Figure 4). Second,

potential effects of anesthesia, which is necessary for animal scanning, need to be considered. General anesthesia was not found to affect steady-state levels of MRS detectable metabolites in Inhibitors,research,lifescience,medical the brain, except for glucose and lactate.121,122 Figure 4. Neurochemical profiles of human and mouse cerebellum. Concentrations ± SD (µmol/g) obtained from the cerebellum of 16 healthy volunteers (35±15 years old) and 6 mice (C57BL/6, 6-8 weeks old) at 4T and 9.4T, respectively. The concentrations Inhibitors,research,lifescience,medical … Diagnosis MRS can be utilized in preclinical and eventually clinical applications to distinguish, for example, transgenic mouse models from wild-type (WT) animals or Bleomycin research buy patients from healthy controls. For the successful translation of biomarker data from animal models to humans,123 not only does the model need to faithfully reproduce the Inhibitors,research,lifescience,medical pathology and phenotype of the human disease, but the same biomarker alterations need to be observed in the mouse Inhibitors,research,lifescience,medical model and in patients. This is a critical consideration. MRS studies with various AD mouse models demonstrate this issue well. For example, among the different AD models studied with 1H MRS, APP-PS1 mice match the neurochemical profile found in human AD best.103 These mice

display reductions in NAA and glutamate, as well as an increase in myo-inositol. The myoinositol difference in particular had not been detected in other AD models, but is a prominent neurochemical alteration detected in human AD.110 A more recent studydemonstrated these neurochemical profile changes at an even earlier age than the APP-PS1 mice in a different AD of mouse model.124 In MPTP-intoxicated mice, well-accepted model of the dopaminergic denervation in Parkinson’s disease (PD), high field MRS enabled detection of elevated glutamate, glutamine and GABA levels in the striatum.125 Of these alterations, the GABA difference was confirmed in human PD at ultra-high field.126 Longitudinal changes in neurochemical profiles were also reported in transgenic117 and knock-in118,127 mouse models of Huntington’s disease (HD).

Community Entry The project was introduced into the sub-district through the Keta District Health Directorate. The district director of health services, who was a

collaborator on the project, informed selected communities and together with community leaders planned for stakeholders’ durbar in each of the four study communities. At these durbars, the project was officially introduced to the entire community members by the research team, where they took advantage to sensitize the people and asked for their support and cooperation. After explaining every aspect of the project, community members were given opportunity to buy Hydroxychloroquine ask questions to which appropriate answers were provided. The target population for the project was children from 6 to 60 months old. The issue of why children alone were covered by the intervention came up for discussions and it was made known to the people that children are the most vulnerable to malaria and therefore needed protection. Community Assistants (CAs) Selection At the durbars, communities were asked Selleckchem GDC-0199 to nominate two volunteers each to serve as project CAs

who will deliver the interventions. The qualifications requested of a CA were to be able to read and write clearly, not involved in active politics and must have integrity in the eyes of the community leaders. Besides the CAs (two per community) an assemblyman (local government representative) was selected as a supervisor. All children aged 6 to 60 months old in the chosen communities whose parents/caregivers consented participated in the project. At the beginning of the intervention, 413 children were recruited into the study and this had increased GPX6 to 433 by the end of the study. No caregiver dissented participation. However, when a child attained 60 months, he/she was taken out of the study. Data collection This was a descriptive cross-sectional study using both qualitative and quantitative data collection techniques. Semi-structured questionnaire was administered to 105 randomly selected caregivers. Simple random sampling technique was used to select respondents

from the community register compiled for the intervention and regularly updated. The four communities had a total of 351 Caregivers (Galo-Sota 114, Agbatsivi 57, Agortoe 73 and Salo 107) whose children were enrolled into the project. About 30% of Caregivers in each community were selected to participate in this study. Focus group discussion was organized with nine Community Assistants (CAs) and 16 in-depth interviews were conducted with 16 opinion leaders (four per community). FGD and in-depth interview respondents were purposively selected as key informants. All the tools were translated into the local language (Ewe) and pretested in a community with similar characteristics before the actual data collection was done.

Furthermore, retained towels and sponges during abdominal surgery results in serious postoperative morbidity and potential mortality and risks the reputation of the surgeon and institution. Lap Pak was developed with the intent of decreasing these known consequences of sponges and towels when used for facilitating surgical exposure during

major abdominal surgery. Radical cystectomy with pelvic lymphadenectomy and urinary diversion is a major abdominal surgical procedure that requires cephalad packing of the abdominal content in order to gain access to the bladder and retroperitoneum. For this review, five high-volume urologic oncology this website surgeons were invited to participate in the first testing Inhibitors,research,lifescience,medical of Lap Pak. The surgeons agreed to perform five radical cystectomies Inhibitors,research,lifescience,medical using the device without any prior training sessions. Prior to the first procedure, the technique for intraoperative placement of the device was reviewed with the engineer who developed the device. Of the five surgeons investigating Lap Inhibitors,research,lifescience,medical Pak, four (80%) and three (60%) agreed with the premise that decreasing the

risk of retained foreign body and minimizing trauma to the bowel was a clinically significant potential benefit of Lap Pak, respectively. Overall, three surgeons (60%) had a favorable experience using Lap Pak. None of the surgeons had a negative impression of the device and two (40%) had a neutral impression. Overall, Lap Inhibitors,research,lifescience,medical Pak was used in 23 cases. Of these cases, Lap Pak successfully facilitated exposure in 14 cases (61%). Three (60%) of the surgeons indicated they would use Lap Pak routinely on future radical cystectomy

procedures. Two of the five surgeons were less enthusiastic about the potential benefits or the performance of the device. These surgeons used Lap Pak together with a Balfour retractor. The Balfour retractor has a single blade for cephalad exposure which may not be adequate Inhibitors,research,lifescience,medical to hold Lap Pak securely in place. Those surgeons using retractors that had two cephalad-oriented limbs all thought Lap Pak facilitated exposure and were both willing and enthusiastic about using the device on future cases. At the moment, Lap Pak comes in only one size primarily because of the limited else variability in the dimensions of the adult abdominal cavity. Based on preliminary experience, additional sizes may be required for patients at the extremes of BMI. We recognize that we cannot overgeneralize based on the view of only five surgeons whose experience may differ based on their level of expertise. Nevertheless, the generally favorable initial experience with Lap Pak provides the basis for further investigation of the device in order to optimize its use. It is likely that with further experience, minor adjustments will be made in the design or additional sizes will be required for its more universal role in abdominal surgery.