Step Change in Improving the Accuracy of Nitrous Oxide Reference Materials for Underpinning Atmospheric Composition Measurements.

We have employed a new approach to quantify the amount fraction of nitrous oxide in a synthetic air matrix gas used to prepare high-accuracy reference materials of the same component. Until now, this was the largest contributor to the measurement uncertainty of nitrous oxide in air reference materials at atmospheric amount fractions (∼330 nmol mol-1), as identified in a recent international comparison. A novel preconcentration method has resulted in a measurement of 363 pmol mol-1 of nitrous oxide in a synthetic air matrix gas with an expanded uncertainty of 27 pmol mol-1. This represents a significant breakthrough as using these developments with an optimized dilution hierarchy (to minimize the gravimetric uncertainty) promises to result in SI traceable reference materials with expanded uncertainties as low as 0.032% relative (k = 2). This supports the World Meteorological Organization-Global Atmosphere Watch network compatibility goal for underpinning atmospheric observations.

Exploring the role of advanced clinical practitioners (ACPs) and their contribution to health services in England: A qualitative exploratory study.

BACKGROUND: An extended role being explored globally is the advanced clinical practitioner (ACP). In England this is an extended role for allied health professions, nurses and midwives in a range of settings. OBJECTIVES: This paper focuses on three research questions: 1) What is the role of ACPs in England? 2) What are the barriers and facilitators to implementing the role? and 3) What is the contribution of ACPs to health services in England? DESIGN/SETTING: A qualitative, exploratory study to explore perspectives on the ACP role in a range of clinical settings. PARTICIPANTS: We recruited 63 stakeholders, including 34 nurses, working in a ACP role or ACP education. A purposive snowball sampling technique identified participants meeting inclusion criteria. METHODS: One-to-one semi-structured interviews throughout 2020, recorded and transcribed verbatim, anonymised and thematically analysed. RESULTS: The ACP role in England was undertaken in a broad range of clinical contexts. In England 'advanced clinical practitioner' was not a protected title. There were high levels of variability and ambiguity of understanding and deployment of the ACP role in England. Facilitators to the implementation process included training and education, clinical supervision and organisational support. Lack of protection for the role and variances in experience were barriers. Employer support facilitated development of the ACP role, however where support was limited, at either an individual or organisation level, this was a barrier. Our study highlighted the wide range of ways the ACP role benefitted patient outcomes and workforce development. CONCLUSIONS: This study outlines the contribution that ACPs can make to health services, contributing factors and key barriers and facilitators to implementing this role. The work showed the positive contribution ACPs can make to service redesign, workforce development and patient outcomes, whilst accepting there is much work to do to ensure protected status and parity across all professions and clinical contexts.

Enhancing healthcare students' clinical placement experiences.

Over the past few years, efforts to address a shortage of nurses in the UK has led to an increase in nursing student numbers. However, in one large UK healthcare trust, this increase in student numbers led to a need to improve the quality of the trust's clinical placements. To address this issue, the authors undertook a quality improvement project, in which focus groups were used to enable 53 nursing, allied health professional, midwifery and nursing associate students to have in-depth discussions about their clinical placement experiences in the trust. Three main themes emerged from the data: being part of a team; support; and being unprepared. Following the project, the trust introduced student-led clinical learning environments to provide an innovative practice-based experience for students.

Strategies to improve uptake and adherence of non-pharmacologic interventions for orthostatic hypotension in older people: a qualitative study.

PURPOSE: Non-pharmacologic therapies are a safe and effective treatment for orthostatic hypotension (OH) in older adults. However, adherence to non-drug therapies is challenging and may require specific behaviour change approaches to promote uptake and adherence. The study aim is to identify specific behavioural change techniques to promote uptake and adherence with non-pharmacologic interventions for older adults with OH. METHODS: Forty semi-structured, qualitative interviews were performed in 25 older adults with OH. Each participant experienced bolus-water drinking, physical counter-manoeuvres and compression garments during two efficacy studies. Emergent themes were identified through framework analysis, based on The Behaviour Change Technique Taxonomy. RESULTS: Several themes to encourage uptake and adherence arose. Motivation to adhere with an intervention may be improved by demonstrating its effectiveness, either through symptom monitoring or biofeedback. Practising or rehearsing how to use an intervention may improve self-efficacy and promote habit formation. Embedding therapies into daily life so that they become second nature was felt to be a useful strategy. Educating older adults about why they are being asked to use a therapy and demonstrating how to use it is important. More specific barriers may be overcome by encouraging a personal problem-solving approach. CONCLUSION: These specific behaviour change techniques, derived by older people with OH and based on evidence-based approaches, provide useful strategies to improve the uptake and adherence of non-drug therapies in the treatment of OH. TRIAL REGISTRATION: ISRCTN15084870.

