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Are Miracles for Today?
Dr. Sproul notes that there is no word for "miracle" in the original languages of Scripture. Our English term miracle translates Hebrew and Greek terms that are more literally rendered as "signs" or "wonders." That shows that miracles are not ...Read More
The Gifts of the Spirit
Today's passage is an important text on the priesthood of all believers. Paul does not mean to deny the roles of elders, teachers, and other officers in the church; rather, he tells us that every Christian is to be involved ...Read More
The Body of Christ
In summarizing today's passage and the communion of saints, answer 55 of the Heidelberg Catechism says that "each member should consider it a duty to use these [spiritual] gifts … for the service and enrichment of the other members." One ...Read More
Gift-giver and Protector
"The body they may kill: God's truth abideth still" is the cry of the believer's confidence in the protecting work of Christ. We may suffer in this world, but in Jesus we are kept from everlasting destruction. We, therefore, will ...Read More
A Cause to Glory in Christ Jesus
In saving us from sin, death, and His holy wrath, our God has placed us in a community that, according to His sovereign determination, needs our gifts and talents. To refuse to serve the body of Christ is tantamount to ...Read More
Every Member Ministry
Do you consider yourself a minister in the church? Although you might never be ordained to a church office, your gifts are critical to the healthy functioning of Christ's body. Determining your specific role may not be easy, but you ...Read More
The Gift of Officers
All Christians rest upon the teaching of the apostles and prophets in sacred Scripture, but God has ordained that evangelists, pastors, and teachers are also necessary for healthy spiritual growth. The Lord does not ordinarily bring us to maturity through ...Read More
Gifts from the Ascended Christ
Christ's ascension to the right hand of God the Father demonstrates His sovereign authority to distribute good gifts to us as He wills. Because He has conquered death and hell, Jesus can give what is best to each of us, ...Read More
Sovereign Gifting
Christ bestows gifts upon His people as He sees fit, guaranteeing that all of us have an important part to play in the advance of His kingdom (1 Cor. 12:1–11). As Christians, then, we must truly appreciate the variety of ...Read More
The Pastor's Progress
John Calvin writes, "To neglect a gift is carelessly to keep it unemployed through slothfulness, so that, having contracted rust, it is worn away without yielding any profit." Some of us know what our gifts are but are not using ...Read More


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IF we spend as much cash money as we can
THEN the owners of Matching Half will spend 200% of profit on a bike trailer and reusable food storage containers.
23 Oct 2010
Matching Half Cafe
1799 McAllister St
San Francisco, CA 94115, USA
Want that feel good feeling? Join the Wigg Party in helping support a small local business do something awesome for our neighborhood: They've committed 200% of what **WE** spend to purchasing a bike trailer so they can haul produce from a farmer's market car-free.
Matching Half Cafe brought in 300% of what they would normally make on a rainy Saturday afternoon. The NOPA community showed up in force, brought live music and a whole lotta bikes. Matching Half put $863 dollars towards a bike trailer, reusable food storage containers, and piloting the use of organic milk.
This campaign was also featured in a national TV broadcast on PBS, viewable here: http://www.pbs.org/wnet/need-to-know/culture/video-using-carrots-not-sticks-to-get-companies-to-do-good/10308/
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The fastest and easiest way to join Carrotmob is by connecting with your Facebook account. You will also be able see what your friends are doing on Carrotmob and quickly share some of your activities with your network. To learn more about how this works, read this. If you are curious about the permissions we're requesting of your Facebook account, read this. Clicking this button will NOT post anything to your Facebook wall.

subset: commoncrawl


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Law enforcement officers conducting a legal search have always been able to pursue evidence of other crimes sitting in "plain view." Investigators with a warrant to search a house for drugs can seize evidence of another crime, such as bombmaking. But the warrant does not allow them to barge into the house next door.
But what are the comparable boundaries online? Does a warrant to search an e-mail account expose the communications of anyone who exchanged messages with the target?
Similarly, FBI agents monitoring wiretaps have always been obligated to put down their headphones when the conversation is clearly not about a criminal enterprise. It's known as minimization, a process followed by intelligence and law enforcement agencies to protect the privacy of innocent people.
"It's harder to do with e-mails, because unlike a phone, you can't just turn it off once you figure out the conversation didn't relate to what you're investigating," said Michael DuBose, a former chief of the Justice Department's Computer Crime and Intellectual Property Section who now handles cyber-investigations for Kroll Advisory Solutions.


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Ad Hoc Meeting Space Available
During the Conference, we will have two small meeting rooms available to accommodate pop-up meetings of up to 15 people each. If you need a room to accommodate a larger number of people, please check with us first. Space will be available on a first-come, first-served basis and may be requested in advance for meetings such as committee meetings or project discussions. Participants may also sign-up for meeting space on-site via sign-up sheets on the conference message board in the Poster Display Area.
Ad-Hoc meeting rooms do not contain AV equipment. Should you require computer projection, phone services, or internet, you will be responsible for covering applicable costs.) Each room has a permanent arrangement of tables and chairs. In order to accommodate the most groups possible, custom set-ups will not be permitted.
To request ad-hoc meeting space in advance, email Beth Miller-Tipton at email@example.com.
CLICK HERE to open PDF of Program Book including
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Abstract Submission Deadline:
- January 7, 2013
Notification of Selected Presenters:
- March 1, 2013
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- April 15, 2013
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- May 17, 2013
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- June 14, 2013
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Gorloks Ranked in Top 10
Apr. 17, 2013
ST. LOUIS, APRIL 17, 2013 - On the heels of a 6-0 week, the Webster University baseball team has moved up to 10th place in the D3Baseball.com national poll for the week of April 15. The Gorloks, who are ranked 15th in the American Baseball Coaches Association (ABCA) poll, have won 19 of their last 20 games.
Webster is 22-6 overall and sits atop the St. Louis Intercollegiate Athletic Conference standings at 14-0. The Gorloks were ranked 10th in the D3Baseball.com pre-season poll and after a 2-4 start to the season, have climbed to that spot. The 6-0 week was highlighted by Webster's first nine-inning no-hitter, thrown by Dylan Dean Smith (JR, Edwards County HS, IL) in a 6-0 win over MacMurray College.
The Gorloks entered the 2013 season with much anticipation, being ranked in the pre-season top ten in two national polls after its fifth place finish in the 2012 NCAA III World Series. The Gorloks have not disappointed. In early April, they were ranked at 15th in the national polls. Then the team went on a 13 game winning streak before being stopped by Washington University in an 8-6 match. Since that game, the Gorloks have won their last six.
Webster is hoping its continued success in 2013 will lead to its seventh straight SLIAC title, another trip back to the NCAA III championships and, ultimately, another berth in the College World Series.
The Gorloks have a game at 1:30 p.mm. on April 19 vs. Fontbonne University at GCS Ballpark, then host the Griffins for a doubleheader on April 21 at GCS Ballpark.


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Friends, I believe in teaching children to appreciate other cultures, other ways. That's why I encouraged my daughter to sample something from every country in the world before she turned five. So pull up a chair and enjoy these videos. Watch her grow up. Watch her taste food from around the world. Watch her picky moments and her brave moments. Smile.
P.S. Show them to your kids and grandkids. Babies love to watch babies.
P.P.S. Learn more about Miss Ava here.
At some point we transitioned videos to a slightly different format. They pickup after Ava Eats Uganda.
YouTube responded with an error: The playlist identified with the request's playlistId parameter cannot be found.


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In the true tradition of the Nikita Chickita, that is combing girls, shredding and fun in the best possible way, the US leg of the event went down in Brighton, Utah last weekend.
Slightly different from the European events, this one held two contests divided into the categories Amateurs and Pros, to give all Chickitas a chance to show what they got and compete against equals. In the end it turned out a bit different than expected with one girl winning both categories – being an amateur! Make sure you stay on the watch for Miss Jessica Jensen and her super clean back 5s. With only 17 years at the moment she is very sure to impress us even further in the future…
Other riders making an impression were Nikita Team rider and NC USA regular Colleen Quigley, who took 3rd again in the PROs category, and Paige Rainear getting tech on the rails with front board back one's and gnarly nollie back tails.
Winner AMs:
1st Place – Jessica Jensen, Idaho
2nd Place – Midori Oatari, Japan
3rd Place – Ranae Palma, Massachusetts
Winner Pros:
1st Place – Jessica Jensen, Idaho
2nd Place – Lynn Neill, Utah
3rd Place – Colleen Quigley, Massachusetts


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In most developing countries, government used to be the major actor in the energy supply sector. With the emerging privatisation wave public utilities are losing their monopolistic advantage and opening opportunities for private entrepreneurs. The government is losing importance as an energy supplier, but still has an important role in the sector as controller, and as the responsible body for the definition of policies which can shape the energy market (e.g. regulation, market-based incentives). Government interest is the major single item able to define the country attitude regarding GHG emission control. For example, under the auspices of the US EPA Coal Bed Methane Program, technology transfer to other major coal mining states is being promoted. For example, Coal Bed Methane Centres or Clearinghouses have been set up to help overcome economic and institutional barriers to technology transfer in China and Russia. These centres promote information exchange, demonstration projects, and commercial development. Also, the Asian Pacific Economic Council (APEC) is starting a coal mine gas project to recover and utilise methane from deep coal mines in Southeast Asian countries.
