Assessing professional competence in optometry - a review of the development and validity of the written component of the competency in optometry examination (COE).

BACKGROUND: Credentialing assessment for overseas-educated optometrists seeking registration in Australia and New Zealand is administered by the Optometry Council of Australia and New Zealand. The aim was to review the validation and outcomes of the written components of this exam to demonstrate credentialing meets entry-level competency standards. METHODS: The Competency in Optometry Examination consists of two written and two clinical parts. Part 1 of the written exam comprises multiple choice questions (MCQ) covering basic and clinical science, while Part 2 has 18 short answer questions (SAQ) examining diagnosis and management. Candidates must pass both written components to progress to the clinical exam. Validity was evaluated using Kane's framework for scoring (marking criteria, item analysis), generalization (blueprint), extrapolation (standard setting), and implications (outcome, including pass rates). A competency-based blueprint, the Optometry Australia Entry-level Competency Standards for Optometry 2014, guided question selection with the number of items weighted towards key competencies. A standard setting exercise, last conducted in 2017, was used to determine the minimum standard for both written exams. Item response theory (Rasch) was used to analyse exams, produce reliability metrics, apply consistent standards to the results, calibrate difficulty across exams, and score candidates. RESULTS: Data is reported on 12 administrations of the written examination since 2014. Of the 193 candidates who sat the exam over the study period, 133 (68.9%) passed and moved on to the practical component. Ninety-one (47.2%) passed both the MCQ and SAQ exams on their first attempt. The MCQ exam has displayed consistently high reliability (reliability index range 0.71 to 0.93, average 0.88) across all 12 administrations. Prior to September 2017 the SAQ had a set cutscore of 50%, and the difficulty of the exam was variable. Since the introduction of Rasch analysis to calibrate difficulty across exams, the reliability and power of the SAQ exam has been consistently high (separation index range 0.82 to 0.93, average 0.86). CONCLUSIONS: The findings from collective evidence support the validity of the written components (MCQ and SAQ) of the credentialing of the competency of overseas-educated optometrists in Australia and New Zealand.

Doping in sport: an analysis of sanctioned UK rugby union players between 2009 and 2015.

To inform anti-doping policy and practice, it is important to understand the complexities of doping. The purpose of this study was to collate and systematically examine the reasoned decisions published by UK Anti-Doping for doping sanctions in rugby union in the UK since the introduction of the 2009 World Anti-Doping Code. Case files were content analysed to extract demographic information and details relating to the anti-doping rule violation (ADRV), including individuals' explanations for how/why the ADRV occurred. Between 2009 and 2015, 49 rugby union players and one coach from across the UK were sanctioned. Over 50% of the cases involved players under the age of 25, competing at sub-elite levels. Reasons in defence of the ADRV focused on functional use and lifestyle factors rather than performance enhancement. An a priori assessment of the "need", "risk" and "consequence" of using a substance was not commonplace; further strengthening calls for increasing the reach of anti-doping education. The findings also deconstruct the view that "doped" athletes are the same. Consequently, deepening understanding of the social and cultural conditions that encourage doping remains a priority.

Using the prototype willingness model to predict doping in sport.

To enable preventive measures to be designed, it is important to identify modifiable distal and proximal factors underlying doping behavior. This study investigated aspects of the prototype willingness model in relation to doping. A cross-sectional study was conducted involving 729 competitive athletes. Following ethical approval, athletes (mean age = 28.8 ± 10.1 years; 63% male) completed an online questionnaire, which assessed doping-related attitudes, norms, prototype perceptions, outcome expectancies, and behavioral willingness. Using hierarchical multiple regression analysis, 54.4% of the total variance in willingness to dope was explained. Specifically, past doping, attitudes, and favorability of performance enhancing substance user prototypes were the strongest unique predictors of willingness to dope. Athletes appeared most willing to dope if they were to suffer an injury, a dip in performance, or think others are doping and getting away with it. National-level athletes displayed significantly greater willingness to dope (Kruskal-Wallis γ2 = 35.9, P < 0.001) and perceived themselves as significantly more similar to a doper (Kruskal-Wallis γ2 = 13.4, P = 0.004) than athletes competing at any other level. The findings highlight the importance of extending anti-doping provision beyond elite-level sport and the need to target athletes' doping-related perceptions.