Isotopically characterised N2 O reference materials for use as community standards.

RATIONALE: Information on the isotopic composition of nitrous oxide (N2 O) at natural abundance supports the identification of its source and sink processes. In recent years, a number of mass spectrometric and laser spectroscopic techniques have been developed and are increasingly used by the research community. Advances in this active research area, however, critically depend on the availability of suitable N2 O isotope Reference Materials (RMs). METHODS: Within the project Metrology for Stable Isotope Reference Standards (SIRS), seven pure N2 O isotope RMs have been developed and their 15 N/14 N, 18 O/16 O, 17 O/16 O ratios and 15 N site preference (SP) have been analysed by specialised laboratories against isotope reference materials. A particular focus was on the 15 N site-specific isotopic composition, as this measurand is both highly diagnostic for source appointment and challenging to analyse and link to existing scales. RESULTS: The established N2 O isotope RMs offer a wide spread in delta (δ) values: δ15 N: 0 to +104‰, δ18 O: +39 to +155‰, and δ15 NSP : -4 to +20‰. Conversion and uncertainty propagation of δ15 N and δ18 O to the Air-N2 and VSMOW scales, respectively, provides robust estimates for δ15 N(N2 O) and δ18 O(N2 O), with overall uncertainties of about 0.05‰ and 0.15‰, respectively. For δ15 NSP , an offset of >1.5‰ compared with earlier calibration approaches was detected, which should be revisited in the future. CONCLUSIONS: A set of seven N2 O isotope RMs anchored to the international isotope-ratio scales was developed that will promote the implementation of the recommended two-point calibration approach. Particularly, the availability of δ17 O data for N2 O RMs is expected to improve data quality/correction algorithms with respect to δ15 NSP and δ15 N analysis by mass spectrometry. We anticipate that the N2 O isotope RMs will enhance compatibility between laboratories and accelerate research progress in this emerging field.

Nationwide evaluation of the advanced clinical practitioner role in England: a cross-sectional survey.

BACKGROUND AND STUDY OBJECTIVE: In response to growing pressures on healthcare systems, the advanced clinical practice (ACP) role has been implemented widely in the UK and internationally. In England, ACP is a level of practice applicable across various healthcare professions, who exercise a level of autonomy across four domains, referred to as the four pillars of practice (education, leadership, research and clinical practice). A national framework for ACP was established in 2017 to ensure consistency across the ACP role, however current ACP governance, education and support is yet to be evaluated. This study aimed to analyse data from a national survey of the ACP role to inform the development and improvement of policies relating to ACP in the National Health Service (NHS) in England. DESIGN: A cross-sectional survey with free-text comments. SETTING: The survey was distributed across primary and secondary levels of care to three distinct groups in England, including individual ACPs, NHS provider organisations and Trusts and primary care settings. PARTICIPANTS: A total of 4365 surveys were returned, from ACP staff (n=4013), NHS provider organisations and Trusts (n=166) and primary care organisations (n=186). RESULTS: Considerable variation was found in role titles, scope of practice, job descriptions and educational backgrounds of ACPs. Differing approaches to governance were noted, which led to inconsistent ACP frameworks in some organisations. A further challenge highlighted included committing time to work across the four pillars of advanced practice, particularly the research pillar. ACPs called for improvements in supervision and continuing professional development alongside further support in navigating career pathways. CONCLUSIONS: A standardised approach may support ACP workforce development in England and enable ACPs to work across the four pillars of practice. Due to the wide uptake of ACP roles internationally, this study has relevance across professions for global healthcare workforce transformation.

Men, trans/masculine, and non-binary people negotiating conception: Normative resistance and inventive pragmatism.