The choice of generating technologies for capacity expansion is deeply influenced by the planning tools available. Energy plans rely strongly on the knowledge and manpower from utilities, which greatly prefer the old technologies they are familiar with, and often distrust new technologies. Quite often their actions optimise only the energy supply side and do not take demand into account. The integrated resource planning (IRP)8 approach is a valuable tool to examine the potential and barriers for new technology transfer, and thus to stimulate the analysis of the interventions governments could prescribe to overcome these barriers. In many industrialised countries, IRP is introduced by law. In Denmark, for example, the electric utilities are required to present such plans and to update them on a regular basis. In developing countries IRP is being done when required, but it also can provide substantive information on the technology priorities for development of the energy system. In China, for example, an extensive study on the energy sector development using the IRP approach was conducted recently. The study explored options, effects and costs of GHG mitigation in the energy demand versus energy supply. Hydro, nuclear and wind options were considered (IEA, 1997). The role of IRP is changing under the conditions of a liberalised market. It provides a basis for a dialog between companies and the government with respect to the objectives of the future technology development and deployment, and the policy framework necessary to support these objectives. The presence of the government, which is likely have a better and broader view of the country's requirements, is imperative when energy plans are under development (Greene and Hallberg,1995):
Multilateral Development Banks (MDBs) are financing many activities necessary to ensure the transfer of technology. For example, they finance building institutional capacity, establishing research centres and funding demonstration projects. The World Bank funding of ESTs is estimated to be approximately US$ 2 to 3 billion per year. Acting as a lead investor, however, these banks have influenced a significantly larger proportion of the total investment in ESTs. Environmental loans totalled US$ 1.63 billion and MDBs leveraged another US$ 1.64 billion in fiscal year 1996 (United Nations, 1997). ODA has addressed about 3% (US$ 1.3 billion) of total reported bilateral energy assistance to renewable projects (except large hydro) between 1979 and 1991 (Kozloff and Shobowale, 1994)9 .
Regional organisations have an important function at this stage of technology transfer, since they have a number of generic strategies that can promote and/or facilitate the implementation of some of the emission reduction options described in this Report. These strategies (Von Hippel, 1996) could include, but are certainly not limited to, the following:
Provide Information and General Training to Government Officials - Getting initiatives such as industrial energy efficiency, and utility boiler emissions control programmes, and fuel switching/renewable energy initiatives off the ground in most developing countries (particularly China and India) will be impossible without top officials embracing the concept. Consequently, the advantages and local/international opportunities provided by the measures and technologies must be presented to top officials in a manner that is both forceful and forthright10 .
Provide Specific Information and Training to Local Actors - Training of a very specific and practical nature must be provided to personnel at the local level. Examples include workshops and courses for factory energy plant managers, and power plant and heating system operators; and new job classifications such as energy-efficiency and pollution control equipment installers, energy auditors, and environmental officials.
Encourage the Implementation and Enforcement of Energy and Environmental Standards - Although some countries of Northeast Asia and Latin America have general policies supporting energy efficiency and environmental sustainability, not all have a well-defined, quantitative set of standards in place to codify these general policies. Where standards exist, furthermore, they may not be stringent enough to satisfy GHG emissions reduction targets. Once standards are set, it will be necessary to create the capability to enforce them by recruiting and training enforcement personnel and supplying them with the tools necessary to do their job, as well as the high-level administrative support needed for credible implementation of sanctions. Setting up these regulations and support structures is an area where international assistance may be valuable for some countries.
Establish Programmes of Grants and Concessional Loans - Experience in China has shown that such a programme in itself can have a significant positive impact in overall sectorial energy efficiency (Liu et al., 1994). The benefits of institutionalising support for pollution control and energy efficiency, however, would go beyond those obtained through the various individual projects themselves. Creating government agencies or corporations with their own budgets would signal a strong commitment to acid gas and GHG emissions reduction on the part of the government, and would create a constituency within official circles for promoting EST (see Case Study 3, Chapter 16). Moreover, by establishing a pool of funds for which government ministries, sectors, and/or individual enterprises could compete, it would stimulate at all levels awareness of the potential, methods, and technologies for reducing local, regional and global gas emissions (see Case Study 24, Chapter 16).
Promote Joint Ventures and Licensing Agreements - The growth in the need for pollution control and energy efficient equipment could be met by domestic production through joint ventures and licensing agreements between governmental or private organisations in developing countries and foreign companies with the necessary expertise to produce the needed equipment. For example, a wide variety of efficient industrial equipment and controls - including adjustable speed drives, higher-efficiency electric motors, and improved industrial boilers - have already been introduced to China through commercial channels and are being or will be manufactured there.
The effort of such organisations in promoting EST cannot be neglected. The United Nations Development Programme (UNDP) over the last two decades committed over US$ 400 million to energy sector activities, and funded more than 900 projects in energy planning, energy efficiency and conservation, conventional energy, electric power, nuclear energy, and new and renewable energy. Such UNDP funding helped energy-endowed developing countries develop their resources and train national staff in cost-effective and environmentally cleaner methods of producing and using energy resources. Despite its success, UNDP energy assistance was fragmented, reflecting the constantly shifting international consensus about what is needed (renewables in the 1970s; conservation in the 1980s and concern about the environment in the 1990s) (Gururaja,1995). Also, the amount of financial support (on average US$ 20 million/yr in the last two decades) is quite small to induce significant results in the energy sector11 . Most of the contribution has been in providing information on feasible projects (ESMAP activities), provision of small-scale lending for renewable energy (FINESSE initiatives) and acting as an intermediary to obtain loans from multilateral lenders. One of the areas most benefited by UNDP actions has been the use of renewable sources of energy, promoted as early as 1981 in the UN Conference on New and Renewable Sources of Energy in Nairobi. Another very useful contribution of many regional organisations has been the promotion of non-commercial energy technology transfer through many international conferences, employment of personnel through technical assistance programmes, education and training of host country's labour force and information databases.
Agreement and Implementation
Availability of capital is the major obstacle for the implementation of a selected technology. The gap between the foreign exchange needs of developing countries in the power sector and total aid flows from abroad implies that total investments will have to be reduced, foreign aid increased, domestic finance increased, or private foreign investment increased even more12 . All these options play a role in the oil sector and in the power sector expansion, but the last is the most likely to dominate (Barnett, 1992).
Oil and natural gas are being produced in many developing countries through one or several of the following arrangements: concession, production-sharing contracts, risk service contracts, service contracts, joint ventures and nationalisation. Excluding nationalisation, all other arrangements are made between an International Oil Company (IOC) and the Government, usually through the National Oil Company (NOC). This means that agreement and implementation procedures for technology transfer are well established. With the emerging privatisation wave, opportunities for FDI are growing (see Figure 9.4, Chapter 9).
Laws allowing increased presence of the private sector in the oil and gas markets, as well as laws allowing private electric power sales, are no guarantee that power generation markets will develop or that EST will be used. Nevertheless, improvements in the efficiency of energy supply should be achieved through improving efficiency in oil exploration and exploitation, in power generation, transmission and distribution, and increased investments in system-interconnections. Through competition it is expected that improved efficiency will occur. Global conversion losses in these areas are responsible for 85 EJ or 22 per cent of global commercial energy used in 1990 (SAR II-B1, 1996).
For energy production from conventional energy sources, usually based in large centralised plants, FDI can be the preferred option. The investment required may be unavailable in the host country, so FDI can very quickly create new job opportunities, raise technological and educational levels of the labour force, transfer technical and management skills, and help the local R&D institutions. Nevertheless, it is important to remember that through FDI various elements of the technology are supplied in "bundled" or "packaged" form (Able-Thomas, 1996). FDI enables the technology supplier to retain ownership and to exercise control over the new production plant which is inconvenient to the host country from a technology transfer viewpoint, but provides a flow of productive capital from one country to another (Able-Thomas, 1996). Thus, FDI is suitable for the energy sector where technological progress and spin-off opportunities are less common, as is the case of mature technologies like hydroelectricity, or for the manufacturing of solar cells and PV modules where technological improvements are occurring so fast that developing countries have little chance of recovering commercial investments from the technology before it becomes obsolete (Able-Thomas, 1996).
Government has a significant role as a promoter of ESTs, since a large part of the R&D money used is coming from public sources. Policies for the diffusion and accelerated transfer of publicly funded ESTs are available (Korea, 1998), and include financial incentives for their transfer to developing countries and promotion of the transfer of uncommercialised publicly funded R&D results to enhance capacity building in developing countries and CEITs. For other energy supply technologies with small commercial markets, which are still in the development stage, or are publicly owned, joint ventures and licensing may be a more appropriate way for technology transfer. Joint ventures are dependent on a reasonable national partner with similar technological capabilities and complementary skills and resources, and necessary where relations with host-country governments and institutions would be difficult for foreign companies (partners) alone (Chowdhury, 1992). At the other extreme comes licensing, which is of value if the transfer is limited to product and processes that the nation is capable of producing or using at internationally competitive costs, or products serving purely domestic markets, for which neither imports or exports are an option (Able-Thomas, 1996).
