, 2013) or SABIO-RK (Wittig et al , 2012) to obtain the appropria

, 2013) or SABIO-RK (Wittig et al., 2012) to obtain the appropriate references along with the functional enzyme data and to enter these data in a spread sheet. After the compilation of all relevant data you will make the

surprising discovery that the functional data is fragmented DZNeP in such a way that for particular enzymes there are no published data at all, or that they exist but span an excessively broad range. For example, Km values from the literature (as stored, for example, in BRENDA) may have been measured at pH values from 3 to more than 10, and at temperatures from 0 to more than 100 °C. This is clearly not the fault of curators of these databases, but arises from the inadequacy of the data in the literature,

since the functional data were extracted from publications in primary biochemistry journals. Imagine another researcher who characterizes the ATP-coupled transport of ions across biological membranes. Usually these transporters are ion pumps that couple the transport of, for example, protons across the plasma membrane or intra-cellular membranes of compartments such as lysosomes or vacuoles against chemo-osmotic gradients to the hydrolysis of ATP. Among other issues regarding the catalytic properties of this enzyme, in particular, the thermodynamic coupling Obeticholic Acid purchase ratio is the relationship of the number of ATP molecules hydrolyzed per number of ions transported in the focus of research (Rea and Sanders, 1987). This ratio is calculated as a function of ΔG

and both the transport of charges and equilibrium reaction of the hydrolysis of ATP (see for example Kettner et al., 2003). However, this calculation requires the value of the apparent equilibrium constant of the ATP hydrolysis, KATP, which depends on a number of parameters such as the pH and the concentrations of Mg2+, K+ and Ca2+ ( Alberty, 1968 and Rosing and Slater, 1972). When the calculations have been done our imaginary researcher wants to know whether his coupling ratios are consistent with those previously published with other organisms. However, he fails, despite finding coupling ratios in biochemical or biophysical papers, either because the calculations are not available or because they are insufficiently set out in the Materials and Methods section of the papers. Evodiamine Thus, he can neither understand the published values nor compare his results with the published ones. These two following examples demonstrate the dilemma of protein functional data: Even though there are few projects that collect and organize functional and kinetic enzyme data such as the BRENDA database for enzyme functions and properties, SABIO-RK for biochemical reactions within metabolic pathways, KEGG, BioCyc (Caspi et al., 2010), and BioCarta for the representation of metabolic pathways, the availability of comparable functional enzyme data is limited or sometimes non-existent.

The scDNA produced two clear bands representing the super-coiled

The scDNA produced two clear bands representing the super-coiled (Form-I) and relaxed circular form (Form-II) of scDNA in the absence of the M(bpy)2 complex, as expected. The presence of the Cu(bpy)2 complex resulted in the disappearance of both bands corresponding to Forms-I and -II (lanes 2–3, Fig. 2). The bands were smeared, suggesting that scDNA cleavage occurred at more than one place. On the other hand, the Zn(bpy)2 and Cd(bpy)2 complexes showed very small or no cleavage activity under the conditions adopted in this study. A range of reactive oxygen species (ROS) might be involved in the cleavage process. To identify

MG-132 research buy the nature of ROS species, the effect of ROS scavengers was tested [28], [29], [30] and [31]. Fig. 3 shows the effect of the scavengers on scDNA cleavage by the Cu(bpy)2 complex detected by electrophoresis.

The presence of 5 mM sodium azide and 50 mM DMSO (lanes 4 and 5, Fig. 3) showed very little inhibition for the cleavage process. Similar to that in the absence of scavengers Trametinib mouse which produced a predominantly smeared band (lane 1), the presence of either sodium azide or DMSO resulted in a smeared band. Considering that sodium azide and DMSO are scavengers for singlet oxygen (1O2) and hydroxyl radicals (·OH), these two oxygen species did not participate in the cleavage process. Tiron, a superoxide radical, ·O2−, scavenger, had a large inhibition effect on the cleavage of scDNA (lane 3). The smeared band did not appear whereas the amount of scDNA decreased with increasing Form-II band (nicked open circular form). The presence of catalase, a H2O2 scavenger, also resulted in the disappearance of the smeared band whereas the bands correspond to nicked circular and linear forms were apparent. This suggested that the role of the oxygen radical is essential for the Cu(bpy)2-induced scDNA cleavage. LD is an excellent tool for probing the cleavage of sc and dsDNA [15], [16], [17], [18] and [32]. This real-time LD technique is based

