Exploring perceptions of factors aiding the development of critical thinking in adult dysphagia: A study among fourth-year speech-language pathology students.

BACKGROUND: The assessment and management of adult dysphagia in South Africa is complex as appropriate intervention requires a balance of theoretical knowledge and critical thinking to ensure service delivery is appropriate within a resource-constrained health care system. Critical thinking involves the skilful evaluation of information to make informed decisions for effective assessment and intervention. It is imperative for Speech-Language Pathologists (SLPs) to cultivate these skills from an early stage in their careers. This study therefore aims to investigate the factors perceived to enhance critical thinking to shed light on how students transition theory into clinical decision-making. This is vital to inform future practice in the realm of dysphagia and to enhance Speech Therapy education. METHODS: A qualitative research design was utilised to identify what facilitators assist SLP students to develop critical thinking skills in adult dysphagia. Data were gathered from students across three universities. Fifteen participants answered a self-developed online survey, and of those, four participated in a follow-up focus group. The data were analysed using a top-down approach and reflexive thematic analysis. RESULTS AND DISCUSSION: The results revealed that viewing videos on instrumental assessment measures, case studies and peer learning were perceived to expand critical thinking theoretically. Similarly, critical thinking was best supported in clinical contexts, which provided opportunities to observe expert clinicians at the bedside, obtain individual feedback and access supervision. CONCLUSION: The findings yielded recommendations for clinical educators involved in dysphagia training. This is necessary to better prepare SLP students to provide contextually relevant and responsive dysphagia services.

Long term experience of robotic retroperitoneal partial nephrectomy as the default approach in the management of renal masses: should the paradigm shift?

Although retroperitoneal surgery has demonstrated a better quality of recovery compared to transperitoneal routes, Retroperitoneal Robot Assisted Partial Nephrectomy (RRAPN) remains proportionally infrequent. As the boundaries of what is achievable robotically continue to be pushed, we present our experience at a high-volume tertiary referral centre that specialises in retroperitoneal surgery, exploring its feasibility as standard of care in the management of small renal masses. A prospective database of 784 RAPNs (2009-2020) was reviewed and 721 RRAPNs (92%) were performed at our centre. In our practice, we utilise a four-port approach to RRAPN. Patient, tumour and operative characteristics were assessed and both oncological outcomes and trifecta and pentafecta achievements were determined. Pentafecta was defined as achieving trifecta (negative surgical margin, no post-operative complications and WIT of < 25 min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1 year. Multivariate analysis was conducted to predict peri-operative factors which may prevent achieving a trifecta/pentafecta outcome. From 784 cases, 112 RAPNs were performed for imperative reasons, whilst the remainder were elective. Mean BMI ± s.d amongst our cohort was 28.6 ± 5.7. Mean tumour size was 3.1 cm (range 0.8-10.5 cm) and 47% of cases were stratified as intermediate/high risk using R.E.N.A.L nephrometry scoring. Forty-six patients had lesions in a hilar location, and 31% were anterior. Median blood loss was 30mls, with an open conversion rate of 1% and transfusion rate of 1.6%. Median warm ischaemic time (WIT) was 21 min, positive surgical margins were found in 4% and our post-operative Clavien 3/ > complication rate was 2.6%. We had a 1-day median length of stay with a 30 day readmission rate of 2%. Of 631 patients (80%) with a definitive histological diagnosis of cancer, 23% had T1b/ > disease. Over a mean 15 month follow-up period (range 1-125 months), 2% of patients developed recurrences and our cohort demonstrated a 99% 5 year cancer specific survival. Trifecta was achieved in 67% of cases and pentafecta in 47%. Age (p = 0.05), operative time (p = 0.008), pT1b tumours (p = 0.03), R.E.N.A.L score and blood loss (p = 0.001) were found to statistically significantly influence achievement of trifecta. Pentafecta achievement was influenced by R.E.N.A.L score (p = 0.008), operative time (p = 0.001) and blood loss (p = 0.001). We demonstrate the retroperitoneal approach in RAPN is feasible and safe irrespective of lesion location and complexity. In the hands of high-volume centres that are skilled in the retroperitoneal approach the benefits of retroperitoneal surgery can be extended even to challenging cohorts of patients without compromising their oncological or functional outcomes.