Even considering the strong and emerging presence of the private sector in energy supply there are other important actors involved in technology transfer.
MDBs influence private financial markets to support technology transfer. At the macro level, this is done by encouraging financial reforms in banking, privatisation, and stock market development. At the micro level, influence comes through developing, demonstrating and transferring the innovative financial instruments needed to accelerate access to technology (United Nations, 1997). In the short term the most effective contribution of MDBs regarding GHG abatement is through the money used to fund and leverage other loans in the energy sector (see Case Study 14, Chapter 16). MDBs have significant leadership in this sector, and in the period 1991 to 1995, 44% of all the external financing of infrastructure in developing countries has been addressed to this sector (United Nations, 1997). Funding has impacted GHG emission through the large share which financed hydroelectric plants and the share invested in promoting sectorial reforms in favour of competition in the developing countries' power sector (World Bank, 1994). These actions abated GHG through the options of switching to renewable sources of energy and more efficient conversion of fossil fuels to power and heat. Loans to thermoelectric plants and oil refineries also impacted GHG emission, since it is assumed that under the MDB management, projects are more technically appropriate to the country economy with implications on efficiency optimisation of plants (United Nations,1997).
Since the establishment of the pilot phase of the Global Environmental Facility (GEF)13 a total US$ 5.2 billion have been allocated to climate change activities. Of this sum, US$ 775 million was provided in grants from the GEF Trust Fund. An additional US$ 4.4 billion was contributed through co-financing (GEF, 1998). About one third of these projects are to enhance penetration of advanced renewable and cogeneration technologies in the developing countries' energy markets, such as PV, solar-thermal hybrid technology, micro-hydro and biomass. Another objective of these projects is to improve energy facilities operation, production management and marketing capabilities (GEF, 1997). A very interesting example is the US$ 6 million joint USAID/India and GEF project to prevent GHG emissions, which addresses the major market, financial and institutional barriers that hinder penetration of the modern energy supply technologies. The first, near-term component of the project aims at introducing cost-effective conversion measures and state-of-the-art coal technologies at the existing power plants. The second, long-term component promotes more efficient bagasse (sugarcane processing residue) cogeneration technologies based on high pressure multi-fuel boilers and high-efficiency turbines. This component will provide incremental cost support for six demonstration projects in addition to the technical assistance, training and cost-shared research grants for developing cane trash and other biomass fuels. (Climate Action Report, 1997).
In the same way as the World Bank has exhibited leadership in requiring developing countries' hydroelectric projects to take into account social and local environmental issues, MDBs have the capability to enforce international regulations on GHG emissions and promote the use of International Standards (ISO-series), in addition to their traditional role of addressing funding and verifying the feasibility of EST projects. One difficulty associated with these actions is the necessity to invest in projects based on new technologies that conflict with the traditional posture of most of these institutions, which are technologically risk adverse (ECOSOC, 1994).
Another multilateral source of support for transfer of climate friendly energy supply technologies to CEITs is the European Bank for Reconstruction and Development (EBRD). In fact, EBRD is the first international financial institution with a proactive environmental mandate, having sustainable development goals among its highest priorities. Its objective is to foster the transition of the CEITs to a market driven economy and to promote entrepreneurial initiative.
Bilateral organisations have special programmes with technology transfer as an objective. For example the Japanese government provides technical assistance in the electric power field through studies of project development, training of overseas technicians, sending industry experts overseas, etc. Development studies consists of initial master-plan development and preliminary best-plan scenario development, and feasibility studies requested from partner-countries. Total loans from the Japanese government equal nearly ¥ 1,000 (approx. US$ 9.5) billion in 1991. Of this total, ¥ 100 (approx. US$ 0.95) billion is in the electric power field. Of this aid, ¥ 40 (approx. US$ 0.38) billion is for hydroelectric power development assistance. In the period 1959 to 1991, the total amount of loans the Japanese government offered in the hydropower field was ¥ 700 (approx. US$ 6.6) billion (Fujino, 1994). Another example is the Swedish government programme for biomass boiler conversion in the Baltic states (see Case Study 18, Chapter 16).
As is well known, an important objective of many bilateral aid programmes is to promote donor country exports of goods and services (Kozloff and Shobowale, 1994). Although the distinction between development assistance and export promotion is frequently blurred, it is no accident that bilateral donors often direct assistance to technologies and products in which they have a comparative advantage in domestic world markets (e.g. The Energy Policy Act, 1998). Under this approach, more sophisticated alternative technologies are being promoted in the energy supply sector. Most of the resources have been addressed to increasing the use of renewables through geothermal energy, wind resources and photovoltaic cells. Also, technology transfer is mostly provided through provision of equipment. There is little support for developing human capabilities for environmentally sustainable energy technology, which is strongly needed by developing countries (der Werff et al., 1994).
Considering the emerging presence of the private capital in the energy sector of the developing countries and the relatively small amount of incentives provided by the GEF, World Bank, Regional Development Organisations and Bilateral Organisations compared to the amount of investment needed in the energy sector, as extensively discussed in this section, it is necessary to recognise that incentives are almost non existent for the governments of these countries to stop using their cheap natural resource of coal and oil in favour of more expensive, imported ecologically-friendly fuels such as LNG or pipeline gas.
Evaluation & Adjustment
Adjustment is almost always needed due the difference in infrastructure, social, and economic system of the technology provider and recipient countries (see Case Studies 3 and 5, Chapter 16). Creation of labour opportunities is a high priority in most developing countries. Due to the large investments in the energy supply sector, the potential number of job opportunities are often underestimated. Adjustment in favour of manpower versus automation is important. Heavy automation implies more importation of goods and more hard currency expenditures, which is seriously constrained in developing countries and CEITs.
Evaluation of all potential gains in the technology recipient country must be performed with care, including short, medium, and long-term views, checking all aspects considered important for the country's development by extrapolating the energy boundary. As an example, in the oil sector, there is already a well-established system for technology transfer from International Oil Companies (IOCs) and the Government, usually through the National Oil Companies (NOCs)14 (Barrows, 1993). Technology transfer occurs through provision of state of the art technology and capacity building, such as training. Most legislation or contracts today contain provisions obliging the IOCs to provide training of nationals of the host country (personnel from NOCs, the Government, and relevant government agencies (Barrows, 1993). Transfer of more detailed technology is required in some countries (such as Norway), and this necessitates a special agreement to assure patent protection and secrecy regarding technical processes (Barrows, 1993). On the other side, the combination of business and social objectives is a feature of the public-private partnership requiring disbursement of IOC money in the economic and social development of host countries (See Box 10.2 and Case Study 13, Chapter 16). Indirect technology transfer is induced through agreements on Preference for Use of Domestic Goods and Services. Generally the legislation obliges the oil companies to purchase domestically produced goods and services, if they are available at competitive terms; in particular the World Bank financed projects allow a cost differential of up to 15% in favour of local suppliers. Because of potential demand by the IOCs, the national suppliers of goods are stimulated to search and make arrangements for acquisition of new technologies which can make their products and services more competitive.
From the above example it is clear that technology transfer has been used by the recipient country as a way to get fuel, job opportunities, commercial and industrial activities, hard-currency savings or gains, human and institutional capacity building, and social and economic development. All of these gains must be properly evaluated by the country's society. Lessons must be derived from past experiences and results used for better agreements able to promote even more country development.
|Box 10.2 - Liquefied Natural Gas (Case Study 13 in Chapter 16)
|The development of the remote Arun natural gas field in North Sumatra
by Mobil Oil and Pertamina, the state oil company of Indonesia, is a good
example of capacity building and technology transfer. The Arun field is
located in a rural area lacking industrial infrastructure and a trained
Capacity building included building bridges, roads, water supply, schools, mosques, training, etc. Training in operation, health, safety, and environmental issues was provided for the local workforce. Now 98% of the nearly 3000 workers are Indonesians.
Liquefied natural gas is supplied to Japan and Korea for use in power generation, displacing the alternative of heavy oil or coal. The technology transfer was state of the art and has been constantly updated as new developments emerge. Lessons learned in Indonesia are now being applied to other LNG projects in developing countries.
Opportunities for replication of the new technology are favourable in developing countries due the large and rapidly growing energy supply markets. Developing Countries now have the opportunity to promote innovative energy technologies that would be helpful in meeting their sustainable development objectives (Reddy et al., 1997). Adoption of advanced technologies not only provides increases in the energy supply, but can also provide opportunities to fulfil one of the characteristics of technology transfer. This is putting it into operation in its new environment, and through incremental innovation (small improvements in existing products and process, or relatively small extensions of the scope of existing applications of the product design or technology (Greene and Halberg,1995)) producing major changes on behalf of the country's economy. Incremental innovations generate new business opportunities that do not require the same level of advanced knowledge necessary for radical innovations. Developing countries with a minimum level of basic education in their work force and minimum industrial experience may be able to capitalise on these opportunities quite successfully, often at lower cost than industrialised countries.