on the fact that the magnitude of LD in the DNA absorption region solely reflects the flexibility and length of DNA if the other factors including the optical density, viscosity, temperature and flow rate (in the flow orientation case) are kept constant. Fig. 4 shows the LD spectrum of the Clomifene DNA in the presence and absence of the Cu(bpy)2 complex at the time of mixing and 20 min after mixing. In the absence of the Cu(bpy)2 complex, the LD spectrum of dsDNA was negative and its shape resembled the negative of the absorption spectrum as expected from the set-up adopted in this study [17], [18] and [19]. Both the shape and intensity of the LD spectrum of dsDNA remained in the absence of the Cu(bpy)2 complex. The maximum intensity was observed at 258 nm. The presence of the Cu(bpy)2 complex caused a decrease in intensity, a 5 nm red-shifted maximum and a positive band above 300 nm at the time of mixing.

05 level) Over the whole period, the Z-value was 5 6, 5 5 and 5

05 level). Over the whole period, the Z-value was 5.6, 5.5 and 5.3 in the upstream, midstream and downstream areas, respectively. These large Z-values imply a high level of warming trend. The MK test results of seasonal precipitation and temperature variations in the upper, middle and lower HRB from 1960 to 2012 are shown in Fig. 10. In the upstream areas, check details the MK test analysis shows significant increasing in precipitation for the summer. Therefore, the increase of precipitation

in summer was the most important reason for annual precipitation rising in the upstream areas. In the midstream and downstream areas precipitation in the winter shows the most obvious increasing trend compared to other seasons. Temperature increased significantly for all seasons at the α = 0.01 level. The highest increasing trend in the upstream areas occurred in the autumn and winter with Z-value of 5.82, while in the downstream areas the highest increasing

trend occurred in the summer with Z-value of 6.53. However, in the midstream areas, the Z-values for all four seasons were approximately the same, at 3.55, implying a constant increasing trend within the year. Fig. 11(a) shows trends of the annual precipitation and mean temperature spatially. Among the 17 stations, precipitation for only three stations located in the upstream indicates a significant upward trend at the significant level of a = 0.05. Trends of the precipitation are insignificant for the other meteorological stations. Among GDC0449 them, four stations show a slight decreasing trend (one outside the upstream and three in the downstream). For the annual mean temperature, all 17 stations show statistically significant increasing trends with Z-value changes ranging from 3.85 to 6.29. The magnitude of precipitation and temperature changes is shown in Fig. 11(b). On average, the precipitation has increased by about 6–9 mm/decade Reverse transcriptase in the upper HRB, and 3–6 mm/decade in the middle HRB. In the downstream region, the precipitation has decreased by −0.71 mm/decade

in the northwest. For temperature, the magnitude of the increasing tread ranges from 0.30 °C/decade in the southwest to 0.51 °C/decade in the northwest. Change points of the precipitation and temperature were also investigated in this study, and the results are shown in Fig. 12. For precipitation, only three out of 17 stations have a step change point. Two of them exhibited an upward abrupt change occurring in 1981 and 1986, respectively, while the other one exhibited downward abrupt changes occurring in 1997. Unlike precipitation series, all of the annual mean temperature series have an upward abrupt change. Of them, 13 occurred in 1986, three occurred in 1992, and one occurred in 1996. Climate change is the main cause to explain streamflow increasing in the upper HRB for less human activities have occurred in the mountain regions so far.

Plates were washed six times and 100 μl of rabbit polyclonal anti

Plates were washed six times and 100 μl of rabbit polyclonal anti-Hsp70 (1/400) diluted in PBS/T containing 4% mouse serum was added. After 1 h on shaker at 37 °C, plates were washed and incubated with 100 μl of an anti-rabbit immunoglobulin peroxidase conjugate in selleck screening library PBS/T/BSA (1/10,000) for 1h on shaker at 37 °C. Plates were then washed and 200 μl of o-phenylenediamine dihydrochloride (OPD) substrate

was added. After 45 min on shaker and at 37 °C, the reaction was stopped with 50 μl of sulphuric acid (1 N H2SO4) and the absorbance determined at 490 nm with background subtraction at 620 nm using a microplate reader (Ceres 900C, Bio-Tec Instruments, Inc., Belgium). Hsp70 concentrations in serum were detected by comparing sample absorbance with the absorbance of a reference purified human recombinant Hsp70 protein. The serum levels of 25-OH-vitamin-D were determined using the 25 hydroxyvitamin D125I RIA Kit (Diasorin Inc., Stillwater, USA; normal values: 16–74 μg/l). Vitamin B12 and folate were determined with the Simultrac Radioassay Kit (Becton Dickinson Immunodiagnostics, USA; normal values: 0.22–0.94 μg/l and 2.0–14.0 μg/l for vitamin B12 and folate, respectively). The serum levels of parathyroid hormone (PTH) were determined using the N-tact