Reporting doping in sport: national level athletes' perceptions of their role in doping prevention.

This paper qualitatively explores national level athletes' willingness to report doping in sport. Following ethical approval, semi-structured interviews were conducted with nine national level athletes from rugby league (n = 5) and track and field athletics (n = 4). Thematic analysis established the main themes within the data. Contextual differences existed around the role that athletes perceived they would play if they became aware of doping. Specifically, track and field athletes would adopt the role of a whistle-blower and report individuals who were doping in their sport. In comparison, the rugby league players highlighted a moral dilemma. Despite disagreeing with their teammates' actions, the players would adhere to a code of silence and refrain from reporting doping. Taking these findings into account, prevention programs might focus on changing broader group and community norms around doping. In doing so, community members' receptivity to prevention messages may increase. Moreover, developing skills to intervene (e.g., speaking out against social norms that support doping behavior) or increasing awareness of reporting lines could enhance community responsibility for doping prevention. In sum, the findings highlight the need to consider the context of sport and emphasize that a one-size-fits-all approach to anti-doping is problematic.

Athlete support personnel and anti-doping: Knowledge, attitudes, and ethical stance.

Athlete support personnel (ASP) failing to meet responsibilities under the World Anti-Doping Code risk sanction. It is unclear whether the poor knowledge of responsibilities seen in sports physicians and coaches applies to other ASP (e.g., administrators, chiropractors, family, nutritionists, physiotherapists, psychologists, and trainers). A purposive sample of Australian ASP (n = 292) responded to a survey on knowledge of anti-doping rules (35 true/false questions), ethical beliefs and practice, and attitudes toward performance enhancement. Some ASP declined to participate, claiming doping was irrelevant to their practice. Physicians were most knowledgeable (30.8/35), with family and trainers the least (26.0/35). ASP reported that improvements were needed to support anti-doping education (e.g., basis for anti-doping) and practice (e.g., rules). ASP also had a slightly negative attitude toward performance enhancement. Linear regression showed that being a sports physician, providing support at the elite level, and 15 years of experience influenced knowledge. The results confirm gaps in knowledge, suggesting that stronger engagement with ASP anti-doping education and practice is needed. Applying the principles of andragogy could help foster active engagement through emphasis on active inquiry, rather than passive reception of content. Future work on the context within which ASP experience anti-doping is needed, exploring acquisition and translation of knowledge into practice.

Gateway to doping? Supplement use in the context of preferred competitive situations, doping attitude, beliefs, and norms.

Nutritional supplement (NS) use is widespread in sport. This study applied an integrated social cognitive approach to examine doping attitudes, beliefs, and self-reported doping use behavior across NS users (n = 96) and nonusers (n = 116). Following ethical approval, 212 competitive athletes (age mean = 21.4, s = 4.5; 137 males) completed self-reported measures of doping-related social cognitions and behaviors, presented in an online format where completion implied consent. Significantly more NS users (22.9%) reported doping compared with nonusers (6.0%; U = 4628.0, P < 0.05). NS users presented significantly more positive attitudes toward doping (U = 3152.0, P < 0.05) and expressed a significantly greater belief that doping is effective (U = 3152.0, P < 0.05). When presented with the scenario that performance-enhancing substances are effective and increase the possibility of winning, NS users were significantly more in favor of competing in situations that allow doping (U = 3504.5, P < 0.05). In sum, doping use is three-and-a-half times more prevalent in NS users compared with nonusers. This finding is accompanied by significant differences in doping attitudes, norms, and beliefs. Thus, this article offers support for the gateway hypothesis; athletes who engage in legal performance enhancement practices appear to embody an "at-risk" group for transition toward doping. Education should be appropriately targeted.