"I must do this!": A latent profile analysis approach to understanding the role of irrational beliefs and motivation regulation in mental and physical health.

In the research concerning rational emotive behaviour therapy (REBT) in sport and exercise, irrational beliefs are proposed as a risk factor for health. Concurrent to this, researchers have also indicated that autonomous and controlled motivation, as proposed in organismic integration theory could, together with irrational beliefs, determine individual health. However, research is yet to align irrational beliefs and motivation, and explore how this alignment relates to mental health. The present two study paper identifies individual subgroups, drawn from data concerning irrational beliefs, motivation, and health (psychological distress, and physical health), in a sample of exercisers (study 1) and student athletes (study 2). We examined the latent profile structure of irrational beliefs and motivation, and how these latent profiles relate to psychological distress (studies 1 and 2), and physical health (study 2). Results indicate a two class profile whereby class 1 is characterised by high irrational beliefs, low self-determined motivation, and poor health outcomes. Class 2 is characterised by low irrational beliefs, high self-determined motivation, and better health outcomes. The findings are discussed in relation to the theoretical implications for REBT and organismic integration theory, and the practical implications for key stakeholders in the health of exercise participants and athletes.

The impact of a fellow on a regional robotic-assisted partial nephrectomy service.

INTRODUCTION: Training a fellow has a cost in time and effort for the surgeon and their team. Their relative inexperience may also negatively affect the patient. The aim of this study was to determine and quantify the impact of a fellow on a regional robotic-assisted partial nephrectomy service and on perioperative outcomes. MATERIALS AND METHODS: We reviewed the prospectively collected data for 522 patients who had undergone robotic-assisted partial nephrectomy since 2015 during the tenure of six fellows. Perioperative outcomes for three groups were compared: group A (no fellow participation), group B (some participation) and group C (fellow completed entire operation). We also reviewed progression over 12 months. RESULTS: Demographics were similar in all groups apart from the percentage of men, which was lower in group C (p < 0.05). Operative time was 27 minutes longer for group B (p < 0.001). Warm ischaemia time was significantly shorter for group A but the difference was only four minutes (p < 0.001). Length of stay was slightly shorter for group C compared with the other groups (p < 0.01). Trifecta achievement was greatest for group A (p < 0.001). There were no perioperative deaths in any group and positive margins, complications and readmissions were low and similar in all groups. Towards the end of their fellowship, fellows performed more operations independently. CONCLUSION: There is a measurable, but small, negative impact of a fellow on a robotic-assisted partial nephrectomy service, which reduces with experience. With appropriate supervision and patient selection, a fellow can be taught robotic-assisted partial nephrectomy without affecting patient safety or treatment outcome.

Strong and recurring seasonality revealed within stream diatom assemblages.

Improving stream water quality in agricultural landscapes is an ecological priority and a legislative duty for many governments. Ecosystem health can be effectively characterised by organisms sensitive to water quality changes such as diatoms, single-celled algae that are a ubiquitous component of stream benthos. Diatoms respond within daily timescales to variables including light, temperature, nutrient availability and flow conditions that result from weather and land use characteristics. However, little consideration has been given to the ecological dynamics of diatoms through repeated seasonal cycles when assessing trajectories of stream function, even in catchments actively managed to reduce human pressures. Here, six years of monthly diatom samples from three independent streams, each receiving differing levels of diffuse agricultural pollution, reveal robust and repeated seasonal variation. Predicted seasonal changes in climate-related variables and anticipated ecological impacts must be fully captured in future ecological and water quality assessments, if the apparent resistance of stream ecosystems to pollution mitigation measures is to be better understood.

Conspecific and Heterospecific Aboveground Herbivory Both Reduce Preference by a Belowground Herbivore.