Trade, which is an important system for technology transfer15 , has a direct impact on the energy supply system of developing countries and CEITs. In general, trade liberalisation can have a positive effect on the environment, by helping to allocate resources more efficiently, provided effective environmental policies are implemented (OECD, 1994; OECD, 1995a). Since energy is an ingredient always present in products and services, international competition poses price constraints on it, stimulating more efficient use of primary fuels in the energy sector. However, search for lower energy prices can stimulate the use of cheap fuels (e.g. coal), which are intrinsically environmentally aggressive, or can be as such, due to the shortage of investments in end-of-pipe cleaning equipment. Thus the enforcement of effective environmental policies is a necessary condition to increase the positive and decrease the negative environmental effects of trade liberalisation. A quite serious problem that needs to be addressed is conflict between existing trade rules and environmental issues (see Box10.3).
|Box 10.3 - Conflicts between Trade Rules and Environmental Issues
|Trade issues became more complex when the various stages of the product's
life cycle are at issue (i.e. processes and production methods - PPMs).
For example, recent packaging and recycling requirements which address environmental
issues, but which are associated with the disposal stage of the product
life cycle, have caused some trade concerns. This is because waste reduction
policies tend to have a national focus, and can thereby impose relatively
higher costs on importers, amounting to de facto protection for domestic
products (OECD, 1997). To date, trade rules have been interpreted as precluding
policy differentiation on the basis of non-product related PPM requirements
(the ones that do not affect product characteristics, but generate an environmental
impact at the production stage, such as emissions). Similarly, adjusting
the price of imported products at the border, to account for the additional
cost incurred by domestic industry in complying with non-product related
PPM requirements has generally been considered to be incompatible with existing
trade rules (OECD, 1997).
An interesting case is import taxes set to a certain level for products, without any consideration of the implicit environmental benefits.
Shortage of money is a serious obstacle for any project development. This chronic issue in developing countries is even aggravated by the difficulty that innovative projects are usually undertaken by small enterprises. Larger enterprises traditionally finance their projects through corporate financing, where the assets of the corporation are used as a guarantee. Small enterprises must rely mostly on project finance where the guarantee for a loan is provided by the cash-flow of the project.
Innovative third party financing can be obtained through multilateral organisations (i.e. GEF), but with limited availability of funds. Joint Implementation (JI) and the Clean Development Mechanism (CDM) can be a way of directing investment to CEITs and developing countries. Money from the private sector may be more available than from government organisations depending on the incentives.
The participation of non-governmental organisations (NGOs) has become important to the growth of simple distributed energy supply facilities which have low energy output and relatively low capital cost. For example, an important intervention programme to alleviate the rural energy crisis in India has been the dissemination of biogas technology among rural households through which 2.5 million individual biogas plants were constructed up until March 1997. The diffusion of such biomass technology has relied on the cooperation among government agencies, private firms, and NGOs. Technological exchange with China led to the adaptation from the floating dome biogas technology to the less experienced fixed dome biogas technology, mainly because capital subsidy remained with the organisations - mainly the NGOs - which were constructing the plants. Most technological improvements were incremental and resulted from local innovations (Ramana and Shukla, 1998).
Commercialisation of new technologies is an important part of the innovation process, and policies to facilitate these actions are urgently needed in developing countries and CEITs. Although developing countries' enterprises may be developing renewable energy technologies and have advanced scientific and technical capabilities and skilled workforces, the translation of these capabilities into commercial products is still a major problem. The associated market-oriented skills and institutions to take full advantage of these technological capabilities are still poor.
In Russia these market-related deficiencies are the persistent legacy of the former Soviet paradigm of central economic planning and development. Central planning avoided the need for many market-oriented skills and created a variety of disincentives and structural economic conditions that stifled innovation, creativity, efficiency, and quality (Cooper, 1991; Nove, 1986; Martinson and Valdemars, 1992). Key underdeveloped capabilities are business management, finance systems, marketing, creative product development and innovation, quality assurance and economic analysis (like cost-benefit and life cycle analyses); and legal, contracting, and accounting skills. Quality assurance, statistical quality control, management for quality, and other methods common in the West are uncommon in Russian industries (but not in the military sector), because incentives in the Soviet economic system emphasised quantity over quality. Another problem is the excessive presence of monopolies in Russia. In Poland, the Czech Republic, and Hungary markets are being developed while these countries have also been out of the market economy for 50 years. Thus, business planning and training will be helpful, but only if there is a market environment to use them (Martinot, 1999).
Other important aspects of commercialisation are continuous product improvement and cost reduction. As an example, product improvement was often intentionally avoided in the former Soviet economic system because enterprise incentives encouraged quantity over quality, and because design changes could mean changes in needed inputs that might not be available. For example, in the West, extensive experience with operating and maintaining wind turbines through commercial markets over the past 15 years has led to a refinement of designs and cost reductions. This experience has been critical to the current success of modern wind turbines.
A promising process for speeding up the commercialisation of new and renewable sources of energy is through the acquisition of small companies with good products in the energy supply sector by large ones with well established positions in the energy market. Small companies find it difficult to commercialise their products worldwide, while this can be an easier process for large companies. Several energy multinationals are taking up the commercialisation challenge of renewables by drastically expanding their investments and acquisitions in the area of solar, biomass and wind technologies. With the exception of the two Japanese companies, Kyocera and Sharp, all companies with a global PV market share above 10% are owned by large energy companies such as Siemens, BP, Amoco and Enron. Shell has recently established a fifth business group under the name of Shell International Renewables. Although still dwarfed by the other groups in every respect, it signifies a strong commitment to renewables. Half a billion (US) dollars of investment will be spent in the first five years of operation. Concentrating on PV, forestry and biomass power, Shell intends to obtain a strong position in rural energy development by coupling biomass plantations with local power production. Similar trends are evident in the wind power industry. Although independent producers are still strong, mergers and acquisitions are increasing.
Other reports in this collection


text:
Overall bariatric case volume at Tufts-New England Medical Center from March 1998 to April 2004. During that period, there has been a sharp increase in total cases and the number of laparoscopic Roux-en-Y gastric bypass (LRYGBP) procedures performed. The number of open Roux-en-Y gastric bypass (RYGBP) procedures performed annually decreased dramatically as the LRYGBP became more routinely offered. Other bariatric procedures refer to laparoscopic adjustable gastric bands and revisional procedures.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Shikora SA, Kim JJ, Tarnoff ME, Raskin E, Shore R. Laparoscopic Roux-en-Y Gastric Bypass: Results and Learning Curve of a High-Volume Academic Program. Arch Surg. 2005;140(4):362–367. doi:10.1001/archsurg.140.4.362
© 2020
Laparoscopic Roux-en-Y gastric bypass is a complex procedure performed on a high-risk patient population. Good results can be attained with experience and volume.
Retrospective study.
Tertiary care academic hospital.
Seven hundred fifty consecutive morbidly obese patients undergoing surgery from March 1998 to April 2004.
All patients underwent laparoscopic Roux-en-Y gastric bypass.
Main Outcome Measures
Perioperative deaths and complications.
The patient population was 85% women and had a mean body mass index of 47 kg/m2 (range, 32-86 kg/m2). The overall complication rate was 15% and the mortality was 0.3%. For the first 100 cases, the overall complication rate was 26% with a mortality of 1%. This complication rate decreased to approximately 13% and was stable for the next 650 patients. The incidence of major complications has also decreased since the first 100 cases. Leak decreased from 3% to 1.1%. Small-bowel obstruction decreased from 5% to 1.1%. Overall mean operating time was 138 minutes (range, 65-310 minutes). It decreased from 212 minutes for the first 100 cases to 132 minutes for the next 650 and 105 minutes (range, 65-200 minutes) for the last 100 cases.
Laparoscopic Roux-en-Y gastric bypass is a technically difficult operation. This review of a large series in a high-volume program demonstrated that the morbidity and mortality could be reduced by 50% with experience. The results are similar to those reported from other major centers. In addition, as reported elsewhere, the learning curve for this procedure may be 100 cases.
Over the past 20 years, the United States and the world at large have seen a staggering increase in the prevalence of obesity. Recent surveys by the Centers for Disease Control and Prevention (Atlanta, Ga) suggest that more than 64% of US adults are overweight and 5% are morbidly obese, defined as having a body mass index (BMI) greater than or equal to 40 kg/m2.1 Obesity is associated with health-affecting comorbidities such as diabetes mellitus, hyperlipidemia, hypertension, and obstructive sleep apnea. These adverse conditions contribute to the increased risk for premature death and disability for persons with BMIs greater than 25.2 Commonly refractory to conservative weight loss treatments, morbid obesity has become a surgical disease. Operations to treat obesity are the most effective interventions for achieving meaningful and sustainable weight loss.3 Mirroring the rise in prevalence of obesity has been the dramatic increase in the number of bariatric procedures performed. In fact, the number of procedures performed yearly in the United States has increased a staggering 644% in the last decade.4 This increase can be attributed to the increased public awareness of the health risk associations of obesity and its staggering societal cost and the greater acceptance of surgery as a legitimate treatment. Equally significant is the adaptation of minimally invasive techniques to the field of bariatric surgery.
Laparoscopic and minimally invasive surgery have now extended into almost all surgical disciplines. The benefits of decreased postoperative pain, length of hospital stay, wound morbidity, and even improved cosmesis are particularly appealing for this complex patient population.