BACKGROUND: Growing numbers of men, trans/masculine, and non-binary people are undertaking pregnancies, yet relatively little is known about the experiences of this diverse population in regard to conception. AIMS: This study sought to examine men's, trans/masculine, and non-binary people's experiences of pregnancy, including conception. METHODS: Interviews were conducted with 51 men, trans/masculine, and non-binary people who were gestational parents living in Australia, Canada, the European Union (including the United Kingdom), and the United States. Thematic analysis was undertaken, focusing on accounts of conception. Pfeffer's conceptual frameworks of normative resistance and inventive pragmatism were used as an analytic tool. RESULTS: Themes developed focused on: 1) choosing a clinic donor, 2) kinship with donors, 3) conceiving via intercourse with a partner, 4) negotiating receipt of donor sperm, 5) challenges associated with known donors, 6) challenges associated with fertility clinics, and 7) experiences of conception. DISCUSSION: The forms of normative resistance and inventive pragmatism identified suggest that men, trans/masculine, and non-binary people who are gestational parents seek to normalize their experiences of conception, while also acknowledging the specific challenges they face.

Characterising the outcomes, impacts and implementation challenges of advanced clinical practice roles in the UK: a scoping review.

OBJECTIVES: In response to demographic and health system pressures, the development of non-medical advanced clinical practice (ACP) roles is a key component of National Health Service workforce transformation policy in the UK. This review was undertaken to establish a baseline of evidence on ACP roles and their outcomes, impacts and implementation challenges across the UK. DESIGN: A scoping review was undertaken following JBI methodological guidance. METHODS: 13 online databases (Medline, CINAHL, ASSIA, Embase, HMIC, AMED, Amber, OT seeker, PsycINFO, PEDro, SportDiscus, Osteopathic Research and PenNutrition) and grey literature sources were searched from 2005 to 2020. Data extraction, charting and summary was guided by the PEPPA-Plus framework. The review was undertaken by a multi-professional team that included an expert lay representative. RESULTS: 191 papers met the inclusion criteria (any type of UK evidence, any sector/setting and any profession meeting the Health Education England definition of ACP). Most papers were small-scale descriptive studies, service evaluations or audits. The papers reported mainly on clinical aspects of the ACP role. Most papers related to nursing, pharmacy, physiotherapy and radiography roles and these were referred to by a plethora of different titles. ACP roles were reported to be achieving beneficial impacts across a range of clinical and health system outcomes. They were highly acceptable to patients and staff. No significant adverse events were reported. There was a lack of cost-effectiveness evidence. Implementation challenges included a lack of role clarity and an ambivalent role identity, lack of mentorship, lack of continuing professional development and an unclear career pathway. CONCLUSION: This review suggests a need for educational and role standardisation and a supported career pathway for advanced clinical practitioners (ACPs) in the UK. Future research should: (i) adopt more robust study designs, (ii) investigate the full scope of the ACP role and (iii) include a wider range of professions and sectors.

Boreas: A Sample Preparation-Coupled Laser Spectrometer System for Simultaneous High-Precision In Situ Analysis of δ13C and δ2H from Ambient Air Methane.

We present a new instrument, "Boreas", a cryogen-free methane (CH4) preconcentration system coupled to a dual-laser spectrometer for making simultaneous measurements of δ13C(CH4) and δ2H(CH4) in ambient air. Excluding isotope ratio scale uncertainty, we estimate a typical standard measurement uncertainty for an ambient air sample of 0.07‰ for δ13C(CH4) and 0.9‰ for δ2H(CH4), which are the lowest reported for a laser spectroscopy-based system and comparable to isotope ratio mass spectrometry. We trap CH4 (∼1.9 µmol mol-1) from ∼5 L of air onto the front end of a packed column, subsequently separating CH4 from interferences using a controlled temperature ramp with nitrogen (N2) as the carrier gas, before eluting CH4 at ∼550 µmol mol-1. This processed sample is then delivered to an infrared laser spectrometer for measuring the amount fractions of 12CH4, 13CH4, and 12CH3D isotopologues. We calibrate the instrument using a set of gravimetrically prepared amount fraction primary reference materials directly into the laser spectrometer that span a range of 500-626 µmol mol-1 (CH4 in N2) made from a single pure CH4 source that has been isotopically characterized for δ13C(CH4) by IRMS. Under the principle of identical treatment, a compressed ambient air sample is used as a working standard and measured between air samples, from which a final calibrated isotope ratio is calculated. Finally, we make automated measurements of both δ13C(CH4) and δ2H(CH4) in over 200 ambient air samples and demonstrate the application of Boreas for deployment to atmospheric monitoring sites.