Insect herbivores damage plants both above- and belowground, and interactions in each realm can influence the other via shared hosts. While effects of leaf damage on aboveground interactions have been well-documented, studies examining leaf damage effects on belowground interactions are limited, and mechanisms for these indirect interactions are poorly understood. We examined how leaf herbivory affects preference of root-feeding larvae [Acalymma vittatum F. (Coleoptera: Chrysomelidae)] in cucumber (Cucumis sativus L.). We manipulated leaf herbivory using conspecific adult A. vittatum and heterospecific larval Spodoptera frugiperda Smith (Lepidoptera: Noctuidae) herbivores in the greenhouse and the conspecific only in the field, allowing larvae to choose between roots of damaged and undamaged plants. We also examined whether leaf herbivory induced changes in defensive cucurbitacin C in leaves and roots. We hypothesized that induced changes in roots would deter larvae, and that effects would be stronger for damage by conspecifics than the unrelated caterpillar because the aboveground damage could be a cue to plants indicating future root damage by the same species. In both the greenhouse and field, plants with damaged leaves recruited significantly fewer larvae to their roots than undamaged plants. Effects of conspecific and heterospecific damage did not differ. Leaf damage did not induce changes in leaf or root cucurbitacin C, but did reduce root biomass. While past work has suggested that systemic induction by aboveground herbivory increases resistance in roots, our results suggest that decreased preference by belowground herbivores in this system may be because of reduced root growth.

A framework for managing runoff and pollution in the rural landscape using a Catchment Systems Engineering approach.

Intense farming plays a key role in increasing local scale runoff and erosion rates, resulting in water quality issues and flooding problems. There is potential for agricultural management to become a major part of improved strategies for controlling runoff. Here, a Catchment Systems Engineering (CSE) approach has been explored to solve the above problem. CSE is an interventionist approach to altering the catchment scale runoff regime through the manipulation of hydrological flow pathways throughout the catchment. By targeting hydrological flow pathways at source, such as overland flow, field drain and ditch function, a significant component of the runoff generation can be managed in turn reducing soil nutrient losses. The Belford catchment (5.7 km(2)) is a catchment scale study for which a CSE approach has been used to tackle a number of environmental issues. A variety of Runoff Attenuation Features (RAFs) have been implemented throughout the catchment to address diffuse pollution and flooding issues. The RAFs include bunds disconnecting flow pathways, diversion structures in ditches to spill and store high flows, large wood debris structure within the channel, and riparian zone management. Here a framework for applying a CSE approach to the catchment is shown in a step by step guide to implementing mitigation measures in the Belford Burn catchment. The framework is based around engagement with catchment stakeholders and uses evidence arising from field science. Using the framework, the flooding issue has been addressed at the catchment scale by altering the runoff regime. Initial findings suggest that RAFs have functioned as designed to reduce/attenuate runoff locally. However, evidence suggested that some RAFs needed modification and new RAFs be created to address diffuse pollution issues during storm events. Initial findings from these modified RAFs are showing improvements in sediment trapping capacities and reductions in phosphorus, nitrate and suspended sediment losses during storm events.

Antimicrobial usage in dogs and cats in first opinion veterinary practices in the UK.

OBJECTIVES: To provide baseline data on patterns of antimicrobial usage in dogs and cats through the analysis of data stored in electronic practice management systems. METHODS: Clinical data from 11 first opinion veterinary practices were extracted for the year 2007. Descriptive statistical analysis was performed to assess the usage of antimicrobials. RESULTS: Widespread usage of systemic broad-spectrum antimicrobials was observed. Antimicrobials most frequently used in both species were potentiated amoxicillin (44·4% and 46.1% in cats and dogs, respectively) and amoxicillin (14·3% and 20·7%). Cephalexin (13·4%) and cefovecin (15·0%) were also commonly used in dogs and cats, respectively. Systemic critically important antimicrobials in human medicine were widely used in dogs (60·5%) and cats (82·7%). Topical antimicrobials used in both species included fusidic acid (48·4% and 54·8%), framycetin (20·4% and 13·4%), polymyxin B (12·6% and 9·3%) and neomycin (6·5% and 6·6%). CLINICAL SIGNIFICANCE: Inappropriate usage of broad-spectrum antimicrobials may contribute to the development of antimicrobial resistance and loss of efficacy of antimicrobials in veterinary settings. Data recorded in practice management systems were demonstrated to be a practical source for monitoring antimicrobial usage in pets.

Mapping stakeholders for system evaluation - the case of the Electronic Prescription Service in England.