Roux-en-Y gastric bypass (RYGBP) is currently the procedure of choice in the United States for intractable morbid obesity.5 However, it has traditionally been a formidable operative procedure with the potential for catastrophic complications. In 1994, Wittgrove and Clark6 described the first successful laparoscopic gastric bypass procedure. Since that time, the number of laparoscopic gastric bypass procedures has increased dramatically as the equipment has improved and surgeons across the country have undergone extensive training. However, the laparoscopic Roux-en-Y gastric bypass (LRYGBP) remains a more technically challenging operation compared with its open counterpart. Some surgeons have reported that the learning curve is approximately 75 to 100 cases.7,8 In addition, other studies have suggested that the operative morbidity and mortality were somewhat dependent on case volume.9-11 The purpose of this study was to evaluate the role of technical experience and patient volume in reducing the rate of perioperative and postoperative complications in patients who underwent LRYGBP.
To be considered for surgery, all patients had to satisfy the criteria for gastric bypass surgery as stated in the 1991 National Institutes of Health Consensus Development Conference Statement on obesity.12 All patients also had to successfully complete the interdisciplinary screening and preparatory process for bariatric surgery by the various health care professionals of the Obesity Consult Center of Tufts-New England Medical Center in Boston, Mass.
We have maintained a prospective database for all patients undergoing LRYGBP at Tufts-New England Medical Center since March 1998. Baseline patient characteristics, including age, sex, height, weight, BMI, percentage excess weight, and comorbid conditions, were recorded in the program's bariatric database. At the time of surgery, operating time, blood loss, length of stay, and operative complications were recorded. Following surgery, patients were monitored for complications including signs of staple-line leak (signs of peritonitis or abnormal output from the drain), hemorrhage, obstruction, and infections. After hospital discharge, all patients were followed up as per the protocol for surgical follow-up established by the Obesity Consult Center. Although postoperative radiographic or endoscopic studies were not routinely performed, there was a low threshold to study any patient who returned for a follow-up appointment with any gastrointestinal symptoms such as pain, vomiting, or inadequate weight loss.
For this investigation, a retrospective analysis was performed on the database of the first 750 consecutive morbidly obese patients undergoing LRYGBP from March 1998 to April 2004. Operative time, blood loss, length of hospitalization, and 30-day morbidity and mortality were analyzed. The data were analyzed after segregation into 5 different categories based on chronology: the first 100 cases (1-100), the second 100 cases (101-200), all cases after the first 100 cases (101-750), the last 100 cases (651-750), and all cases (1-750).
Except for some minor alterations, all patients underwent LRYGBP performed in a similar fashion. The gastric pouch was created with the Endo GIA linear cutting stapler with 60-mm long, 3.5-mm cartridges (US Surgical Corp, Norwalk, Conn). Pouch size was approximately 30 cm3. The Roux limb was 100 cm long for patients whose BMI was 50 kg/m2 or less, 150 cm for patients whose BMI was greater than 50 kg/m2, and occasionally even longer for those whose BMI was greater than 65 kg/m2. The Roux limb was brought retrocolic and retrogastric. The gastrojejunostomy was created using the 25-mm CEEA (circular end-to-end anastomosis) stapler (US Surgical Corp) with the stapler's anvil placed into the pouch via a transabdominal technique. The pouch's staple line and the gastrojejunostomy were checked for leakage by inflating the pouch and proximal Roux limb with 2 L of oxygen and flooding the left upper quadrant of the abdomen with saline. Bubbling observed in the saline pool would identify a leak. This would then be corrected with sutures until normal air test results were achieved. A closed suction drain was placed between the staple lines of the pouch and excluded stomach in all patients.
The jejunojejunostomy was created in a side-side fashion between the biliopancreatic limb and the Roux limb. The Endo GIA linear cutting stapler with a 60-mm long, 2.5-mm cartridge was passed distally into each limb of bowel through small enterotomies created on the antimesenteric borders. After firing the stapler, it was reintroduced with a 30-mm long, 2.5-mm cartridge proximally through the now common enterotomy. After firing, the common enterotomy was closed transversely with a 60-mm long, 2.5-mm cartridge. The mesenteric defect was closed initially with interrupted silk sutures (first 440 cases) but has since been closed with running silk suture. At the conclusion of the gastric bypass, the internal hernia spaces were closed. The Petersen space was obliterated by tacking the proximal Roux and biliopancreatic limbs together. The mesocolic defect was controlled by tacking the Roux limb to the cut edges of the mesocolon. Twelve-millimeter port wounds were closed at the level of the fascia, and all port sites were closed with subcuticular running suture.
From March 1998 to April 2004, 750 patients underwent LRYGBP at Tufts-New England Medical Center. The patients were predominantly female (85%) with a mean age of 41 years (range, 14-69 years). Body mass index spanned the range of 32 kg/m2 to 86 kg/m2, with an average BMI of 47 kg/m2 and a median BMI of 46 kg/m2. The Figure shows the breakdown of the different case types since the first LRYGBP was performed. Over the ensuing 6 years, the total number of bariatric cases performed annually increased from 166 to 370 per year. The number of LRYGBPs increased from 16 in the first year to 303 the last year. Similarly, the number of open RYGBPs dramatically decreased over the same period. The number of open cases peaked in the second year at 169 but decreased to only 6 in the last year. The LRYGBP made up only 10% of the practice in year 1 but was 91% of the practice in year 5. It decreased to 82% in year 6 because of the increasing popularity of the laparoscopic band. Other bariatric cases included revisional procedures and laparoscopic adjustable gastric bands. The striking increase in the number of other bariatric cases performed in year 6 also represents the more liberal offering of the laparoscopic band.
As depicted in Table 1, the percentage of women who underwent surgery decreased from 98% in the first 100 cases to 81% for the last 100. Men were rarely offered the LRYGBP during the first 100 cases but were rarely denied the LRYGBP thereafter. Mean age and BMI increased slightly over time. Of note, while the mean BMI seems to have only risen slightly from the first 100 to last 100 cases (from 44 kg/m2 to 47 kg/m2), no patients with a BMI greater than 55 kg/m2 were offered the LRYGBP in the first 100 cases. Estimated blood loss, operative time, and hospital length of stay consistently dropped. Mean operating time was 212 minutes for the first 100 cases, 163 minutes for the next 100 cases, 132 minutes for all cases after the 100th, and only 105 minutes per case for the last 100 cases.
The overall mortality for the patient population was 0.3% with a complication rate of 15%. As presented in Table 2, for the first 100 cases, the complication rate was 26% with a mortality of 1%. Across the next 100 cases, the morbidity dropped to 11%. This rate was rather stable for the rest of the series. The complication rate was 13.4% for all patients operated on after the 100th case and 11% for the last 100 patients in the series. In addition, complications possibly related to technique, such as trocar site wound infection (8% vs 2%), splenic injury (1% vs 0%), bowel obstruction (5% vs 0%), and gastrointestinal track leak (3% vs 0%), decreased while others such as intraluminal bleeding and anastomotic stricture and thromboembolism remained essentially unchanged.
The RYGBP was first described by Mason and Ito13 in 1967. For more than 30 years, it has been the "gold standard" operative procedure for the treatment of intractable morbid obesity. The recent dramatic increase in the number of RYGBPs performed yearly4 can be attributed to many factors, most significantly, the growing public awareness of the disease of obesity and the successful evolution of the procedure from open to laparoscopic.6,14,15 The procedure has never been safer owing not only to the introduction of minimally invasive technologies but also to the improvements in patient preparation, anesthetic management, and postoperative care.
Yet despite the advances in bariatric surgery in the last 30 years, the procedure remains a technically difficult operation performed on high-risk patients. As most bariatric surgeons are well aware, morbidly obese patients do not tolerate complications. Complications, such as leaks, often result in catastrophic outcomes for these patients.
The introduction of laparoscopy into bariatric surgery has been of tremendous overall benefit but also a "double-edged sword." As with other abdominal procedures, laparoscopy dramatically reduces wound complications. With RYGBP, the risk of wound infection, said to be as high as 20% to 25% with open surgery,16 is reduced to approximately 1% with laparoscopy.17 Most significantly, a prospective, randomized trial by Nguyen et al,18 comparing open RYGBP with LRYGBP, found that with laparoscopy there are decreases in postoperative fluid shifts, pulmonary derangements, cytokine release, and temperature changes.19
Despite the potential overwhelming benefits of performing LRYGBP, the technical challenges cannot be overstated. The procedure is performed in deep abdominal cavities and requires exposure of the gastroesophageal junction. The liver is often steatotic and enlarged, limiting exposure and light penetration. Massive abdominal adiposity also compromises exposure to the viscera. Despite these hazards, the operation requires proximal gastric staple division and the creation of 2 anastomoses. As with other complex procedures, there is strong opinion that these procedures have a long and steep learning curve.