PTH Irma Kit (Diasorin Inc, Stillwater, USA; normal values 15–65 ng/l). Calcium was measured in serum by the o-cresolphthalein complexone method (Bio Phase Diagnostics Laboratory, Ontario, CA; normal values 8.6–9.8 mg/dl). Raf inhibitor drugs Wilson disease protein Antimalarial antibody concentration was determined in the clinical laboratory of the Institute of Tropical Medicine (Antwerp, Belgium) as reported elsewhere (Njemini et al., 2002). Antimalarial antibodies were tested by an indirect immunofluorescence using antigens from the Institute of Tropical Medicine and an anti-human immunoglobulin (IgGAM) conjugate. Titers ≥ 1/40 were considered positive. Fresh skin snips, taken from the lower extremities, as well as fresh blood were screened microscopically for the presence of filarial parasites. All reagents were applied according to manufacturers’ recommendations. Column statistics (with statistical package prism 3.0) was used to test

the approximation of the population distribution to normality. Spearman’s rank test was used to examine the relationship between the serum concentrations of Hsp70 and the levels of the other parameters. For the comparison of Hsp70 levels between two groups, the nonparametric Mann–Whitney test was applied. A 2-sided p < 0.05 was considered statistically significant. Table 1 summarizes the data for women and men. The Hsp70 serum levels varied between 0 and 47 ng/ml (median 13 ng/ml) in female and between 0 and 78 ng/ml (median 13 ng/ml) in male. There were no relationships with gender. Hsp70 concentrations were found to be dependent on the degree of inflammation, as measured by the circulating CRP levels (r = 0.172, p = 0.044), as well as by the WBC count (r = 0.

Oil and gas exploration has increased in the BHS Since early 201

Oil and gas exploration has increased in the BHS. Since early 2010, at least four vessels have conducted seismic surveys for

seabed oil and gas deposits in Raja Ampat, close to Kofiau, Salawati and Misool Islands. These large specialized ships tow cables that fire airgun blasts/sound waves at the seabed to elucidate underwater geological formations and structures. AG-014699 datasheet Potential impacts from unregulated seismic surveys include disturbance to migratory species such as cetaceans and turtles which can become displaced (McCauley et al., 2000), lethal and sub-lethal effects on adult fish, fish larvae or fish eggs (Hirst and Rodhouse, 2000), and negative impacts to community fisheries (Skalski et al., 1992 and Hirst and Rodhouse, 2000). Although the vessels had licenses from the national government, the surveys were conducted within 4 nautical miles of the coast without the approval of the provincial or regency governments, and without public consultation or adherence to international standards. This issue highlights the lack of coordination between national, provincial

and regency governments in the energy sector. Deforestation and coastal Rapamycin chemical structure development have escalated over the last 10 years in the BHS, and are leading to yet unmeasured, but nonetheless observable impacts on watersheds, coastlines and marine environments (Fig. 10). Highly erodible soils, very steep slopes and high rainfall (Fig. 3) in the BHS makes coastal habitats see more (particularly shallow

coral reefs), more vulnerable to damage from land based activities. One or more authors are aware of impacts from deforestation and poorly planned coastal development including: (a) run-off of topsoil to beaches and marine habitats causing smothering of coral and soft-sediment communities; (b) loss of mangroves due to road construction and logging; (c) direct loss of critical habitat for threatened species (e.g. green, hawksbill, and leatherback turtles, estuarine crocodiles, and Wilson’s Bird of Paradise Cicinnurus respublica) through beach modification and coastal vegetation removal; (d) direct loss of coral reefs through reclamation; (e) altered salinity and temperature profiles at river mouths due to interrupted water flow; and (f) introduction of invasive species to forests. It has been estimated that 85% of Papua is still covered with intact forests (GRM International, 2009). However, most of the lowland forests have been designated for logging and agriculture. There is extensive logging in the Bomberai Peninsula between Fakfak and Kaimana, and the Wandammen Peninsula in Cendrawasih Bay (M.V. Erdmann, personal observations). As far back as 2002, illegal logging has been taking place on the islands of Waigeo and Batanta in Raja Ampat, including in three gazetted nature reserves (McKenna et al., 2002) and appears to be increasing as infrastructure improves to support the capital of Raja Ampat. In addition, the Indonesian government is committed to establish 5.