This paper discusses the process of identifying stakeholders for the evaluation of health information systems through a map. Defining the multiplicity of stakeholders associated with a new system as well as the nature of their relationships is an important aspect of evaluating any intervention. We report a study of the Electronic Prescription Service (EPS) in primary care in England. We describe the complexity associated with the process of identifying stakeholders and illustrating their dynamic relationships. Reflecting upon our experience of map-making and map-using, we discuss the role of a stakeholder map to generate and communicate knowledge. The EPS stakeholder map - in its variety of possible alternative representations - reveals the complexity of the electronic prescribing scenario and the challenge of its evaluation. Recognising the drawbacks of a static two dimensional representation, we argue that a dynamic use of a stakeholder map and a reflective map-making practice is useful and important for the evaluation of IT programmes in healthcare.

Complete transection of the pelvi-ureteric junction in an adult.

We present a unique case report of a 41-year-old man involved in a hit-and-run accident. The patient suffered a complete disruption of the pelvi-ureteric junction along with a fracture of the L3 transverse process. Occasionally seen in children, we believe this to be the first reported adult case. The report details the presentation and symptoms, with subsequent radiology. This case also demonstrates how using an effective multidisciplinary team approach and the ATLS principles, uncommon injuries can be identified and managed successfully. We revisit the classification of ureteric trauma and the accepted best surgical management.

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

INTRODUCTION: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. METHODS: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. RESULTS: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. CONCLUSIONS: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Does the placement of a FRECA gastrostomy at the time of laparoscopic fundoplication impact on outcome?

AIM: To assess the performance of a paediatric cohort having a FRECA PEG (FP) placed at the time of laparoscopic fundoplication. METHODS: This is retrospective study of a single surgeon's experience of laparoscopic fundoplications over a decade. Patient details were retrieved form a Microsoft Excel database and demographic, operative, and performance measures analysed. RESULTS: Of a series of 67 laparoscopic fundoplications, 20 with neurological compromise underwent FP placement at the time of surgery. Mean age was 3.37 years with a male to female ratio of 1.1:1. A size 9 French FRECA was placed in patients less than 10 kg (12) with larger patients (8) having a size 15 device. A Watson anterior wrap was performed in 16 cases with the rest having a Nissen fundoplication. Seven of these cases had pre-existing FPs which were taken down before replacement post fundoplication. Feeding was resumed the next morning except in three with delayed gastric emptying. Other complications (3) were seen but were not PEG related. The median stay for the series was 4 days (SD 3) and patients were followed up for a mean of 684 days. Over this period four patients relapsed and resumed medical treatment. A single mortality occurred in a syndromic 3-year-old a year later from problems unrelated to surgery. FPs were changed to a button device under general anaesthetic 3-24 months following placement. CONCLUSION: FP placement at the time of laparoscopic fundoplication does not appear to compromise the outcome of surgery. Neither the size of patient nor the type of wrap is an impediment to its placement and the device can be used shortly after surgery in the majority allowing for an early discharge. Complications are infrequent; however, change to a button device within 2 years of initial placement requires general anaesthetic.

To knot or not to knot? Sutureless haemostasis compared to the surgeon's knot.

INTRODUCTION: The aim of this study was to carry out an independent evaluation of the efficacy and security of a number of vessel ligation devices and ligatures. MATERIALS AND METHODS: A vascular ligation model was devised using fresh, ex vivo porcine internal carotid arteries of varying external diameters. Coloured normal saline was infused via a pressure/monitor device through the artery. The end lumen was occluded by five different techniques: (i) braided suture in a surgeon's knot; (ii) a monofilament suture in a granny knot; (iii) a metallic clip (Ligaclip, Johnson and Johnson); (iv) a bipolar diathermy system (Ligasure, ValleyLab); and (v) an ultrasonically activated scalpel (Harmonic Scalpel, Johnson and Johnson). The vessels were subjected to supraphysiological pressures. Loss of haemostasis was evident by leakage of coloured perfusion fluid. RESULTS: Secure haemostasis was obtained with all the techniques in all vessels below 5 mm in diameter. In vessels over 5 mm, secure haemostasis was obtained with all modalities except harmonic scalpel. With the harmonic scalpel, leaks occurred in 3/27 (11%) vessels between 5-6 mm and 3/5 (60%) vessels over 6 mm, confirming the manufacturer's instructions. CONCLUSIONS: In this first, independent, randomised study comparing vessel ligation devices and ligatures, the manufacturer's claims for each of the haemostatic methods were accurate. We find that all the modalities tested perform as well as the traditional surgeon's knot in vessels of 5 mm and below.