In surgery, the learning curve is defined as the number of cases performed necessary to acquire a familiarity with the operative technique. This also implies the point in training where technical complications should not occur more often than accepted frequencies. The concept of a learning curve became more relevant with the introduction of a major breakthrough in surgical technique, the ability to perform traditional surgery laparoscopically. This paradigm shift required the training of an entire surgical community to completely new techniques and totally new dexterities. For cholecystectomy, the first common open procedure adapted for laparoscopic surgery, the learning curve was assumed to be the number of cases a surgeon should perform to reduce the incidence of common bile duct injury to that of the open procedure. As more procedures were adapted, learning curves were suggested for them as well. The more complex the procedure, the greater the number of cases the surgeon must perform to master the learning curve. For laparoscopic inguinal herniorrhaphy, more than 50 cases are thought to be required.20 At least 20 cases were found necessary in 1 study to lower complications after laparoscopic splenectomy.21 Similar findings have been described for laparoscopic fundoplication and colectomy.22,23
The LRYGBP is generally considered to be one of the more technically challenging laparoscopic procedures. As previously described, the patient size and the complexity of the procedure contribute to the major challenges. Consistent with this is the support that the learning curve is as high as 100 cases. Schauer et al7 reviewed their first 150 LRYGBP procedures and reported that the operative complications halved after their 100th case. Operative time and the incidence of wound infections and leaks also decreased. Oliak et al8 found dramatic reductions in operating time (from 189 to 125 minutes) and perioperative complications from 32% to 15% after the 75th case. In a follow-up study, Oliak et al24 reported that advanced laparoscopic training could reduce this long, steep learning curve.
Another point of controversy is whether LRYGBP surgery should only be performed at high-volume centers. Many bariatric surgeons believe that the degree of difficulty of the procedure and the unique high-risk nature of the patient population mandates limiting this field to centers that specialize in it and perform it on a regular basis. Theoretically, high volume enables the surgeon to develop a significant experience with the procedure in a shorter period. High frequency leads to the acquisition of a comfort level with the nuances of the technique and the ability to modify the procedure based on trial-and-error learning. The result is to perform the operation with fewer technical problems and in less time. This comfort extends beyond the surgeon to all health care professionals involved with the care of these patients. All become comfortable with the unique aspects of the physiologic characteristics of the postoperative morbidly obese patient. Clinical pathways can be developed and implemented. Resources can be directed to the high-volume programs. Complications, even when occurring at a low frequency, will be seen more often because of the volume of cases. This allows the care team to better recognize these complications and therefore be better prepared to address them.
Numerous publications in several surgical disciplines support the notion that high volume leads to better patient outcome. For pancreatic cancer, the literature is clear that high-volume programs improved outcome for both curative as well as palliative surgery. Sosa et al25 found that increased hospital volume of all pancreatic surgery for cancer was associated with decreased in-hospital mortality rates and length of stay. Birkmeyer et al26 found that late survival after pancreaticoduodenectomy was markedly better for patients undergoing surgery at high-volume centers. Similarly, Parks et al27 reported better results for patients undergoing surgery by surgeons specializing in pancreatic cancer and with higher case loads. For carotid surgery, both stroke rate and mortality were lower for high-volume surgeons.28 Similar results have been reported for primary colon cancer resection.29
The association between case volume and outcome has also been reported for bariatric surgery. Courcoulas et al10 analyzed the 3-year outcome results of gastric bypass surgery in Pennsylvania from 1993 to 2000. They found that surgeons who performed fewer than 10 procedures per year had a statistically significantly higher risk of adverse outcome (28% vs 14%; P<.05) and risk of death (5% vs 0.3%; P = .06) than higher-volume surgeons. They further found that while hospital volume differences did not reach significance, surgeons who performed only 10 to 50 cases per year in low-volume hospitals had a 55% risk of adverse outcome (P<.01). Hospital volume differences did reach statistical significance in a study by Liu et al.11 Using the California inpatient hospital discharge database, they analyzed all gastric bypasses performed between 1996 and 2000. They found that complications were more likely to occur in patients who had surgery at very low–volume (< 50 cases per year) and low-volume hospitals (50-99 cases per year) with odds ratios of 2.72 and 2.70, respectively, when compared with higher-volume hospitals performing more than 200 cases annually.
Our data seem to support both premises that the learning curve is approximately 100 cases and a high-volume program may achieve better patient outcome than a low-volume program. With regard to learning curve, our data are consistent with those published by Schauer et al.7 Despite an increasing tendency to offer LRYGBP to more complex patients (ie, male patients and those with higher BMIs, previous abdominal surgery, higher comorbidity), we were able to simultaneously reduce our complication rate and operative time by 50%. Operating time did not level out after the first 100 cases but continued to fall. This may reflect that while the learning curve may be approximately 100 cases, learning and improvements in operating efficiency may continue beyond that point.
Further support for the steep and protracted learning curve can be seen in the pattern of morbidity reduction achieved in our series. Complications that could be attributed to technique or patient management demonstrated the greatest improvements with experience. Most notably, the gastrointestinal track leak rate was 3% for the first 100 cases, 1% for the next 100, and 1.1% overall. Trocar wound infections occurred in 8% of the first 100 cases and prompted a technique change from transesophageal passage of the circular stapler anvil to a totally abdominal approach. This is consistent with the results reported by Schauer et al.7 Similarly, improvements in technique led to decreases in splenic injuries, gastrogastric fistula, internal hernias, and early postoperative bowel obstructions due to stricture or kinking of the jejunojejunostomy. On the contrary, complications that are less likely the result of technique or management errors, such as intraluminal bleeding, thromboembolism, and anastomotic strictures, did not decrease in incidence.
Our program is a very high–volume program that is currently performing more than 400 bariatric procedures yearly, approximately 80% of which are LRYGBPs, although only 16 LRYGBPs were performed in the first year of the study. Overall, 166 bariatric procedures were performed (the majority were open RYGBPs). By the next year, total case volume was more than 200. At approximately 3 to 4 cases weekly, the volume was sufficient to provide the necessary experience for all health care professionals involved. Even while we were climbing the learning curve for the LRYGBP (100 cases were not reached until after year 3), patient management experience was being gained from the open cases. The finding that the complications seen in the first 100 LRYGBP cases were operative and technique related and not due to patient care supports this premise.
This study was limited in scope. It was a retrospective observational analysis of a bariatric program. Many other factors could also have influenced the results. The operative technique did change slightly over the course of the study period. Case volume increased at the same time as the learning curve was being climbed. Were the improvements due more to conquering the learning curve, increasing the weekly case volume, or both? Furthermore, the true number of cases performed to conquer the learning curve was not proven nor was the necessary yearly volume.
Despite the limitations of a retrospective review, there is no dispute that the complications associated with the LRYGBP were dramatically reduced after approximately 100 cases were performed at a high-volume bariatric program.
Correspondence: Scott A. Shikora, MD, Tufts-New England Medical Center, Box 900, 750 Washington St, Boston, MA 02111 (email@example.com).
Accepted for Publication: December 13, 2004.
Previous Presentation: This study was presented at the New England Surgical Society annual meeting; October 2, 2004; Montreal, Quebec; and is published after peer review and revision. The discussions that follow this article are based on the originally submitted manuscript and not the revised manuscript.
John Kelly, MD, Worcester, Mass: Your statistics have improved as you have gone through and yet you have had many fellows, you have young attendings that are starting with you, and by all rights they should have problems during their 100 or their first 50 that would drag down your statistics. I wonder if you could comment on what you think keeps them safe.
Dr Shikora: Well, first of all, we keep these folks on a very tight leash in the operating room. When we have somebody who is training with us, we often will scrub 2 attendings with the trainee so that if the trainee is starting to get into difficulty, the attending can switch places from holding the camera to operating. Remember that the number 1 priority, even though we are all very interested in training, is keeping our patients safe.
The explanation I have for the fact that our complication rate has stabilized at about 12% or 13% is that we have liberalized our patient selection. We are no longer denying the higher-risk patient, for example, the larger BMI, males, the older patient with more comorbidity, or the patient with significant previous abdominal surgery. It also may take into account that we have been more liberal with who we are training.
William Laycock, MD, Lebanon, NH: My question really is, I heard about fellows. I have heard about minifellowships, young attendings. I have not heard about residents. Currently I imagine at Tufts this has to be the highest-volume abdominal operation you do. At Dartmouth, it is more common than laparoscopic cholecystectomy. In our environment, I do all these with either a fourth- or a second-year resident. At the second-year resident level it is a little bit painful, but by the end of a specific laparoscopic rotation of 3 months, our fourth-year residents are doing the case. Now the problem is our time. We have not seen that diminution of time to the level that you have, but at the end of the day, I think we have to get this to the resident level at some point given the volume and the likely impact this is going to have on the general surgeon. I would like you to comment on how you are incorporating residents into the program.
Dr Shikora: It has always been a problem, and it continues to be a problem. Because of the new resident work hours, about a third of the residency goes home every morning so that there are a third less residents that would be potentially available to scrub with us. The ones that remain are divided up among the other surgeons who are operating that day. For many cases, we do not have a resident asking to scrub with us. We do welcome the residents and when they scrub, what we would do is have either myself and the fellow or myself and another attending operate along with the resident. We let the resident go as far as they can, keeping an eye on the clock and also to make sure that the technique is not being in any way, shape, or form compromised by the inexperience of the resident. We are willing to say, "okay, you could start now" and at a point where they get into trouble, switch places so that the more experienced set of hands can make progress. We then will get to another spot in the case where the resident can again contribute. That is how we have managed it. We would like to see residents with us more frequently than we do, but we are faced with the problems of the work hours and the other restrictions.