Men, trans/masculine, and non-binary people's experiences of pregnancy loss: an international qualitative study.

BACKGROUND: Growing numbers of men, trans/masculine, and non-binary people are becoming gestational parents, yet very little is known about experiences of pregnancy loss among this diverse population. METHODS: The study employed a cross sectional design. Interviews were undertaken with a convenience sample of 51 trans/masculine and non-binary people who had undertaken at least one pregnancy, living in either Australia, the United States, Canada, or the European Union (including the United Kingdom). Participants were recruited by posts on Facebook and Twitter, via researcher networks, and by community members. 16 (31.2%) of the participants had experienced a pregnancy loss and are the focus of this paper. Thematic analysis was used to analyse interview responses given by these 16 participants to a specific question asking about becoming pregnant and a follow up probe question about pregnancy loss. RESULTS: Thematic analysis of interview responses given by the 16 participants led to the development of 10 themes: (1) pregnancy losses count as children, (2) minimizing pregnancy loss, (3) accounting for causes of pregnancy loss, (4) pregnancy loss as devastating, (5) pregnancy loss as having positive meaning, (6) fears arising from a pregnancy loss, (7) experiences of hospitals enacting inclusion, (8) lack of formal support offered, (9) lack of understanding from family, and (10) importance of friends. CONCLUSIONS: The paper concludes by outlining specific recommendations for clinical practice. These include the importance of focusing on the emotions attached to pregnancy loss, the need for targeted support services for men, trans/masculine, and non-binary people who undertake a pregnancy (including for their partners), and the need for ongoing training for hospital staff so as to ensure the provision of trans-affirming medical care.

Advanced Clinical Practitioners in Primary Care in the UK: A Qualitative Study of Workforce Transformation.

Escalating costs and changing population demographics are putting pressure on primary care systems to meet ever more complex healthcare needs. Non-medical 'advanced clinical practitioner' (ACP) roles are increasingly being introduced to support service transformation. This paper reports the findings of a qualitative evaluation of nursing ACP roles across General Practices in one region of the UK. Data collection involved telephone interviews with 26 participants from 3 different stakeholder groups based in 9 practice sites: ACPs (n = 9), general practitioners (n = 8) and practice managers (n = 9). The data was analysed thematically. The study found a high degree of acceptance of the ACP role and affirmation of the important contribution of ACPs to patient care. However, significant variations in ACP education, skills and experience led to a bespoke approach to their deployment, impeding system-wide innovation and creating challenges for recruitment and ongoing professional development. In addition, a context of high workforce pressures and high service demand were causing stress and there was a need for greater mentorship and workplace support. System wide changes to ACP education and support are required to enable ACPs to realise their full potential in primary care in the UK.

Characterising the evidence base for advanced clinical practice in the UK: a scoping review protocol.

INTRODUCTION: A global health workforce crisis, coupled with ageing populations, wars and the rise of non-communicable diseases is prompting all countries to consider the optimal skill mix within their health workforce. The development of advanced clinical practice (ACP) roles for existing non-medical cadres is one potential strategy that is being pursued. In the UK, National Health Service (NHS) workforce transformation programmes are actively promoting the development of ACP roles across a wide range of non-medical professions. These efforts are currently hampered by a high level of variation in ACP role development, deployment, nomenclature, definition, governance and educational preparation across the professions and across different settings. This scoping review aims to support a more consistent approach to workforce development in the UK, by identifying and mapping the current evidence base underpinning multiprofessional advanced level practice in the UK from a workforce, clinical, service and patient perspective. METHODS AND ANALYSIS: This scoping review is registered with the Open Science Framework (https://osf.io/tzpe5). The review will follow Joanna Briggs Institute guidance and involves a multidisciplinary and multiprofessional team, including a public representative. A wide range of electronic databases and grey literature sources will be searched from 2005 to the present. The review will include primary data from any relevant research, audit or evaluation studies. All review steps will involve two or more reviewers. Data extraction, charting and summary will be guided by a template derived from an established framework used internationally to evaluate ACP (the Participatory Evidence-Informed Patient-Centred Process-Plus framework). DISSEMINATION: The review will produce important new information on existing activity, outcomes, implementation challenges and key areas for future research around ACP in the UK, which, in the context of global workforce transformations, will be of international, as well as local, significance. The findings will be disseminated through professional and NHS bodies, employer organisations, conferences and research papers.