We recommend the definitions of span and skew given in the Maryla

We recommend the definitions of span and skew given in the Maryland Consortium paper [1], including the subtle difference Ibrutinib cell line illustrated

therein between the definition of tensor span for shielding and shift tensors. That having been said, although span and skew are provided as specification conventions in SpinXML, we would also support IUPAC [4] and [7] in discouraging their use – whenever possible, both chemical shift and chemical shielding should be specified using 3 × 3 interaction matrices that leave no room for ambiguity. At the top level of the SpinXML format hierarchy, the spin_system element ( Fig. 1, bottom middle) contains an arbitrary number of spin and interaction elements. Each spin element has an integer id, an isotope identification string and an optional set of Cartesian coordinates. The interaction elements conform to the interaction_term complex type described in the previous paragraphs. An example of SpinXML specification for the spin system of

13C-labelled formaldehyde given in Fig. 2 illustrates the format structure. Because of its similarity to HTML (which is actually a subset of XML), SpinXML syntax appears similar to a web page specification. This self-documenting property of XML [20] and [21] is useful because edits can be made without consulting format documentation. Note that the isotope specification is not limited to magnetic isotopes – retaining oxygen atoms as 16O in particular is often useful in visualizations because it puts magnetic interaction schematics into a general chemical context. A much needed stage in the AZD5363 cell line spin system simulation setup process is interaction visualization. Ellipsoid plots [27] and [28] and spherical harmonic representations [11] of second rank tensors have been around for a while, and visualization tools dealing with subsets of spin interactions (e.g. Simmol [30]) are available, but a general

interactive 3D GUI that would be applicable to both NMR and EPR, and be capable of exporting input files for spin dynamics simulation Baricitinib packages, particularly in EPR spectroscopy, has so far been missing. Spinach GUI (designed primarily to accompany our Spinach library [17], hence the name) is an interactive 3D graphical user interface that implements all SpinXML features. It supports point-and-click specification of NMR and EPR spin systems, interaction tensor import from popular electronic structure theory programs (Gaussian [31], CASTEP [32], ADF [33], ORCA [34]) and export of spin system specifications into popular spin dynamics simulation packages (EasySpin [15], Spinach [17] and SIMPSON [14] at the time of writing). Import and export filters for other major programs will be added in the near future. The main GUI window is shown in Fig. 3. The atom table on the left and the interaction table on the right are self-explanatory.

Because of the possible effects of stress interacting with the PY

Because of the possible effects of stress interacting with the PYY(3-36) treatment, our animals were habituated to the injection protocol. As noted above, when food deprived Siberian hamsters are refed, large increases in food hoarding and foraging occur persisting for ∼7 d, whereas food intake does not increase beyond the first few h [18]. Arc injected PYY(3-36) inhibited food intake and food hoarding in the true foraging group (10REV) during the first few hours

of refeeding, a timeframe of effectiveness similar to that of 24 h food-deprived-refed laboratory rats after PYY(3-36) treatment for food intake [9]. The finding that the effect of PYY(3-36) only was seen in the hamsters ‘earning’ their food via foraging Obeticholic Acid ic50 (wheel running, i.e., 10REV) is consistent with our findings with other anorexigenic peptides that exhibit their greatest inhibition in the 10REV group including the NPY Y1-R antagonist 1229U91 [29], leptin [30], melanocortin 4-R agonism [melanotan II [28]] as well as triggering the greatest increases in food hoarding for orexigenic peptides administered centrally [NPY [15] and [20], AgRP [19]]. The reason that ‘earned’ food elicits both larger decreases and increases in food hoarding is not clear. It is not that these animals are in any greater increase in negative energy

balance due to the wheel running because the FW group runs approximately the same number of wheel revolutions as the 10REV