Steven Schwaitzberg, MD, Boston, Mass: Having watched the development of the learning curve and all those people that you have trained, you and Phil Schauer and other people have been pioneers and even self-trained in a pioneering period. I think that we owe it to our surgical community to keep chipping away at this 100-case barrier and go back and look at the people that have been trained now that you have really refined this operation, really have gotten the techniques down, because this is going to become a political issue, a financial issue, a legislative issue, and those higher numbers have very high costs for surgeons who want to learn this and for institutions that want to initiate these programs. We don't want to turn it into the "haves" and the "have nots" so I would encourage you to go back to your minifellows and look at their learning curves and see if we have knocked it down a bit over the next few years.
Dr Shikora: That is an excellent point. I alluded to that in the conclusion, that people who have had specialized training may have a lower learning curve than those who had to start from scratch. I did review an unpublished paper by somebody who had done some fellowship training in this and his suggestion was his own personal learning curve after 100 cases was 50 cases, but I agree with Steve that it is probably going to be less for those that had the opportunity to "jump on my back" and learn from my mistakes, because I can tell them "don't do this," "I did this and it didn't work out," or "here is a nice trick to keep you out of trouble."
Dr Kevin Looser, MD, Portsmouth, NH: I am one of Scott's minifellows, and our group of 3 surgeons started a program at Portsmouth and I think a learning curve number is difficult to come up with and varies obviously from surgeon to surgeon. I think if a surgeon has done a lot of laparoscopic surgery as we had to start out with and 1 of our surgeons did an advanced laparoscopic training for a year, I am not sure if that number of 100 holds up. Our program has been off and running for a little over a year now. We have done 75 cases, have not had any deaths, have had a number of complications, which you would expect, but I would certainly agree that a minifellowship is absolutely mandatory and important to do this procedure and that if you are just going to start off doing it without that kind of training you are going to have problems.
Dr Shikora: Well, Kevin, I agree with you in part. I still think that you and your partners benefited because I could tell you what I did wrong and how to prevent it. It does not necessarily have to do with how advanced your laparoscopic training was. It is some of the nuances of this particular operation. For example, it is learning a novel way to do the enteroenterostomy that decreases bowel obstruction when the standard technique that I had been doing resulted in a few more bowel obstructions.
Jeremy Morton, MD, Portland, Me: We may have already gotten the answer to my question, but there are many hospitals that want to start programs like this and we are strapped with the responsibility of credentialing these folks. I mean they have to credential themselves within the hospital but those of us involved with insuring them from medical liability have to decide whether or not they are adequately trained, and my question is what is the minimum amount of training, say a minifellowship or whatever, that you consider represents adequate training in the process of retrofitting the previously trained surgeon?
Dr Shikora: That is a very difficult question to answer, and many of us have different opinions on it. In Massachusetts, you may or may not know, we just convened an expert panel that was sponsored by the Department of Public Health to come up with standards for Massachusetts. Certainly a year fellowship would be the best, but that is not practical for surgeons who are out beyond their residency and in practice. Phil Schauer talks about doing a 3-month fellowship as a minimum, but even that is not practical if you have a busy practice. Many of us offer a couple of weeks of advanced training with hands-on in the operating room at high-volume centers such as ours where in a week's time you get to see 8 to 12 cases plus clinic and everything else that we do. That is probably the bare minimum for somebody who already has advanced laparoscopic skills. In addition, you should probably take certain courses put on by the ACS [American College of Surgeons] or the ACS in conjunction with the American Society of Bariatric Surgery, but I think we are still evolving what should be the appropriate training.
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This GivingTuesday, help drive innovation forward.
Treatments for recurrent esophageal cancer
The following are treatment options for recurrent esophageal cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan. They will usually do a nutritional assessment before treatment starts. You may need a feeding tube to make sure you get enough nutrition during treatment.
The types of treatment offered will depend on where the cancer comes back, if it has spread (metastasized) to distant sites and what treatments you've already had.
You may be offered surgery to treat cancer that comes back in the esophagus after endoscopic mucosal resection (EMR) or photodynamic therapy (PDT). The most common surgery used is esophagectomy, which removes the esophagus, nearby lymph nodes and part of the stomach.
Chemoradiation is treatment that combines chemotherapy with radiation therapy. Chemotherapy is given during the same time period as radiation therapy. Some types of chemotherapy make radiation therapy more effective.
You may be offered chemoradiation if esophageal cancer comes back after surgery, and it comes back near where the original tumour started. Chemoradiation is offered if you haven't already had radiation therapy.
The most common chemotherapy drugs used in chemoradiation for recurrent esophageal cancer are:
- cisplatin (Platinol AQ) and 5-fluorouracil (Adrucil, 5-FU)
- cisplatin and capecitabine (Xeloda)
- oxaliplatin (Eloxatin) and 5-fluorouracil
- oxaliplatin and capecitabine
- paclitaxel (Taxol) and carboplatin (Paraplatin, Paraplatin AQ)
Other combinations of drugs that may be used include:
- paclitaxel and cisplatin
- docetaxel (Taxotere) and cisplatin
- irinotecan (Camptosar) and cisplatin
- paclitaxel and 5-fluorouracil
- paclitaxel and capecitabine
- docetaxel and 5-fluorouracil
- docetaxel and capecitabine
You may be offered chemotherapy alone for recurrent esophageal cancer that comes back after surgery. Chemotherapy is offered if you have already had radiation therapy, or if you can't have chemoradiation or more surgery.
Chemotherapy is also used to treat esophageal cancer that recurs in a distant part of the body (called metastatic esophageal cancer).
The most common chemotherapy drugs used to treat recurrent esophageal cancer are:
- cisplatin and 5-fluorouracil
- ECF – epirubicin (Pharmorubicin), cisplatin and 5-fluorouracil
- ECX – epirubicin, cisplatin and capecitabine
- EOX – epirubicin, oxaliplatin and capecitabine
- DCF – docetaxel, cisplatin and 5-fluorouracil
- 5-fluouracil and irinotecan
Radiation therapy
You may be offered radiation therapy alone to relieve symptoms of recurrent esophageal cancer, such as pain and difficulty swallowing. This is called palliative radiation therapy. External beam radiation therapy or brachytherapy (internal radiation therapy) may be used.
Endoscopic treatments
You may be offered endoscopic treatments for recurrent esophageal cancer. Endoscopic treatments are used to relieve the symptoms of advanced esophageal cancer, such as difficulty swallowing. This is called palliative therapy.
Esophageal dilation may be done to open up an area of narrowing, or stricture, in the esophagus caused by cancer.
An esophageal stent is a tube placed in the esophagus to keep it open.
Laser surgery uses an intense, narrow beam of light to destroy cancer cells.
Photodynamic therapy (PDT) uses drugs that make cells sensitive to light (called photosensitizers) to destroy cancer cells.
Radiofrequency ablation (RFA) is a procedure that uses a high-frequency electrical current to destroy cancer cells.
Electrocoagulation or argon plasma coagulation uses an electrical current to destroy cancer cells.
Targeted therapy
Targeted therapy uses drugs or other substances to target specific molecules (usually proteins) involved in cancer cell growth while limiting harm to normal cells.
You may be offered targeted therapy if you have recurrent adenocarcinoma of the esophagus that is HER2 positive (which means it overexpresses, or makes too much, HER2 protein) and you aren't having radiation therapy. The targeted therapy drug used is trastuzumab (Herceptin).
Trastuzumab is given along with chemotherapy. The most common chemotherapy drugs used with trastuzumab are:
- cisplatin and 5-fluorouracil
- cisplatin and capecitabine
Trastuzumab may be continued alone after chemotherapy is completed. It is given until the cancer starts to grow or spreads.
Clinical trials
You may be asked if you want to join a clinical trial for esophageal cancer. Find out more about clinical trials.
How can you stop cancer before it starts?
Discover how 16 factors affect your cancer risk and how you can take action with our interactive tool – It's My Life! Presented in partnership with Desjardins.


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When asked if a sequel to Predators is in the works, director Nimród Antal mentioned that he and producer Robert Rodriguez have been discussing one, but that his next project will be his own dystopian film, Paraffin.
Playlist recently asked Antal about the future of the Predator franchise. The director said that he and Rodriguez had spoken about a sequel, but that a Predators 2 (Predator IV? Predatorses?) was contingent on demand:
We'll see what happens this next weekend [...] I couldn't care less about the box office [...] But clearly Fox and the people hiring me do. I just want to make a good movie, and we'll see what happens. I certainly hope people come and see it.
He also gave some hints about his next project Paraffin, a dystopian film named after the waterproof sealant:
I can't quite give you a storyline yet [...] I can give you a teaser: men and women will build a boat out of plastic bottles in Cuba to escape oppression, right? So imagine if our world has become that [kind of] oppression. You aren't building plastic bottle boats anymore, you have to build something else to get out of here.
Predators comes out next Friday, July 9.


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This is the basic building block of milkshakes. You can change the flavor of the ice cream or add your favorite fruit to create a completely different beverage.