The Practice of Character Strengths: Unifying Definitions, Principles, and Exploration of What's Soaring, Emerging, and Ripe With Potential in Science and in Practice.

What does it mean to be "strengths-based" or to be a "strengths-based practitioner?" These are diffuse areas that are generic and ill-defined. Part of the confusion arises from the customary default of practitioners and leaders across many cultures to label anything positive or complimentary as "strengths-based," whether that be an approach, a theoretical orientation, an intervention, or a company. Additional muddle is created by many researchers and practitioners not making distinctions between very different categories of "strength" in human beings - strengths of character, of talent/ability, of interest/passion, of skill/competency, to name a few. To add clarity and unification across professions, we offer seven characteristics and a comprehensive definition for a character strengths-based practitioner. We center on the type of strength referred to as character strengths and explore six guiding principles for understanding character strengths (e.g., character is plural; character is being and doing) and their practical corollaries. Reflecting this foundation and based on character strengths research, our longstanding work with strengths, discussions with practitioners across the globe, and a practitioner survey asking about strength practices (N = 113), we point out several character strengths practices or approaches we describe as soaring (e.g., explore and encourage signature strengths; practice strengths-spotting), emerging (e.g., the integration of mindfulness and character strengths), or ripe with potential (e.g., phasic strengths; the tempering effect; the towing effect). We use the same framework for describing general research domains. Some areas of research in character strengths are soaring with more than 25 studies (e.g., workplace/organizations), some are emerging with a handful of studies (e.g., health/medicine), and others are ripe with potential that have none or few studies yet opportunity looms large for integrating character science (e.g., peace/conflict studies). Using this framework, we seek to advance the exchange and collaboration between researcher and practitioner, as well as to advance the science and practice of character strengths.

Transnormativity in the psy disciplines: Constructing pathology in the Diagnostic and Statistical Manual of Mental Disorders and Standards of Care.

The psy disciplines (i.e., psychiatry, psychology, psychoanalysis, and psychotherapy) have played a significant role in shaping understandings of transgender people's lives in ways that are transnormative (i.e., by emphasizing one particular account of what it means to be transgender). This article documents (a) how the rise of the psy disciplines created opportunities for transgender people to access treatment (but that such access often required tacit acceptance of transnormativity), and (b) how transgender people have resisted transnormative accounts within the psy disciplines. More specifically, this article explores how both the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, and what is now the World Professional Association for Transgender Health's Standards of Care, have often enshrined highly regulatory accounts of transgender people's lives, while also changing over time, in part as a result of the contributions of transgender people. The article concludes by considering recent contributions by transgender people in terms of the use of informed consent models of care and clinical research, and highlights the ongoing marginalization of transgender people in terms of access to ethical, transcompetent care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Breakthrough in Negating the Impact of Adsorption in Gas Reference Materials.

We have shown that an exchange dilution preparation method reduces the impact of surface adsorption of the target component in high-pressure gas mixtures used for underpinning measurements of amount-of-substance fraction. Gas mixtures are diluted in the same cylinder by releasing an aliquot of the parent mixture. Additional matrix gas is then added to the cylinder. This differs from conventional methods where dilutions are achieved by transferring the parent mixture to another cylinder, which then stores the final reference material. The benefit of this revolutionary approach is that losses due to adsorption to the walls of the cylinder and the valve are reduced as the parent mixture pacifies the surface with only a negligible relative change in amount-of-substance fraction. This development allows for preparation of gas reference materials with unprecedented uncertainties beyond the existing state of the art. It has significant implications for the preparation of high accuracy gas reference materials which underpin a broad range of requirements, particularly in atmospheric monitoring of carbon dioxide, where understanding the adsorption effects is the major obstacle to advancing the measurement science. It has the potential to remove the reliance on proprietary surface pretreatments as the method provides an in situ and consistent alternative.

Impairments in cognitive performance in chronic fatigue syndrome are common, not related to co-morbid depression but do associate with autonomic dysfunction.

