Amphibian diversity across three adjacent ecosystems in Área de Conservación Guanacaste, Costa Rica.

Amphibians are the most threatened species-rich vertebrate group, with species extinctions and population declines occurring globally, even in protected and seemingly pristine habitats. These 'enigmatic declines' are generated by climate change and infectious diseases. However, the consequences of these declines are undocumented as no baseline ecological data exists for most affected areas. Like other neotropical countries, Costa Rica, including Área de Conservación Guanacaste (ACG) in north-western Costa Rica, experienced rapid amphibian population declines and apparent extinctions during the past three decades. To delineate amphibian diversity patterns within ACG, a large-scale comparison of multiple sites and habitats was conducted. Distance and time constrained visual encounter surveys characterised species richness at five sites-Murciélago (dry forest), Santa Rosa (dry forest), Maritza (mid-elevation dry-rain forest intersect), San Gerardo (rainforest) and Cacao (cloud forest). Furthermore, species-richness patterns for Cacao were compared with historic data from 1987-8, before amphibians declined in the area. Rainforests had the highest species richness, with triple the species of their dry forest counterparts. A decline of 45% (20 to 11 species) in amphibian species richness was encountered when comparing historic and contemporary data for Cacao. Conservation efforts sometimes focus on increasing the resilience of protected areas, by increasing their range of ecosystems. In this sense ACG is unique containing many tropical ecosystems compressed in a small geographic space, all protected and recognised as a UNESCO world heritage site. It thus provides an extraordinary platform to understand changes, past and present, and the resilience of tropical ecosystems and assemblages, or lack thereof, to climate change.

Patterns of narcotic utilization in women undergoing hysterectomy for benign indications.

OBJECTIVE: To determine whether perioperative narcotic utilization at the time of hysterectomy has decreased since 2012. STUDY DESIGN: Retrospective cohort study. SETTING: Academic university hospital. PATIENTS: Patients who underwent a laparoscopic hysterectomy for benign indications between January 2012 and December 2018. INTERVENTIONS: Perioperative narcotics administration. MEASUREMENTS AND MAIN RESULTS: We identified 651 patients who underwent a hysterectomy for benign indications from 2012 to 2018. Of these, 377 surgeries were performed using robotic-assistance (58%) and the remainder (42%) were performed by conventional laparoscopy. Narcotic utilization declined significantly by year for both intra-operative and post-operative periods (both p<.001). The largest decline for intraoperative morphine milligram equivalents (MME) was between 2016 and 2017, while for post-operative MME, it was between 2012 and 2013. The pattern remained significant after adjusting for covariates. Intraoperative MME administration was correlated with postoperative MME use (Spearman r = 0.23, p<.001). Of the demographic variables only Body Mass Index was significantly associated with perioperative narcotic administration. CONCLUSION: Administration of opioids for intraoperative and postoperative pain after minimally invasive hysterectomy substantially decreased from 2012 to 2018. Intraoperative narcotic utilization was correlated with immediate postoperative narcotic consumption. Heightened awareness of opioid administration practices during and immediately following surgery is critically important to decreasing risk of chronic opioid dependence and providing the best possible care for the patients we serve.

Superior Hypogastric Plexus Block to Reduce Pain After Laparoscopic Hysterectomy: A Randomized Controlled Trial.

OBJECTIVE: To assess whether a superior hypogastric plexus block performed during laparoscopic hysterectomy reduces postoperative pain. METHODS: We conducted a multicenter, randomized, single-blind, controlled trial of superior hypogastric plexus block at the start of laparoscopic hysterectomy. Women undergoing a laparoscopic hysterectomy for any indication and with any other concomitant laparoscopic procedure were eligible. Standardized preoperative medications and incisional analgesia were provided to all patients. Our primary outcome was the proportion of patients with a mean visual analog scale (VAS) pain score lower than 4 within 2 hours postoperatively. Patients but not surgeons were blinded to the treatment group. Twenty-nine patients per group was estimated to be sufficient to detect a 38% absolute difference in the proportion of patients with a VAS score lower than 4 at 2 hours postoperatively, with 80% power and an α of 0.05. To account for loss to follow-up and potential imbalances in patient characteristics, we planned to enroll 50 patients per group. All analyses were intention to treat. RESULTS: Between January 2018 and February 2019, 186 patients were eligible; 100 were randomized and analyzed. Demographic and clinical characteristics were similar between the two groups. There was no significant difference in the proportion of patients with a mean VAS score lower than 4 within 2 hours postoperatively between patients who received a superior hypogastric plexus block (57%) and patients who did not (43%) (odds ratio 1.63, 95% CI 0.74-3.59; adjusted odds ratio 1.84, 95% CI 0.75-4.51). CONCLUSION: Among patients undergoing laparoscopic hysterectomy with standardized enhanced perioperative recovery pathways, superior hypogastric plexus block did not significantly reduce postoperative pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03283436.

Safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights.