'Valve-stabilised' rhinospirometry can predict the benefit of septal surgery: a pre- and post-operative correlation study.

Septoplasty is a procedure often associated with high levels of patient dissatisfaction post-operatively. This study examined whether rhinospirometry and a modified 'valve-stabilised' technique could pre-operatively predict the outcome of septal surgery and therefore have a role as an objective tool for selection of patients suffering from nasal obstruction due to septal deformity for the procedure of septoplasty. A prospective study was performed of patients attending Singleton Hospital, Swansea, for surgical treatment of nasal obstruction due to septal deformity. Participants were asked to undertake decongested visual analogue scoring (VAS) and rhinospirometric assessment of their nasal obstruction in both normal 'resting' and 'valve-stabilised' nasal positioning. These investigations were undertaken on the day of surgery and 6 weeks post-operatively. Results were converted into nasal partition ratio scores and were assessed statistically for difference, correlation and accuracy. A total of 29 individual participants were included in the study. Septal surgery produced a statistically significant improvement in nasal airflow symmetry in the normal 'resting' nasal position using rhinospirometry (Wilcoxon ranked p > 0.5). This difference was not seen between evaluations in 'valve-stabilised' position (Wilcoxon p < 0.001). No statistical difference was evident between pre-operative 'valve-stabilised' testing and post-operative 'resting position'. The finding was also apparent on VAS nasal assessment. Correlation studies showed a strong relationship between pre-operative 'valve-stabilised' and post-operative 'resting' rhinospirometry results (Spearman's rho = 0. 586, p < 0.002). The strength of this relationship between VAS assessments was less pronounced (Spearman's rho = 0.386 p = 0.07). 'Valve-stabilised' rhinospirometry and VAS appear to be useful pre-operatively to predict the outcome of septal surgery, in terms of airflow symmetry, for nasal obstruction due to septal deformity, with pre-operative 'valve-stabilised' results correlating well with the post-operative standard 'resting' outcomes. Valve-stabilised rhinospirometry may have a role in pre-operatively predicting of likely post-operative patient satisfaction, although further studies are required in this area.

The accuracy and reproducibility of rhinospirometry in detecting flow asymmetry in a nasal cavity model.

The objective of this study is to investigate the appropriateness of the NV1 rhinospirometer in the assessment of asymmetrical nasal airflow using a nasal cavity model. The Study is a laboratory-based basic-science study using an artificial model of nasal airflow. It is conducted in Medical Physics Department, Singleton Hospital, Swansea, Wales. A nasal cavity model was created with a series of parallel flow symmetry/asymmetries that were each assessed using standard flow volume measurements. The results were converted into Nasal Partition Ratios (NPRs) for each trial scenario and were examined against a mathematically calculated NPR derived using Pouseille's law. Experimental scenario results were assessed for correlation, accuracy and precision against the mathematically derived result. In this study 300 individual test scenarios were completed using 2 different flow volumes and 15 different symmetry/asymmetry combinations. Correlation of the attained results against the mathematically derived figure gave a very strong correlation, using Spearman's Rho = 0.975. Accuracy was excellent within one Standard deviation of the expected results. It was concluded that the NV1 rhinospirometer is an accurate and precise objective marker of airflow symmetry in the nasal cavity model giving strong correlation, accuracy, precision and reproducibility. The rhinospirometer, as a precision tool, has displayed potential to become an effective objective marker of nasal airflow in the assessment of nasal obstruction; however, clinical trials are required to examine whether the accurate results of this laboratory study are transferable to clinical practice.

Changing player behaviour in sport during the COVID-19 pandemic: Shake on it?

