Instantaneous photosynthetically available radiation models for ocean waters using neural networks.

Instantaneous photosynthetically available radiation (IPAR) at the ocean surface and its vertical profile below the surface play a critical role in models to calculate net primary productivity of marine phytoplankton. In this work, we report two IPAR prediction models based on the neural network (NN) approach, one for open ocean and the other for coastal waters. These models are trained, validated, and tested using a large volume of synthetic datasets for open ocean and coastal waters simulated by a radiative transfer model. Our NN models are designed to predict IPAR under a large range of atmospheric and oceanic conditions. The NN models can compute the subsurface IPAR profile very accurately up to the euphotic zone depth. The root mean square errors associated with the diffuse attenuation coefficient of IPAR are less than 0.011m-1 and 0.036m-1 for open ocean and coastal waters, respectively. The performance of the NN models is better than presently available semi-analytical models, with significant superiority in coastal waters.

The usefulness of work-based assessments in higher surgical training: A systematic review.

BACKGROUND: Work-based assessments including procedure based assessments, case based discussions, clinical evaluation exercises and direct observation of procedural skills are used in Higher Surgical Training Program. This systematic review aims to investigate the trainer and trainee's perception of the usefulness of workplace based assessments in Higher Surgical Training Programme. MATERIALS AND METHODS: Embase, MEDLINE and PubMed databases were searched for relevant studies published up to Jan 15, 2021. The following search terms were used: procedure based assessments, case based discussions, clinical evaluation exercises, direct observation of procedural skills, Higher Surgical Training Program (with and without their abbreviations), surgical training, formative assessment. Usefulness was analysed according to van der Vleuten's utility formula, which is the product of educational impact, validity, reliability, acceptability, cost-effectiveness and feasibility. RESULTS: 23 studies were included; Six on procedure based assessments, two on case based discussions, one on mini clinical evaluation exercises, three on direct observation of procedural skills and eleven on multiple methods. Overall, procedure based assessments had positive Kirkpatrick level 1 or 2 impact were valid, reliable and acceptable. Mini clinical evaluation exercises showed positive Kirkpatrick level 1 satisfaction in trainees and trainers and were feasible. Case based discussions were shown to have both positive and negative Kirkpatrick levels 1 and 2 impact and were rated valid and reliable. Direct observation of procedural skills were valid with favourable Kirkpatrick level 1 impact with more usage and modification of the forms. Multiple methods as used in the intercollegiate surgical curriculum programme portfolio was found to be less encouraging in achieving positive higher level of educational impact. The barriers included lack of time, lack of faculty development and lack of engagement. CONCLUSION: It is important that work-based assessments are used properly, so that trainees get the maximum benefit from them. None of the studies included in our systematic review demonstrated an impact on behaviour or society (Kirkpatrick level 3 and 4), towards which future research should be directed to.

Candida albicans mycotic aneurysm of aortic arch following laparoscopic right hemicolectomy for colon cancer.

An 81-year-old man was referred to the colorectal surgeons for an elective laparoscopic right hemicolectomy for a caecal adenocarcinoma (T2N0M0). The operation was uneventful; however, 12 days postoperatively the patient developed symptoms of sepsis of unknown origin. After extensive investigations and work up, Candida albicans was grown as the causative organism with the site of infection being a new saccular mycotic aneurysm arising from the distal, posterior aspect of the aortic arch. The mycotic aneurysm was not initially considered as a differential diagnosis, and this case highlights the importance of consideration of mycotic aneurysm as a differential diagnosis in postsurgical septic patients.

The Impact of a Laparoscopic Surgery Training Course in a Developing Country.