group, although food is not contingent on the wheel running. Thus, some factor(s) associated with foraged (‘earned’) INCB28060 in vivo very food rather than freely available food seems in play in the present and our previous studies that certainly warrants further study. Collectively, the present data indicate that NPY Y2-R agonism inhibits food intake and hoarding, albeit in the short term (0–2 h) with refeeding after food deprivation. In addition, there does not appear to be underlying NPY Y2-R signaling inhibiting ingestive behaviors in this species because the antagonism of NPY Y2-R signaling does not increase appetitive or consummatory ingestive behaviors in ad libitum-fed hamsters. The short term nature of PYY(3-36) is not unique to this study, and as such seems to be limited in its ability to decrease foraging/hoarding in Siberian hamsters. Longer lasting NPY Y2-R agonists are being developed [36], however, some of which may have the potential for therapeutic use to curtail food intake and hoarding in humans. The authors thank the Department of Animal Resources at Georgia State University for expert animal care and Dr. Cheryl H. Vaughan, Danni Liu, Alex Thomas, Daniel Vizcaino, Dominiq Okoduwa, Melissa Chaney, and Shasmine Kelly for assistance in data collection. “
“Menopause is a risk factor for many cardiovascular diseases (CVD). Estrogen deficiency is also known to impair cardiovascular function and metabolism [54].

No differences between the four fructose-fed groups were seen reg

No differences between the four fructose-fed groups were seen regarding

the Selleckchem Trichostatin A initial body weight recorded prior to the intervention (p = 0.83, Table 2). Neither did the weight at the time of termination of the experiment (p = 0.84), nor the weight gain during the intervention (p = 0.68), differ between the four groups. No differences were found between the four groups regarding the weight of the fat pad (p = 0.32), and MRI showed no differences in total or visceral adipose tissue volumes between the four groups (see Table 2 for details). However, MRI revealed a greater fat infiltration in the liver of BPA-exposed rats than in the fructose-fed control rats. In the medium-dose and the high-dose group of BPA exposed rats the liver fat content was higher when compared with the fructose control group (p = 0.011, medium dose; p = 0.012, high dose). The lowest dose of BPA did not significantly influence liver fat content ( Fig. 3). Also the MRI liver R2* analysis showed an

effect on the liver by BPA, being significant in all three groups when compared one by one to the fructose control group (low-dose; p = 0.0008, middle-dose; p < 0.0001, high-dose; p = 0.0161, Table 2). A similar picture emerged, although not as pronounced as for the R2* signal, when the liver somatic index (LSI) was investigated. LSI was increased in the low-dose (p = 0.043, not significant following Bonferroni adjustment) and middle-dose group (p = 0.018, not significant following Bonferroni adjustment), but not significantly so CHIR-99021 nmr in the high-dose group when compared with the fructose-fed control rats ( Table 2). Both the medium-dose and high-dose of BPA groups showed significantly higher levels of plasma apo A-I, when compared with the fructose control group (p < 0.0001, medium dose; p < 0.0001 high dose). The lowest dose of BPA did not cause any significant difference in apo A-I ( Fig. 4). Plasma cholesterol and plasma triglycerides were not significantly altered by the BPA exposure. Neither was blood

glucose at week 9, or ASAT and ALAT altered by BPA exposure. Of all variables studied (see Table 2), only plasma triglycerides and LSI were significantly increased by fructose feeding alone when compared to the water-fed control p = 0.0011 and p = 0.0031, respectively. The present study disclosed no evidence that BPA exposure in juvenile female fructose-fed F Interleukin-2 receptor 344 rats would increase fat mass, despite the use of both weights and MR imaging based detailed quantification of different adipose tissue compartments. However, the observed increase in liver fat infiltration, detected by MRI in parallel with increase in LSI, although in the latter case not significant following strict Bonferroni correction for multiple testing, even at dosages close to TDI, is a finding that warrants further investigations. Interestingly, an increase in liver fat infiltration appeared at the middle dose, but was not further increased at the highest BPA dose.