To prevent the spread of infection during matches and training activities is a major challenge facing all sports returning from the enforced COVID-19 shutdown. During training and matches, rugby league players make contact with others which can result in SARS-CoV-2 virus transmission. While these interactions characterise the appeal of the game, a number of them can be avoided, including shaking hands and conversing after the match. This paper presents a framework underpinned by behavioural science (capability, opportunity, motivation and behaviour model, COM-B) to support stakeholders in helping players adopt new social distance norms and behaviours. This framework helps to ensure the players have the capability, opportunity, and motivation to adopt new COVID-19 risk minimising behaviours, which they will need to commit to 100%.

Stressors and affective states among professional rugby union players.

The purpose of the present study was to examine (a) the sources of sport and non-sport stress and their associated symptoms on rest days, training days, and match days and (b) the temporal aspects of sources and symptoms of stress and affective states. Professional male rugby union players (n=16) completed the Daily Analysis of Life Demands in Athletes (DALDA) and the Activation Deactivation Adjective Check List (AD ACL) for 28 days. On match days players reported that few stressors were "worse than normal." Most stressors were "worse than normal" on training days followed by rest days and more stressors were "worse than normal" on the day after a match than on match days. Further, players reported an unpleasant, low activation state across the three analysis days, suggesting they were in an overtrained state. The findings of this study demonstrate that professional rugby players experience negative affect and a multitude of sport and non-sport stressors. Early detection of stressors and negative affective states could help prevent symptoms of overtraining and burnout and facilitate optimal training and sporting performance. Coaches and practitioners are encouraged to integrate the DALDA and AD ACL in their training and performance monitoring regimes.

Effects of the glycemic index of breakfast on metabolic responses to brisk walking in females.

OBJECTIVE: The aim of this study was to examine the metabolic responses during 1 h of brisk walking, 3 h after ingesting high glycemic index (HGI) and moderate glycemic index (MGI) breakfasts. DESIGN AND SUBJECTS: Six females completed three treadmill walking trials (approximately 50% VO2 max), separated by at least 1 month. Three hours before walking, they ingested either water or a HGI or MGI breakfast. The MGI breakfast consisted of a mixture of an HGI breakfast cereal and low GI carbohydrate (CHO) foods. The GI values of the HGI and MGI meals were 77 and 51, respectively. SETTING: The study took place in the School of Sport and Exercise Sciences at Loughborough University, Loughborough, UK. RESULTS: In the HGI and MGI trials, plasma glucose and serum insulin concentrations peaked 15 min into the postprandial period. At the onset of exercise, plasma insulin concentrations were twofold higher in the HGI (31.5+/-7.7 microl U l(-1)) than in the MGI trial (15.2+/-1.9 microl U l(-1)) (P<0.05). However, there were no differences in substrate utilization between the two CHO trials. CONCLUSION: These results suggest that although the addition of LGI CHO foods to an HGI breakfast cereal reduces the overall GI of the meal, the metabolic response to exercise is similar to that following a breakfast comprised entirely of HGI foods.

The relationship between hassles, uplifts and irritable bowel syndrome: a preliminary study.

In a preliminary study, 30 sufferers of irritable bowel syndrome filled in daily symptom sheets and the combined Hassles and Uplifts questionnaire for five weeks. Initially, analyses were carried out for each symptom separately. Results showed that ratings on the hassles and symptoms questionnaires completed in the same week were more highly associated than ratings for hassles and symptoms in different weeks. No one symptom in any week was significantly associated with the following week's hassles. Similarly, hassles in any one week were not associated with the following week's symptoms. However, total symptoms were found to be significantly associated with hassles in the following weeks, whereas the association between hassles and total symptoms in the following weeks was not significant. The study suggests that there is a cumulative effect of symptoms such that an increase in the severity of the combined effect of symptoms is associated with an increase in severity of stress in the next week. Increased hassles do not appear to exacerbate symptoms. There was no evidence of an association between uplifts and IB symptoms.

Patterns of hospital attendance with epistaxis.