INTRODUCTION: Surgeons training junior colleagues to perform laparoscopic surgery find the 'apprenticeship' model of surgical training inadequate. Therefore, the use of training courses involving simulation have become an important way to teach laparoscopic surgery. An annual laparoscopic surgery course began in Nepal in 2013. It is difficult to assess the impact of the course on trainees and demonstrate a subsequent improvement in patient outcomes, but one way is to ask delegates for reflections on their experience of the course and their perception of how it has impacted patients. METHODS: The course involved simulation and patient-based training. A questionnaire to collect quantitative data and qualitative comments was sent to all 80 previous delegates (at least 9 months after the course) in September 2018. RESULTS: Twenty-eight delegates responded. The majority demonstrated career progression since completing the course (independent practitioners increased from 7 to 50%) and progression in their practice (18% had performed >20 laparoscopic procedures at the time of the course, vs 70% at the time of the questionnaire). All delegates felt that laparoscopic training is useful in the Nepalese context. Delegates felt the course was useful in developing skills, and improving confidence and safety. Suggestions for improvement included lengthening the course and increasing the amount of practical exposure. CONCLUSION: There was a positive outcome of the course to Kirkpatrick level 2. There is a need to expand the course's scope to an advanced level, increase its length and start courses in other centres, to ensure the most possible benefit to patients.

Work-Based Assessments in Higher General Surgical Training Program: A Mixed Methods Study Exploring Trainers' and Trainees' Views and Experiences.

Introduction In the United Kingdom, work-based assessments (WBAs) including procedure-based assessments (PBAs), case-based discussions (CBDs), clinical evaluation exercises (CEXs), and direct observation of procedural skills (DOPS) have been used in Higher General Surgical Training Program (HGSTP) since the introduction of Modernising Medical Careers. Although the Intercollegiate Surgical Curriculum Project states that they should be used for the formative development of trainees using feedback and reflection, there is no study to look at the perception of their usefulness and barriers in using them, particularly in HGSTP. The aim of this study is to investigate trainer's and trainee's perception of their usefulness, barriers in using them, and way forward for their improvement in HGSTP. Methods This was a mixed method study. In phase I, after ethics committee approval, an online survey was sent to 83 trainers and 104 trainees, with a response rate of 33 and 37%, respectively, using Online Surveys (formerly Bristol Online Survey) from July 2018 to December 2018. After analysis of this result, in phase II, semistructured interviews were conducted with five trainees and five trainers who had volunteered to take part from phase I. Thematic analysis was performed to develop overarching themes. Results For professional formative development, 15% of the trainers and 53% of the trainees felt that WBAs had a low value. Among 4 WBAs-CEX, CBD, PBA, and DOPS-PBA was thought to be the most useful WBA by 52% trainers and 74% trainees. More trainers than trainees felt that it was being used as a formative tool (33 vs. 16%). The total number of WBAs thought to be required was between 20 and 40 per year, with 46% of the trainers and 53% of the trainees preferring these numbers. The thematic analysis generated four themes with subthemes in each: theme 1, "factors affecting usefulness," including the mode of validation, trainer/trainee engagement, and time spent in validating; theme 2, "doubt on utility" due to doubt on validity and being used as a tick-box exercise; theme 3, "pitfalls/difficulties" due to lack of time to validate, late validation, e-mail rather than face-to-face validation, trainer and trainee behavior, variability in feedback given, and emphasis on number than quality; and theme 4, "improvement strategies." Conclusions The WBAs are not being used in a way they are supposed to be used. The perception of educational impact (Kirkpatrick levels 1 and 2) by trainers was more optimistic than by trainees. Improvements can be made by giving/finding more time, trainer training, more face-to-face validation, and better trainer trainee interactions.

Diversity and use of wild and non-cultivated edible plants in the Western Himalaya.