OBJECTIVES: To explore cognitive performance in chronic fatigue syndrome (CFS) examining two cohorts. To establish findings associated with CFS and those related to co-morbid depression or autonomic dysfunction. METHODS: Identification and recruitment of participants was identical in both phases, all CFS patients fulfilled Fukuda criteria. In Phase 1 (n = 48) we explored cognitive function in a heterogeneous cohort of CFS patients, investigating links with depressive symptoms (HADS). In phase 2 (n = 51 CFS & n = 20 controls) participants with co-morbid major depression were excluded (SCID). Furthermore, we investigated relationships between cognitive performance and heart rate variability (HRV). RESULTS: Cognitive performance in unselected CFS patients is in average range on most measures. However, 0-23% of the CFS sample fell below the 5th percentile. Negative correlations occurred between depressive symptoms (HAD-S) with Digit-Symbol-Coding (r = -.507, p = .006) and TMT-A (r = -.382, p = .049). In CFS without depression, impairments of cognitive performance remained with significant differences in indices of psychomotor speed (TMT-A: p = 0.027; digit-symbol substitution: p = 0.004; digit-symbol copy: p = 0.007; scanning: p = .034) Stroop test suggested differences due to processing speed rather than inhibition. Both cohorts confirmed relationships between cognitive performance and HRV (digit-symbol copy (r = .330, p = .018), digit-symbol substitution (r = .313, p = .025), colour-naming trials Stroop task (r = .279, p = .050). CONCLUSION: Cognitive difficulties in CFS may not be as broad as suggested and may be restricted to slowing in basic processing speed. While depressive symptoms can be associated with impairments, co-morbidity with major depression is not itself responsible for reductions in cognitive performance. Impaired autonomic control of heart-rate associates with reductions in basic processing speed.

Synthetic Zero Air Reference Material for High Accuracy Greenhouse Gas Measurements.

The purity analysis of zero air is a significant contributor to the uncertainty in preparing reference materials of high impact greenhouse gases, limiting progress toward coherent and comparable measurements required to assess climate trends. We have produced a commutable synthetic zero air reference material with an oxygen, nitrogen, and argon matrix closely matching atmospheric composition. This is the critical step in preventing systematic biases from pressure broadening effects when using these reference materials to calibrate instruments based on optical spectroscopy. The amount fractions of carbon dioxide, methane, and carbon monoxide, which are present as minor impurities in the zero air reference material, have been accurately quantified using a novel dilution device that can generate gas mixtures of these components at trace amount fractions. These developments will have a significant impact on advancing the state of the art in high accuracy reference materials and for baseline calibration of spectroscopic instrumentation.

Acceptability of non-drug therapies in older people with orthostatic hypotension: a qualitative study.

BACKGROUND: Orthostatic hypotension (OH) is highly prevalent in older populations. It is associated with a reduced quality of life and an increased risk of dementia, stroke and death. Non-pharmalogical therapies are the recommended first-line therapy and are preferred to drug treatments by older people. However, uptake and adherence is low and evidence for their use is lacking. OBJECTIVE: Determine the acceptability of non-pharmalogical interventions for OH in older people. METHODS: This qualitative study, nested within a phase II efficacy study, recruited 25 people aged over 60 years from a Falls and Syncope Clinic. All participants had experienced the following non-pharmalogical therapies within a phase II study: bolus water drinking, compression stockings, abdominal compression, physical counter-manoeuvres. Individual semi-structured qualitative interviews were recorded and transcribed verbatim. Emergent themes were identified through framework analysis of transcripts. RESULTS: Physical counter-manoeuvres were considered the most acceptable therapy as no equipment is required, they can be performed discreetly and are only required during postural change. Bolus water drinking was mostly considered as an acceptable therapy, although there were significant concerns around urinary frequency. The idea of bolus water drinking was a barrier to its uptake, but once experienced it was easier than anticipated. Participants had mixed views on acceptability of abdominal compression whereas compression stockings were considered unacceptable by the majority of participants. This was due to the practicalities of applying/removing the compression and the stigma attached to their appearance. CONCLUSIONS: Current first-line treatment with compression stockings is largely unacceptable to older people with OH, challenging current guidelines. In order to promote uptake and adherence, first line therapy should focus on bolus-water drinking and physical counter-manoeuvres.