The Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program was established by SAGES to develop and expand individual surgeon\'s comfort with specific, complex operations using hands-on teaching and longitudinal mentoring. The 2022-2023 Foregut (Dominating the Hiatus) section of the course focused on hiatal hernia dissection and gastric fundoplication techniques. Our aim was to describe the experience of surgeons who participated in the course.
The hands-on component occurred in March 2022 at the SAGES annual meeting. Each expert mentor was matched to two participants. The mentors guided the surgeons through steps of a laparoscopic paraesophageal (PEH) hernia repair and fundoplication using a cadaveric model. Afterwards, monthly group webinars occurred and participants could receive individual coaching from their assigned mentor for a year. Each participant was given a pre-course survey with 3 and 12-month follow-up questionnaires.
The majority of the 16 participants were employed in non-academic settings (87.5%). Years in practice ranged from 1 to 26, and 69% completed a fellowship. 100% completed the pre-course survey, and 53.8% responded to the 12-month post-course survey. Participant-reported effectiveness in performing a PEH hernia repair with fundoplication increased from 37.5% pre-course to 85.7% by the conclusion of the course. Confidence levels for the six core steps of the operation also increased: pre-course only 56-75% were confident with each step, this improved to 100% in four out of six steps. 85.7% said the course has changed their practice.
Since inception, the ADOPT program has aimed to provide expert instruction for practicing surgeons to learn new techniques or improve their confidence in performing operations. The data for the 2022 ADOPT Foregut course shows that 1 year of participation made a positive impact on these surgeons\' practices. This helps to fill in the learning gap that occurs after formal surgical training ends.

After completion of training, practicing surgeons rely on hands-on courses to expand their procedure armamentarium and improve their surgical technique. However, such courses vary in standardized teaching methods. SAGES developed the Acquisition of Data for Outcomes and Procedure Transfer (ADOPT) program as a method of longitudinal instruction utilizing standardized teaching techniques, mentorship, and webinars to cover additional techniques. This study examines the adoption of learned techniques and participant confidence before and after an ADOPT course focused on extended-view totally extraperitoneal (eTEP) hernia repair.
A hands-on course focused on eTEP hernia repair was conducted with enrollment capped at 10 participants. Pre-course and post-course surveys at 3, 6, and 12 months determined implementation of the learned procedure, case volume, and confidence with eTEP skills. A 5-point Likert scale (1 = not confident at all to 5 = completely confident) assessed confidence levels. Survey responses were summarized using descriptive statistics.
Of the 10 participants, 10 (100%) completed the pre-course survey, and 7 (70%) completed at least one post-course survey. Median age was 48.5 years (36,56) with a median of 16 years (2,23) in practice, mostly in the community setting (70%). After the course, 50% had performed an eTEP procedure, and 100% reported considering this technique during surgical planning. Participants reported higher confidence in eTEP-specific skills at three months post-course from pre-course levels. The highest change in confidence was seen for the following skills: accessing the retromuscular/extraperitoneal space for ventral hernia and recognizing when the linea alba has been violated, p < 0.05.
This study shows that rapid incorporation of learned techniques can be achieved through the ADOPT format. Furthermore, through longitudinal mentorship and a structured hands-on course, the ADOPT course supports practicing surgeons to attain autonomy and confidence even when teaching a relatively technically challenging procedure, such as eTEP.