BACKGROUND: Local people in the Himalayan region use a wide range of wild and non-cultivated edible plants (WNEPs) for food, spice, medicinal, and cultural purposes. However, their availability, use, status and contribution to livelihood security are poorly documented, and they have been generally overlooked in recent agro-biodiversity conservation and management programmes. The study aimed to investigate WNEP diversity and current status in a part of the Kailash Sacred Landscape-a transboundary landscape shared by Nepal, India and PR China-in terms of collection, use, management and conservation initiatives. METHODS: Multiple methodologies and tools were used for data collection. A series of participatory tools (45 key informant interviews, 10 focus group discussions, a crop diversity fair, direct observation of species through a transect walk and rapid market assessments) was followed by a household survey (195 respondents) and complemented by a literature review. RESULTS: The study recorded 99 WNEPs belonging to 59 families of which 96 were angiosperms, one gymnosperm and two pteridophytes. Species were used for food, spice, medicine, rituals and income generation. Thirty-five species had multiple uses, including these: 40 species were used for fruit and 31 for vegetables. WNEPs contribute significantly to daily food requirements, especially the vegetables. The use value of Dryopteris cochleata was found highest (0.98) among frequently used vegetable species. The values of informant consensus factor were found maximum for worms in the stomach (0.99) and minimum for skin disease treatment (0.67). Nearly 85% of households depended exclusively on WNEPs for at least more than a month per year. Results on the importance and use of different species, gender roles in WNEP activities and conservation approaches are presented. CONCLUSIONS: People living in the Kailash Sacred Landscape depend significantly on WNEPs, and this is especially critical in times of food shortage. The WNEPs have considerable potential as an important supplement to cultivated food crops. Farmers prioritise species with multiple use values and popular vegetables. However, there are numerous challenges and interventions needed to ensure conservation and management of species and their continued availability to support food security and local livelihoods.

Postpartum hemorrhage prevention in Nepal: a program assessment.

BACKGROUND: In 2009, the Nepal Ministry of Health and Population launched a national program for prevention of postpartum hemorrhage (PPH) during home births that features advance distribution of misoprostol to pregnant women. In the years since, the government has scaled-up the program throughout much of the country. This paper presents findings from the first large-scale assessment of the effectiveness of the advance distribution program. METHODS: Data collection was carried out in nine districts and all three ecological zones. To assess knowledge, receipt and use of misoprostol, household interviews were conducted with 2070 women who had given birth within the past 12 months. To assess supply and provision of misoprostol, interviews were conducted with 270 Female Community Health Volunteers (FCHVs) and staff at 99 health facilities. RESULTS: Among recently delivered women, only 15% received information about misoprostol and 13% received misoprostol tablets in advance of delivery. Yet 87% who received advance misoprostol and delivered at home used it for PPH prevention. Among FCHVs, 96% were providing advance misoprostol for PPH prevention; however 81% had experienced at least one misoprostol stock out within the past year. About one-half of FCHVs were providing incomplete information about the use of misoprostol; in addition, many did not discuss side effects, how to recognize PPH or where to go if PPH occurs. Among health facilities, just one-half had sufficient misoprostol stock, while 95% had sufficient oxytocin stock, at the time of this assessment. CONCLUSIONS: In Nepal, women who receive advance misoprostol are both willing and able to use the medication for PPH prevention during home births. However the supply and personnel challenges identified raise questions about scalability and impact of the program over the long-term. Further assessment is needed.

Effect of Social Deprivation on the Stage and Mode of Presentation of Colorectal Cancer.

PURPOSE: Based in a hospital serving one of the most deprived areas in the United Kingdom (UK), we aimed to investigate, using the Indices of Deprivation 2010, the hypothesis that deprivation affects the stage and mode of presentation of colorectal cancer. METHODS: All newly diagnosed patients with colorectal cancer presenting to a District General Hospital in the UK between January 2010 and December 2014 were included. Data were collected from the Somerset National Cancer Database. The effect of social deprivation, measured using the Index of Multiple Deprivation Score, on the stage and mode of presentation was evaluated utilizing Microsoft Excel and IBM SPSS ver. 22.0. RESULTS: A total of 701 patients (54.5% male; mean age, 76 years) were included; 534 (76.2%) underwent a surgical procedure, and 497 (70.9%) underwent a colorectal resection. Of the patients undergoing a colorectal resection, 86 (17.3%) had an emergency surgical resection. Social deprivation was associated with Duke staging (P = 0.09). The 90-day mortality in patients undergoing emergency surgery was 12.8% compared to 6.8% in patients undergoing elective surgery (P = 0.06). No association was found between deprivation and emergency presentation (P = 0.97). A logistic regression analysis showed no increase in the probability of metastasis amongst deprived patients. CONCLUSION: This study suggests an association between deprivation and the stage of presentation of colorectal cancer. Patients undergoing emergency surgery tend to have a higher 90-day mortality rate, although this was not related to deprivation. This study highlights the need to develop an individual measure to assess social deprivation.