In conclusion, we have shown that Pre-RBCT

alone is still

In conclusion, we have shown that Pre-RBCT

alone is still associated with a lower rate of Non-AMR rejection and an increased risk of HLA antibody. However, peri-operative blood transfusion in sensitised renal recipients with DSA and prior transfusion is associated GSK J4 cell line with AMR. Post-RBCT may therefore be an additional factor modifying the risk of AMR in patients with HLA-antibody. We also confirm and expand upon the previous findings that perioperative blood transfusion is associated with poorer graft and patient survival, and show that this is most evident in those with previous exposure to RBCT, independent of acute rejection episodes. These findings suggest that RBCT remains a potent and complex modifiable immunomodulator of renal transplant outcomes and additional studies to further define mechanisms for these effects are warranted. This is an original work and the manuscript or parts of it have not been submitted elsewhere for publication. All authors have read and approved submission of the

manuscript, selleck chemicals and that material in the manuscript has not been published and is not being considered for publication elsewhere in whole or part in any language except as an abstract. The authors wish to acknowledge the clinicians and transplant nurses at Royal Perth Hospital, Sir Charles Gairdner Hospital and Fremantle Hospital in Western Australia involved in the collection of this data. We wish to thank the Department of Clinical Immunology, G protein-coupled receptor kinase Royal Perth Hospital for compatibility testing of the patients in this study. “
“Kidney transplantation is the preferred treatment modality for patients with ESRD because of improved patient survival and quality-of-life over dialysis [1], [2], [3] and [4]. Several groups have analyzed transplantation in highly HLA-sensitized patients recently. The risks for transplantation can be assessed using currently available standard assays. Today, the techniques that are used to detect anti-HLA antibody include cytotoxicity (CDC) with/without

anti-human globulin, ELISA, and flow cytommetry (using cells and antigen-coated beads). The development of newer, more sensitive assays has led to an increased ability to define highly sensitized patients and identify donor-specific antibody [2]. Several risk factors have been described regarding sensitization to HLA antigens including blood transfusions, pregnancy and previous organ transplantation. The degree of sensitization creates an obstacle for the accessibility and success of kidney transplantation [1]. In patients with high panel-reactive antibodies (% PRA) defined as having a % PRA > 30, transplant rates are dramatically reduced because of the additional immunologic barrier with increased rejection risk [2]. In 2003, only 6.5% of all kidney transplants that were performed in the United States were in patients with PRA > 80%, despite representing approximately 14% of the waiting list [5] and [7].

Studies have shown that NOTES requires a significantly higher men

Studies have shown that NOTES requires a significantly higher mental workload to perform as compared with conventional laparoscopy.12 Animal studies with teams of surgeons and gastroenterologists performing various NOTES procedures demonstrate that technical limitations were more important than differences in medical education, provided that there is a certain level of experience in both flexible endoscopy and laparoscopy as well as a team approach.13 An equally critical aspect of the initial experience

in a teaching program is the ability to adapt the learning curve into a routine training paradigm to ensure competence on the part of trainees—whether residents, fellows, or other practitioners. We have presented our institutional learning curve as it occurred for A-1210477 concentration the primary adopter of this new approach and subsequently transitioned to fellow-level trainees. The senior surgeon involved was skilled at interventional endoscopic procedures and laparoscopic Heller myotomy as well as having extensive laboratory experience with endoscopic Heller myotomy in animal and cadaver models. The two fellows involved, however, as is common with usual surgical training practices, had experience only with the basics

of flexible RAD001 in vitro endoscopy before their postgraduate training had started. Their fellowship curricula included laboratory and hands-on practice in advanced flexible endoscopy (ablation, foreign body removal, endoscopic suturing, ESD/EMR, stenting, etc). They assisted in POEM cases from the beginning of their year and began graduated participation in Bay 11-7085 the cases after the initial transition period of 8 cases. By the end of the year of training, it was thought that both were capable of independently performing uncomplicated POEM cases. Study limitations include the fact that the “plateau

phase” of the primary investigator’s experience included progressive participation by the fellows. Had the senior surgeon primarily performed all 40 cases in the study cohort, rather than training the fellows, he may have become even more technically facile, resulting in further improvements in our study parameters. However, POEMs that the senior author has primarily performed beyond the initial 40 cases in our study cohort have not seen a significant drop-off in mean LOP or complications. Hence, we believe that 20 cases seems to be the plateau for an experienced endoscopist. Because of time limitations of the fellows’ training, we were unable to further validate the learning curve by tracking each of their experiences out to a plateau. Nonetheless, we show that with a phased-in learning approach and careful proctoring, even novice practitioners can be brought to at least minimum competency in 5 to 10 cases.