3 cups ice cream
1-1/2 cups milk (it will definitely be richer with whole milk)
2 teaspoons vanilla
2 teaspoons sugar
Blend all ingredients on low to medium speed in blender and serve. Makes 2 servings – don't forget to share!


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Burton - Double Beeracuda
Over-the-shoulder beer holder. Liquid lunch box stores a vertical stack of cold ones in the insulated sleeve, plus a bonus can on the koozie-enhanced shoulder strap.
Locked and loaded, but mostly loaded, the Burton Beeracuda is the ultimate over the shoulder beverage holder. It's full of technologically complex features like the ability to hold multiple cans at once and the application of gravity to hold it securely to your shoulder. Koozie up front keeps one additional piece of ammo within immediate range of your muzzle.
- Insulated Beverage Sling Holds Five Cans
- Koozie on Shoulder Strap for Extra Can
- Double Beeracuda Offered in 11-Can Double Barrel Design
- Volume: 4L
- Weight: 1lbs
- Dimensions: [26in x 6in x 6in]
- Fabric: bluesign® Approved 600D Polyester with PU Backing
YETI - LoadOut$39.99
Mountainsmith - The Sixer CoolerPrice From:
Save: 32%


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I'll be the first to admit that I'm not far enough along in my kettlebell training to attempt everything on this dvd, but when I am, I'm sure I'll have no problem with Pavel leading the way. As my title states, the amount of detail to teaching in this dvd is incredible. It surpasses Enter…Read More
By Pavel
With Kenneth Jay, Master RKC and Missy Beaver, RKC
DVD, Running time: 48 minutes
Return of the Kettlebell's protocols were born from Pavel's insights while training elite power athletes. Several champions made astonishing, almost mysterious, strength and muscle gains—at least two broke new powerlifting world records—thanks to kettlebell training. Pavel decided to reverse engineer this "What the Hell" effect experienced by the champions—so all others could benefit from their success. Return of the Kettlebell presents the final fruit of Pavel's research—combining the very best of ancient lifting wisdom with modern day scientific breakthroughs.
Central to Pavel's new program for explosive muscle gain is the skillful use of double kettlebells. Discover smokers like the Double Clean, classic strength builders like the Double Snatch and Double Press and enjoy the supreme intensity of the Double Clean and Jerk. Like the Breakfast of Champions, consume what's on the Return of the Kettlebell menu and watch yourself grow—and grow!
How sure are we that Return of the Kettlebell (DVD) will work for you? Simply fill out the form below and put Return of the Kettlebell (DVD) to work for you right now.
If you are not 100% absolutely thrilled with your purchase, Dragon Door Publications will refund of your entire purchase price for up to a FULL YEAR.
That's how sure we are!
Obviously, we would go out of business if Return of the Kettlebell (DVD) didn't work, the way we said, right?
With the promise of a full refund if you're unsatisfied, you have nothing to lose by trying Return of the Kettlebell (DVD). Go ahead and try it today.
Thoroughly master Pavel's Enter the Kettlebell! program and you can consider yourself a "Kettlebell Black Belt". But once you're a Kettlebell Black Belt, then what?
I'll be the first to admit that I'm not far enough along in my kettlebell training to attempt everything on this dvd, but when I am, I'm sure I'll have no problem with Pavel leading the way. As my title states, the amount of detail to teaching in this dvd is incredible. It surpasses Enter the Kettlebell, in my opinion. Each exercise is explained by Pavel in detail, with demonstration being done by Missy Beaver and Kenneth Jay. Kenneth also adds his knowledge to the teaching when necessary, and I literally felt like I had two masters in the room teaching me when viewing this dvd. Again, its not for the beginner - you should be far enough along in your training that your basics are spotless before attempting anything on this disc. But it is definitely worth the price (if not more), and I would highly recommend it to anyone wanting to take their training to the next level of mastery.
The Return of the Kettlebell DVD is a master class in the technique for several of my favorite HARDSTYLE double kettlebell drills, including the front squat, the double clean and press, the clean and jerk and the extra-sinister double snatch. Although geared toward experienced kettlebell lifters, the DVD is an excellent resource for anyone who wants to improve their kettlebell skill. The section where Kenneth Jay and Pavel discuss the technical aspects and application of the Viking push press by itself is worth the price of the DVD. The DVD is not limited to kettlebells, however. Pavel covers post-workout hip opening drills with the same depth and attention to details as Beyond Stretching. Get this DVD.
The DVD is very good quality. Sound and picture are great. Pavel does a good job of explaining all of the drills. Only gripe was that Kenneth Jay was a bit underdressed while Missy Beaver was a bit overdressed.
This video is simply terrific. It is extremely comprehensive. It is ironic that I am one of the earlier viewers, as Pavel opens up with a comment directed squarely at me. But don't worry, fearless Leader, I don't intend to implement anything from the video until passing the ROP, hopefully within this calendar year.Many exercises are covered that I expected - double cleans all the way through double snatches - and there also many new exercises I saw for the first time, such as front lateral snatches and Viking push presses. Each exercise begins with "Kenneth please demonstrate!" and the explanations and demonstrations are crystal clear, and shown from multiple angles. A myriad of tips are presented with each as well, to assist the learning process. There are also some interesting points about double kettlebell exercises with different size kettlebells that were interesting.The most interesting demonstration for me is the double clean and jerk. KJ's footwork is so speedy that it really helps to have Pavel explaining as KJ demonstrates.Additionally, for the female comrades, there are demonstrations of the exercises with appropriate adaptations for the female body by a woman named Missy.Here was the unexpected part for me: You pop the DVD in your computer, and there is a pdf file with a thorough training plan and schedule. A sort of book preview, in a sense.All this and more - all in Pavel's trademark style and with top notch video production to boot.A MUST BUY, COMRADES!
RTK is for individuals who want strength, mass and strength endurance. It is for serious comrades who will continue to trudge forward when the presses get heavy and the clean and jerks become grueling. This program is hard, but anything worth having takes work, and in this case a lot of work. Do not take this lightly; you must be proficient in the exercises and tasks in the ETK workout. After 4 months of RTK I posted new PR's in the PM lifts; new military press (48kg) and snatch test (220) without pressing anything heavier than a 32kg and no snatches during my RTK training. This is not the goal outlined in the RTK, it is much worse, but gives you a sense of the level of conditioning this program affords. I also gained 12-15 pounds over the 4 months; and being 5'7'' and a hard gainer, that is saying a lot. If you are ready for the next step in kettlebell training and endurance, mental as well as physical, buy this book!
I think the dvd is worth the money because of the information provided but I thought it was too informal. It wasn't as professionally presented as the Enter the Kettlebell dvd. The dialogue between Kenneth Jay and Pavel was too relaxed at times. It looked like there were a few outtakes sloppily left in the final edit of the dvd. On the bright side, there are some really cool movements I was unaware of that the dvd thoroughly covers.
Pavel RETURNS with this magnificent instructional that takes The Russian Kettlebell CHALLENGE to higher levels of physical training that will push any strong comrade to their limits.In three words: DOUBLE KETTLEBELL WORK. If that intimidates you, it should. Pavel makes it plainly clear: if you thought SINGLE kettlebell work was rough, this new batch will simply run you over. As they say: two is always better than one. The DVD invites us with familiar dragondoor fare: Pavel talking to the camera, using his trademark dry sense of humor to disarm the viewer/victim, before introducing us to the pain that inevitably follows. The exercises and procedures in the DVD will push ANY strong athlete (or RKC for that matter) to new levels of athleticism and pain. As challenging as the exercises may seem, however, Pavel goes through EXTRAORDINARY detail on execution and injury prevention. The DVD covers the double KB exercises with precision (to name a few):- Correct posture and NEW ways to breathe behind the shield- Proper foot placement - Optimum EYE positioning In addition, the DVD also includes Master RKC Kenneth "Dane of Pain" Jay and RKC Missy Beaver. Having them aboard allows Pavel to further elaborate the details of each exercise, for both male and female athletes. Unlike Pavel's previous DVD's, where he commands full attention, RTK allows Pavel to go even further with his teachings since he discusses the details of each exercise with these two talented RKC's, for the benefit of the viewer. Nice, nice touch.With new exercises, greater detail, and sharp presentation, this DVD lives up to its already very high expectations.DOUBLE THUMBS UP!
There could not have been a better follow up to the first edition on how a kettlebell can transform you body than Return of the Kettlebell. Provided that the Program Minimum and Right of Passage has been milked for all it's worth and the ROP goals have been met, then the next logical step is to follow the ROP w/ 2 kettlebell Clean and Presses. I look forward to seeing where this program will take my strength, body composition and muscle density.
Good quality dvd presentation chock full of useful tips and techniques. Wish I would have known there was a book coming out though. I find books easier to look at over and over. Only gripe is that the program that comes with the dvd only focuses on a couple movements. I understand the P2p approach for it. Still would like a way to integrate double snatches swings etc
OK folks, You have done it again!! I never cease to be amazed at how down to earth and informative your products are. This new DVD by Pavel is superb. I've spent a small fortune on kettlebells, books and DVD's and have gotten more than a return on my investment. Pavel cuts right through the hype and bull that is out there. Keep up the great job!!!
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