The age and sex distribution of epistaxis admissions to hospital was examined. A retrospective analysis of 6,885 patients admitted to hospitals in the whole of Wales was performed, over a period of five years. The findings were compared with data from the 1991 National Population Census for the same region, thus providing a more representative estimate of the behaviour of this disease. A clear age relationship is demonstrated, with the incidence of epistaxis increasing rapidly after the age of 40 years. The female-to-male ratio is also age dependent. In the group aged between 20 to 49 years twice as many males as females were admitted, where no sex difference was expected from the population data. This difference was not present in the group aged 50 years and over where the ratio was similar to that in the underlying population. There was a 1.6 fold difference between the sex ratios of the two groups (95% confidence intervals of 1.9 to 1.4; p < 0.0001). It is possible that the female pre-menopausal state may provide a significant protection from this disease. The mechanism for this is unknown, but may be secondary to a direct effect of oestrogen on the nasal mucosa or vasculature, or the healing of vessels in this region. Alternatively, this observation may simply be a reflection of protection the pre-menopausal state provides against cardiovascular disease in general.

Angiolymphoid hyperplasia with eosinophilia of the parapharyngeal space.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign condition characterized by cutaneous nodules with a predeliction for the head and neck region. Extracutaneous involvement is rare. We report a 44-year-old woman who had a large submucosal ALHE tumour in the parapharyngeal space. Our patient is of interest because of the unusual, and as far as we are aware from the literature, unique site and presentation of her lesion.

Validation of current practice and a near patient testing method for oral-anticoagulant control in general practice.

When oral anticoagulant control is monitored in general practice, venous blood samples are usually transported to a central laboratory for determination of international normalized ratio (INR). An alternative is near patient testing by a commercial method. In a rural general practice 27 km from a central haematology laboratory, whole blood samples were drawn from patients receiving oral anticoagulants and analysed by three methods: after centrifugation, plasma separated and frozen in liquid nitrogen, transported to the laboratory, thawed and immediately analysed (control); courier transport of citrated sample to the laboratory for analysis (routine); near patient testing of whole blood sample (NPT). Maximum temperature achieved and time to analysis for routine samples were recorded. 306 complete sets of data were obtained. Comparison between the routine method and the control method revealed acceptable agreement. On multiple regression analysis, maximum temperature achieved did not contribute to differences observed but time to analysis of over 5 hours did make a significant contribution. Comparison between the NPT method and control method showed acceptable agreement, with persistent under-recording by the NPT method. The routine method for INR determination was validated as robust and reproducible with the proviso that needle-to-analysis time should be kept below 5 hours. The NPT method was valid under conditions of normal general practice. Strict quality control of NPT methods is essential if performance is to be comparable with that of established methods.

Transport and temperature effects on measurement of serum and plasma potassium.

Transport of blood samples from general practice to a central laboratory can result in spuriously high or low potassium concentrations. The importance of this phenomenon was studied in a general practice serving a population of 15,000 patients, 27 km from the pathology laboratory that routinely measured serum potassium. The design involved comparison of potassium levels between control serum (plain gel-separation serum tubes centrifuged in the surgery), routine serum (plain gel-separation tubes centrifuged in the laboratory) and routine plasma samples (lithium-heparin tubes centrifuged in the laboratory). Complete triple sets of data were obtained for 371 samples. Altman and Bland plots for the control serum vs routine serum samples showed a mean difference of +0.1 mmol/L with limits of agreement (+/- 2SD) +0.6 mmol/L, -0.4 mmol/L and for control serum vs routine plasma a mean difference of +0.2 mmol/L with limits of agreement +0.8 mmol/L, -0.4 mmol/L. There was a negative association between mean weekly routine plasma potassium levels with mean weekly temperatures achieved. Regression analysis indicated that both maximum temperature achieved and time to centrifugation significantly contributed to differences observed in the routine plasma samples, but not with the routine serum samples. For plasma samples exposed to high temperatures a clinically significant lowering of potassium concentrations can arise. These results confirm that spurious lowering of potassium concentrations occurs in plasma samples collected in a primary care setting. The preferred method is to centrifuge samples soon after venepuncture. Where this is not possible, collection into plain gel-separation tubes (serum) ensures less variation due to temperature and time to centrifugation than does collection into lithium-heparin tubes (plasma).