BACKGROUND: The rapid diffusion of technology apps may support older adults\' independence and improve the quality of their lives. Models for predicting technology acceptance in older adults are sparse, based on broad questions related to general technology acceptance, and largely not grounded in theories of aging.
OBJECTIVE: This study aimed to use a mixed methods approach involving 5 technologies to comprehensively assess the causal relationships among factors that influence older adults\' willingness to adopt the technologies.
METHODS: In total, 187 men and women aged 65 to 92 years participated in the study. Participants were given presentations on 5 different technologies spanning domains that included transportation, leisure, health, and new learning and provided ratings of each technology on various measures hypothesized to influence adoption. They were also administered other instruments to collect data on their actual and self-assessed cognitive abilities, rates of discounting of the technologies with respect to willingness to invest time to attain higher skills in the technologies, general technology experience, and attitudes toward technology. We used the machine learning technique of k-fold cross-validated regressions to select variables that predicted participants\' willingness to adopt the technologies.
RESULTS: Willingness to adopt technologies was most impacted by 3 variables: perceived value of the technologies (β=.54), perceived improvement in quality of life attainable from the technologies (β=.24), and confidence in being able to use the technologies (β=.15). These variables, in turn, were mostly facilitated or inhibited by the perceived effort required to learn to use the technologies, a positive attitude toward technology as reflected in the optimism component of the technology readiness scale, the degree to which technologies were discounted, and the perceived help needed to learn to use the technologies.
CONCLUSIONS: Our findings demonstrate that participants\' willingness to adopt technologies is mainly determined by perceptions of 3 aspects of the technologies; these aspects possibly mediate many relationships with willingness to adopt. We discuss the implications of these findings for the design and marketing of technology products for older consumers.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) uses the Laparoscopic colectomy Train the Trainer (Lapco TT) framework for standardization of instructor training for Hands-On surgical skills courses. The curriculum focuses on teaching structure, skills deconstruction, trainer intervention framework, and performance enhancing feedback. A halt in the in-person Lapco TT courses due to the Coronavirus Disease 2019 (COVID-19) pandemic necessitated creation of a virtual alternative. We investigated the effectiveness of this virtual course.
Adaptation of the in-person Lapco TT course to the virtual format retained the majority of content as well as the 4:6 instructor-to-participant ratio. The virtual platform and simulators chosen allowed maximal interactivity and ease of use. After participating in the day and one half course, participants completed an 8-item post-course survey using a 5-point Likert scale related to the training experience. In addition, they had the opportunity to provide answers to several open-ended questions regarding the course. For the survey, frequency counts provided an assessment of each item. For the open questions, qualitative analysis included determination of themes for each question. Frequency counts of each theme provided quantitative analysis.
Thirty-six total participants completed a Lapco TT virtual course (six sessions of six participants). Of this number, 32 participants completed post-course surveys and questions. All the participants completing the survey would very likely or definitely (Likert scale 4, 5) recommend the course to a colleague and incorporate the teaching in their practice. The majority of participants completing open-ended questions felt the virtual course format was effective; half thought that post-course follow-up would be useful. Technical concerns were an issue using the virtual format.
A virtual Lapco TT course is feasible and well received by participants. It presents a potentially more cost effective option to faculty development.

Obesity is a multifactorial disease with a variable and underwhelming weight loss response to current treatment approaches. Precision medicine proposes a new paradigm to improve disease classification based on the premise of human heterogeneity, with the ultimate goal of maximizing treatment effectiveness, tolerability, and safety. Recent advances in high-throughput biochemical assays have contributed to the partial characterization of obesity\'s pathophysiology, as well as to the understanding of the role that intrinsic and environmental factors, and their interaction, play in its development and progression. These data have led to the development of biological markers that either are being or will be incorporated into strategies to develop personalized lines of treatment for obesity. There are currently many ongoing initiatives aimed at this; however, much needs to be resolved before precision obesity medicine becomes common practice. This review aims to provide a perspective on the currently available data of high-throughput technologies to treat obesity.

BACKGROUND: Wound classification systems are useful tools to characterise diabetes-related foot ulcers (DFU) and are utilised for the purpose of clinical assessment, to promote effective communication between health professionals, and to support clinical audit and benchmarking. Australian guidelines regarding wound classification in patients with DFU are outdated. We aimed to adapt existing international guidelines for wound classification to develop new evidence-based Australian guidelines for wound classification in people with diabetes and DFU.
METHODS: Recommended NHRMC procedures were followed to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines on wound classification to the Australian health context. Five IWGDF wound classification recommendations were evaluated and assessed according to the ADAPTE and GRADE systems. We compared our judgements with IWGDF judgements to decide if recommendations should be adopted, adapted or excluded in an Australian context. We re-evaluated the quality of evidence and strength of recommendation ratings, provided justifications for the recommendation and outlined any special considerations for implementation, subgroups, monitoring and future research in an Australian setting.
RESULTS: After the five recommendations from the IWGDF 2019 guidelines on the classification of DFUs were evaluated by the panel, two were adopted and three were adapted to be more suitable for Australia. The main reasons for adapting, were to align the recommendations to existing Australian standards of care, especially in specialist settings, to maintain consistency with existing recommendations for documentation, audit and benchmarking and to be more appropriate, acceptable and applicable to an Australian context. In Australia, we recommend the use of the SINBAD system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/national/international audit. In contrast to the IWGDF who recommend against usage, in Australia we recommend caution in the use of existing wound classification systems to provide an individual prognosis for a person with diabetes and a foot ulcer.
CONCLUSIONS: We have developed new guidelines for wound classification for people with diabetes and a foot ulcer that are appropriate and applicable for use across diverse care settings and geographical locations in Australia.

To continue dialogue over proposed Australian trials of Trap-Neuter-Return (TNR), we applied a framework requiring identification of areas of agreement, areas of disagreement, and identification of empirical data collection required to resolve disagreements. There is agreement that Australia has a problem with stray cats, causing problems of impacts on wildlife, nuisance, disease transmission (including public health issues and exchange of diseases between stray cat and pet cat populations), poor welfare outcomes for stray cats, and an emotional burden on staff euthanising healthy stray cats. There is disagreement on whether (i) current measures are failing, leading to unacceptably high euthanasia levels, (ii) some contributors to the debate misunderstand TNR, (iii) TNR trials will reduce urban cat populations and associated problems, (iv) TNR is an ethical solution to cat overpopulation, and (v) some contributors to the debate promulgated misinformation. Although not everyone agrees that TNR trials should proceed, as a hypothetical exploration, we propose an experimental approach explicitly comparing TNR to alternatives. Trials could only be considered if other detailed and well-funded attempts at stray cat control focusing across an entire Local Government Area (LGA) prove ineffective.