One strategy thought to reduce direct costs associated with robotic surgery is minimizing the number of robotic arms used for a surgery. We aim to demonstrate the safety and feasibility of the three-port robot-assisted hysterectomy across uterine weights. Retrospective cohort study in a tertiary care university hospital of consecutive patients undergoing a three-port robot-assisted hysterectomy for benign indications. All surgeries were performed between 2012 and 2018 by fellowship-trained minimally invasive gynecologic surgeons. Data from 232 patients were collected. Eighty-eight (37.9%) patients had a uterine weight < 250 g, 63 (27.2%) had a uterine weight between 250 and 500 g, 51 (22.0%) had a uterine weight between 500 and 1000 g, and 30 (12.9%) had a uterine weight ≥ 1000 g. Multivariable regression analysis revealed no statistically significant differences between uterine weight groups and time spent in PACU, the total length of hospital stay, or direct cost. When setting the < 250 g as referent, patients with uterine weights between 500 and 1000 g, and more than 1000 g had an operative time that was on average 23.4% and 91.6% longer than patients with uterine weight < 250 g, respectively (p < 0.01). Patients with uterine weights between 500 and 1000 g and more than 1000 g had an EBL that was on average 35% and 156% higher than patients with uterine weight < 250 g, respectively (p < 0.01). Our data support the safety and feasibility of the three-port robot-assisted hysterectomy technique across uterine weights.

Cost variance across obesity class for women undergoing laparoscopic hysterectomy by high-volume gynecologic surgeons.

Health-care costs are affected by obesity with both the direct and indirect costs of health care increasing as body mass index (BMI) increases. However, one important aspect of obesity that lacks rigorous study is what impact BMI has on direct surgical cost. We performed a retrospective cohort study of women undergoing a laparoscopic hysterectomy at our single academic university center between January 2012 and December 2017. Women were excluded if their surgery was performed by anyone other than those surgeons with subspecialty training in minimally invasive gynecologic surgery (MIGS), if their hysterectomy was performed by a modality other than conventional laparoscopy or with robotic assistance, or if the indication for hysterectomy was related to any gynecologic malignancy. We identified 600 patients who underwent laparoscopic hysterectomy during the study period. Women who underwent robotic hysterectomy, compared to laparoscopic, had a shorter operative time, lower estimated blood loss, and shorter length of stay. Mean direct cost (± standard deviation) for the cohort was $6398.53 ± $2304.67, age was 44.5 ± 7.5 years, and BMI was 32.2 ± 7.6. Direct cost for all laparoscopic hysterectomies was evaluated across the five different BMI quintiles and no significant difference between groups was found. There was no significant difference in direct cost across procedures between obese and non-obese patients (p = 0.62) and this remained true when separated out by surgical modality. However, when evaluating morbidly obese patients, there appears to be a trend toward cost reduction with robotic hysterectomy compared to conventional laparoscopy. It does not appear that BMI has a statistically significant impact on direct cost between robotic-assisted and conventional laparoscopic hysterectomy. However, these findings may be due to surgical proficiency and warrant further investigation among surgeons with lesser volume.

Perioperative Narcotic Trends in Women Undergoing Minimally Invasive Myomectomy.

STUDY OBJECTIVE: Evaluate the perioperative narcotic utilization patterns at the time of myomectomy, specifically as they relate to the opioid epidemic. We also aim to evaluate the differences between conventional laparoscopy and robotic surgery in terms of narcotic utilization. DESIGN: Retrospective cohort study. SETTING: Single academic university hospital. PATIENTS: Women undergoing minimally invasive myomectomy. INTERVENTIONS: Laparoscopic or robot-assisted myomectomy. MEASUREMENTS AND MAIN RESULTS: We identified 312 minimally invasive myomectomies to be included in the final analysis. For the entire cohort, the mean age (± standard deviation) was 35.7 ± 5.1 years, and the mean body mass index was 28.3 ± 6.3. Of the 312 myomectomies included, 239 (76.6%) were performed using robotic assistance, and the remainder (23.4%) were performed by conventional laparoscopy. A statistically significant inverse relationship was found between year of myomectomy and perioperative narcotic administration (p <.001). Yearly morphine milligram equivalent (MME) administration decreased significantly for both intraoperative and postoperative administration (p <.001). The largest decline for intraoperative MME use was between 2016 and 2017, and for postoperative MME use, it was between 2012 and 2013. There was no statistically significant difference in perioperative narcotic administration between conventional laparoscopy and robot-assisted myomectomy. The time effect for intraoperative (p <.001) and postoperative (p <.001) narcotic administration remained significant after adjusting for covariates, including mode of surgery, race, insurance, age, and body mass index. None of the background variables assessed were associated with perioperative narcotic administration. CONCLUSION: Perioperative narcotic administration for minimally invasive myomectomy has decreased following widespread awareness of the national opioid crisis.

Anthropogenic and ecological drivers of amphibian disease (ranavirosis).

Ranaviruses are causing mass amphibian die-offs in North America, Europe and Asia, and have been implicated in the decline of common frog (Rana temporaria) populations in the UK. Despite this, we have very little understanding of the environmental drivers of disease occurrence and prevalence. Using a long term (1992-2000) dataset of public reports of amphibian mortalities, we assess a set of potential predictors of the occurrence and prevalence of Ranavirus-consistent common frog mortality events in Britain. We reveal the influence of biotic and abiotic drivers of this disease, with many of these abiotic characteristics being anthropogenic. Whilst controlling for the geographic distribution of mortality events, disease prevalence increases with increasing frog population density, presence of fish and wild newts, increasing pond depth and the use of garden chemicals. The presence of an alternative host reduces prevalence, potentially indicating a dilution effect. Ranavirosis occurrence is associated with the presence of toads, an urban setting and the use of fish care products, providing insight into the causes of emergence of disease. Links between occurrence, prevalence, pond characteristics and garden management practices provides useful management implications for reducing the impacts of Ranavirus in the wild.