Laparoscopic adrenalectomy - a cure for male pattern baldness.

A 64-year-old woman presented to a dermatologist with male pattern hair loss and was found to have grossly elevated testosterone levels at 22.3 nmol/l (normal range, 0.0-2.9 nmol/l). The diagnosis of an androgen-secreting adrenal tumour was made and she underwent a laparoscopic retroperitoneal right adrenalectomy with an uneventful speedy recovery, being discharged in less than 48 h, underlining the clear advantage of this approach.

Evaluation of ideal irrigation fluid in 'Greenlight' photoselective vapourization of the prostate.

Although many anecdotal opinions are available that water gives a better visual quality, no studies have analysed the differences in the visual quality of the operative field with the use of either saline or sterile water. As part of a prospective audit we wished to assess the effect of differing irrigant fluids on intraoperative visibility during Greenlight photoselective vapourization of prostate (PVP). Twenty-nine consecutive patients with prostates less than 100 cm(3) who underwent PVP were studied. The irrigation fluid used was randomly connected on a bag-by-bag basis, with the surgeon blinded to the bag's contents. Towards the end of each bag the surgeon gave a score to the quality of vision. All surgeons were familiarized with the vision scoring system in advance. The scores were analysed in two ways. The mean scores for water and saline were compared. In addition, a mean score for each fluid in each patient where both fluids were used (n=24) was separately calculated and the means for each fluid compared. One hundred and twenty-four bags of fluid in 29 operative cases were analysed. The mean overall vision scores were 3.94% for saline and 4.01% for water (P=0.62). The paired data were analysed using the Student's t-test and there was no statistically significant difference (P=0.34). We showed no significant difference in visual quality between water and saline during PVP. Although fluid absorption is almost unknown with PVP, there seems to be no justification for using water irrigation if saline is available, particularly with a theoretical risk of absorption.

Lycopene inhibits DNA synthesis in primary prostate epithelial cells in vitro and its administration is associated with a reduced prostate-specific antigen velocity in a phase II clinical study.

Interest in lycopene has focused primarily on its use in the chemoprevention of prostate cancer (CaP); there are few clinical trials involving men with established disease. In addition, most data examining its mechanism of action have been obtained from experiments using immortal cell lines. We report the inhibitory effect(s) of lycopene in primary prostate epithelial cell (PEC) cultures, and the results of a pilot phase II clinical study investigating whole-tomato lycopene supplementation on the behavior of established CaP, demonstrating a significant and maintained effect on prostate-specific antigen velocity over 1 year. These data reinforce the justification for a large, randomized, placebo-controlled study.

Laparoscopic partial nephrectomy using the potassium titanyl phosphate laser in a porcine model.

INTRODUCTION: To evaluate the potential and feasibility of the potassium titanyl phosphate (KTP) Greenlight laser to perform partial nephrectomy in a porcine model. TECHNICAL CONSIDERATIONS: A total of 15 laparoscopic partial nephrectomies were performed in 4 Danish land-raised pigs under anesthesia. Transperitoneal access was obtained, and using a total of four ports, the 80-W KTP laser was used to perform bilateral upper and lower pole partial nephrectomy. The procedures were done successfully without renal cooling or clamping of the vessels. The estimated blood loss for each procedure was less than 30 mL. Only in one operation, in which a secondary renal vein was transected, was any additional hemostasis required (a single Endoclip). The mean operating time was 42 minutes (range 31 to 59) for each partial nephrectomy. As demonstrated on video, smoke formation was, at times, a problem during the procedure, because it reduced visibility, making only intermittent application of laser energy possible. Histopathologic analysis of the specimens showed a zone of loss of substance (less than 1 mm) at the resection line and narrow adjacent zones on both sides of the resection line with minimal changes. CONCLUSIONS: We have shown for the first time that normally perfused laparoscopic partial nephrectomy using the KTP laser is feasible and efficacious in the porcine model. This represents a novel application for the KTP laser, which produced excellent renal parenchymal hemostatic ablation. We are currently working on ways to improve the visibility by reducing smoke formation before undertaking a clinical trial in humans.