Case of pneumatosis intestinalis and hepatic portal venous gas following a laparoscopic right hemicolectomy.

Hepatic portal venous gas (HPVG) in most cases signifies either mechanical migration of air into the portal system due to bowel ischaemia (pneumatosis intestinalis) or portal sepsis due to gas-forming organisms. Successful management of portal sepsis involves early identification of the condition, intensive resuscitation, broad-spectrum antibiotics and a laparotomy for possible bowel ischaemia. In this report, we discuss the case of a patient with pneumatosis intestinalis and HPVG after an elective laparoscopic right hemicolectomy. After an initial slow recovery, on postoperative day seven, the patient had profuse diarrhoea and confusion, and was hyponatraemic. A CT scan revealed pneumatosis intestinalis and HPVG. A laparotomy showed no obvious cause for HPVG and there was no ischaemic bowel. She was managed with intensive care, hyperbaric oxygen therapy, broad-spectrum antibiotics and total-parenteral nutrition. She has made a good recovery. This case highlights the presenting features, differential diagnoses, and management of pneumatosis intestinalis and HPVG.

A Rare Cause of Postprandial Abdominal Pain.

A 49-year-old woman with medical history of polymyalgia rheumatica presented with 3 weeks history of epigastric pain worse after meal. Gallstones, peptic ulcer, bowel ischemia, bowel obstruction, gastroesophageal reflux disease, chest pathology, etc., were excluded from the study. Computerized tomography showed a short stenotic segment at coeliac trunk with poststenotic dilatation of 8 mm. Ultrasound scan showed peak velocity of 326 cm/s at the coeliac artery. Diagnosis of median arcuate ligament syndrome was made.

E learning in surgery.

E learning means use of electronic media and information technologies in education. Virtual learning environment (VLE) provides learning platforms consisting of online tools, databases and managed resources. This article is a review of use of E learning in medical and surgical education including available evidence favouring this approach. E learning has been shown to be more effective, less costly and more satisfying to the students than the traditional methods. E learning cannot however replace direct consultant supervision at their place of work in surgical trainees and a combination of both called blended learning has been shown to be most useful. As an example of university-based qualification, one such programme is presented to clarify the components and the process of E learning. Increasing use of E learning and occasional face to face focussed supervision by the teacher is likely to enhance surgical training in the future.

General surgery in patients with a bleeding diathesis: how we do it.

BACKGROUND: This study was undertaken to assess perioperative management, postoperative complications, and the adequacy of perioperative plasma factor levels in a regional hemophilia center. METHODS: A total of 113 consecutive patients (75 men, 38 women; median age 48 years, range 18-86 years) with bleeding disorders undergoing general surgical and endoscopic procedures (144 procedures: 15 urgent, 129 elective) were reviewed. The episodes were identified from a prospectively collected database at a regional hemophilia center from 1998 to the end of 2008. In all, 46% of the surgical patients had hemophilia A, 38% had von Willebrand disease, 6% had hemophilia B, 5% had factor XI deficiency, and 4% had other disorders. RESULTS: Procedures carried out were endoscopic in 40%, minor in 25%, and intermediate and major in 35%. There were two postoperative deaths, both in patients undergoing urgent major procedures. Postoperative complications occurred after 7.6% (4.0% hemorrhagic, 3.6% nonhemorrhagic) of the procedures. Four of six patients with postoperative hemorrhage required further operative intervention. The median dose of clotting factor for Hemophilia A patients was 2240 U for endoscopic procedures, 7500 U for minor procedures, and 23,500 U for intermediate/major procedures. In hemophiliacs, the mean preoperative plasma factor level attained was 129 IU/dl (SD 16) in patients who developed postoperative hemorrhagic complications and 125 IU/dl (SD 37) in those who did not have bleeding, indicating that in no case was hemorrhage attributable to inadequate factor replacement. CONCLUSIONS: General surgical and endoscopic procedures can be performed with low morbidity and mortality rates when there is appropriate factor replacement and good support from the hemophilia team.