Trap-Neuter-Return (TNR) programs, in which stray cats are captured, neutered and returned to the environment are advocated as a humane, ethical alternative to euthanasia. We review the TNR literature in light of current debate over whether or not there should be further TNR trials in Australia. We revisit the problems arising from stray cats living in association with human habitation and estimate how many stray cats would have to be processed through a scientifically-guided TNR program to avoid high euthanasia rates. We also identify 10 ethical and welfare challenges that have to be addressed: we consider the quality of life for stray cats, where they would live, whether the TNR process itself is stressful, whether TNR cats are vulnerable to injury, parasites and disease, can be medically treated, stray cats\' body condition and diet, and their impacts on people, pet cats, and urban wildlife, especially endemic fauna. We conclude that TNR is unsuitable for Australia in almost all situations because it is unlikely to resolve problems caused by stray cats or meet ethical and welfare challenges. Targeted adoption, early-age desexing, community education initiatives and responsible pet ownership have greater promise to minimize euthanasia, reduce numbers rapidly, and address the identified issues.

OBJECTIVE: Precision medicine drug therapy seeks to maximize efficacy and minimize harm for individual patients. This will be difficult if drug response and side effects are positively associated, meaning that patients likely to respond best are at increased risk of side effects. We applied joint longitudinal-survival models to evaluate associations between drug response (longitudinal outcome) and the risk of side effects (survival outcome) for patients initiating type 2 diabetes therapy.
METHODS: Participants were randomized to metformin (MFN), sulfonylurea (SU), or thiazolidinedione (TZD) therapy in the A Diabetes Outcome Progression Trial (ADOPT) drug efficacy trial (n=4,351). Joint models were parameterized for 1) current HbA1c response (change from baseline in HbA1c) and 2) cumulative HbA1c response (total HbA1c change).
RESULTS: With MFN, greater HbA1c response did not increase the risk of gastrointestinal events (HR per 1% absolute greater current response 0.82 [95% CI 0.67, 1.01]; HR per 1% higher cumulative response 0.90 [95% CI 0.81, 1.00]). With SU, greater current response was associated with an increased risk of hypoglycemia (HR 1.41 [95% CI 1.04, 1.91]). With TZD, greater response was associated with an increased risk of edema (current HR 1.45 [95% CI 1.05, 2.01]; cumulative 1.22 [95% CI 1.07, 1.38]) but not fracture.
CONCLUSIONS: Joint modeling provides a useful framework to evaluate the association between response to a drug and the risk of developing side effects. There may be great potential for widespread application of joint modeling to evaluate the risks and benefits of both new and established medications.

Practicing surgeons commonly learn new procedures and techniques by attending a \"hands-on\" course, though trainings are often ineffective at promoting subsequent procedure adoption in practice. We describe implementation of a new program with the SAGES All Things Hernia Hands-On Course, Acquisition of Data for Outcomes and Procedure Transfer (ADOPT), which employs standardized, proven teaching techniques, and 1-year mentorship. Attendee confidence and procedure adoption are compared between standard and ADOPT programs.
For the pilot ADOPT course implementation, a hands-on course focusing on abdominal wall hernia repair was chosen. ADOPT participants were recruited among enrollees for the standard Hands-On Hernia Course. Enrollment in ADOPT was capped at 10 participants and limited to a 2:1 student-to-faculty ratio, compared to the standard course 22 participants with a 4:1 student-to-faculty ratio. ADOPT mentors interacted with participants through webinars, phone conferences, and continuous email availability throughout the year. All participants were asked to provide pre- and post-course surveys inquiring about the number of targeted hernia procedures performed and related confidence level.
Four of 10 ADOPT participants (40%) and six of 22 standard training participants (27%) returned questionnaires. Over the 3 months following the course, ADOPT participants performed more ventral hernia mesh insertion procedures than standard training participants (median 13 vs. 0.5, p = 0.010) and considerably more total combined procedures (median 26 vs. 7, p = 0.054). Compared to standard training, learners who participated in ADOPT reported greater confidence improvements in employing a components separation via an open approach (p = 0.051), and performing an open transversus abdominis release, though the difference did not achieve statistical significance (p = 0.14).
These results suggest that the ADOPT program, with standardized and structured teaching, telementoring, and a longitudinal educational approach, is effective and leads to better transfer of learned skills and procedures to clinical practice.