Using a patient satisfaction survey to close the theory-practice gap.

AIM: The objective of this study was to determine whether a patient satisfaction survey could be used as a research tool to improve nursing practice. METHOD: A postal questionnaire was sent to patients after discharge. Questions covered primary nursing, information, ward environment, discharge planning and social activities. RESULTS: A number of respondents were dissatisfied with the information they had received and with their lack of involvement in decisions about care. This was often correlated with lack of primary nurse recognition. The role of the associate nurse was poorly understood. There were high levels of satisfaction with discharge procedures, but little enthusiasm for the introduction of an activities programme. CONCLUSION: The results highlighted areas where changes were needed. This resulted in a nurse-led programme of managed change, including making all experienced D and E grade nurses primary nurses, improving information provision, and involving patients in the decision-making process.

Cochlear implant electrode insertion: in defence of cochleostomy and factors against the round window membrane approach.

INTRODUCTION: The round window membrane (RWM) is an increasingly popular route for electrode insertion in cochlear implantation especially for hearing preservation. Limitations to this route include anatomical, physiological, and surgical aspects. The established soft-tissue cochleostomy route for electrode insertion is thought to place the basilar membrane and spiral ligament at risk. However, the mammalian model response to soft-tissue cochleostomy has not yet been quantified. METHODS: Firstly, an on-line literature search was conducted to gather evidence of the anatomical and physiological functions of the RWM and adjacent structures. Secondly, experimental guinea pigs underwent left soft-surgery cochlestomy. Four weeks post-operatively they were euthanased and the cochlea's harvested for histology. Surgical damage to the cochlea and auditory neurons was assessed. RESULTS: The literature review with regard to the RWM anatomy revealed evidence for difficulty in approach/visualization, possible absence, and impedance of electrode insertion by the hook region. It also has a number of higher functions including immune defence and absorption/secretion of molecules. Experimental cochlea's 4 weeks post-soft-tissue cochleostomy showed only mild and localized inflammatory response adjacent to the scala tympani cochleostomy site. There was no spiral neuronal ganglion loss. CONCLUSIONS: The RWM route may be compromised or absent. Electrode insertion via the RWM could interfere with its higher functions. Mammalian soft-tissue cochleostomy has been shown to elicit a limited tissue response and does not reduce the number of cochlear spiral ganglion neurones. It should therefore remain within the hearing implant surgeon's armamentarium.

Classification of cochlear implant failures and explantation: the Melbourne experience, 1982-2006.

The definition and categorization of reasons for cochlear implant (CI) failure have recently been standardized following the publication of the European Consensus Statement on Cochlear Implant Failures and Explantation (ECSCIFE) (2005). The aim of this study was to review the Melbourne experience with cochlear implant failure and reimplantation, applying ECSCIFE guidelines for categorization and assessing hearing outcomes. A retrospective review was carried out of Melbourne CI clinic's records to identify all cases of implant failure and categorize them using ECSCIFE guidelines. Comparison was made of pre- and post-reimplantation hearing levels for those patients who had undergone ipsilateral reimplantation. Between September 1982 and October 2006 the Melbourne clinic conducted 1164 CIs with 62 implant failures and explantation (5.3%). Reasons included device failure, (ECSCIFE category C, n = 35, 3.0%), medical complication (ECSCIFE category D, n = 19), characteristics decrement (ECSCIFE category B1, n = 2) and performance decrement (ECSCIFE category B2 n = 6). Forty-nine patients underwent ipsilateral explantation/reimplantation. Auditory performance with the second implant was comparable to the first implant levels. The ECSCIFE provides an easy-to-use classification system for international reporting of CI device failures and explantations, however, detailed information of each implant failure may be lost in the final category, however. Cochlear explantation/reimplantation in Melbourne is a safe and effective procedure to restore patients to their pre-operative best auditory function levels.