Litigation claims following laparoscopic and open inguinal hernia repairs.

PURPOSE: Groin hernia repair is the most frequently performed general surgical operation in the UK. Complications from laparoscopic and open repair are well recognised; however, potential differences are yet to be considered in relation to litigation. METHODS: Administrative data were obtained and analysed from the NHS Litigation Authority for inguinal hernia-related claims from 1995 to 2016. Claims identified as using an open or laparoscopic approach were compared. RESULTS: 880 claims were made, 760 had been settled. 88 laparoscopic and 241 open procedures were identified; 65% laparoscopic and 63% open hernia claims were found to be in favour of the claimant. Payouts totalled to 4.1GBP/4.8EUR/5.3USD million and 9.4GBP/11.0EUR/12.1USD million for laparoscopic (mean 82,824GBP/96,579EUR/106,453USD) and open (mean 66,796GBP/77,892EUR/85,852USD) approaches, respectively. The most common reasons for claim initiation were visceral/vascular injury (54%) in the laparoscopic group, and testicular complications or chronic pain (35%) in the open group. Additional procedures were necessary for 48% and 44% of laparoscopic and open claims, respectively. The highest average payouts were associated with visceral injury, (laparoscopic 116,482GBP/135,820EUR/149,715USD; open 199,103GBP/232,246EUR/255,905USD) and vascular injury (laparoscopic 88,624GBP/103,369EUR/113,892USD; open 64,460GBP/75,163EUR/82,870USD). Additional procedures resulted in an average payout of 93,352GBP/108,917EUR/120,008USD (laparoscopic) and 60,408GBP/70,506EUR/77,657USD (open). The most common additional procedures were corrective visceral/vascular repairs, orchidectomy and recurrent hernia repair. CONCLUSIONS: The rate of litigation for clinical negligence in inguinal hernia surgery in the UK is increasing. Whilst there has been a recent increase in laparoscopic hernia repair claims, the volume and burden of claims related to open procedures remain greater.

Guidelines To Validate Control of Cross-Contamination during Washing of Fresh-Cut Leafy Vegetables.

The U.S. Food and Drug Administration requires food processors to implement and validate processes that will result in significantly minimizing or preventing the occurrence of hazards that are reasonably foreseeable in food production. During production of fresh-cut leafy vegetables, microbial contamination that may be present on the product can spread throughout the production batch when the product is washed, thus increasing the risk of illnesses. The use of antimicrobials in the wash water is a critical step in preventing such water-mediated cross-contamination; however, many factors can affect antimicrobial efficacy in the production of fresh-cut leafy vegetables, and the procedures for validating this key preventive control have not been articulated. Producers may consider three options for validating antimicrobial washing as a preventive control for cross-contamination. Option 1 involves the use of a surrogate for the microbial hazard and the demonstration that cross-contamination is prevented by the antimicrobial wash. Option 2 involves the use of antimicrobial sensors and the demonstration that a critical antimicrobial level is maintained during worst-case operating conditions. Option 3 validates the placement of the sensors in the processing equipment with the demonstration that a critical antimicrobial level is maintained at all locations, regardless of operating conditions. These validation options developed for fresh-cut leafy vegetables may serve as examples for validating processes that prevent cross-contamination during washing of other fresh produce commodities.

Disconnection agraphia in a case of multiple sclerosis: the isolation of letter movement plans from language.

We report the case of a left-handed man (MCR), who presented with a peripheral agraphia as an early sign of multiple sclerosis. His left-handed writing was neologistic, whilst oral spelling, typing and spelling with the right hand were intact. Structural MRI scanning revealed a lesion of the body of the corpus callosum. Dichotic listening tests indicated that MCR displayed left hemisphere dominance for language. It is proposed that MCR represents a case of a disconnection syndrome in which right hemisphere systems that provide the basis for movement templates during left-handed writing are isolated from left hemisphere language systems. Analysis of left-handed writing indicated that peripheral movement control was highly structured with both individual letter frequency and sequential dependencies between letters represented within these motor control units. This case represents an opportunity to explore the mechanisms of movement control for writing and to examine the characteristics of isolated letter templates.

Starch fermentation by faecal bacteria of infants, toddlers and adults: importance for energy salvage.

OBJECTIVE: Little is known of the degree to which the colon salvages energy through starch fermentation in young children. Using a simulated colonic environment, we aimed to account for the fate of fermented raw and cooked starch in two groups of young children and in adults. DESIGN: A slurry was prepared from faecal samples from six infants (7-10 months), six toddlers (16-21 months) and seven adults (24-56 y). Each slurry was anaerobically incubated with raw or cooked maize starch in MacCartney bottles in a shaking water bath. Parallel incubations were stopped at 4 and 24 h. The headspace gas volume was analysed for CO(2) and methane. The culture supernatant was analysed for short-chain fatty acids (SCFA), lactate and residual starch. RESULTS: Different patterns of fermentation were seen at 4 and 24 h. For raw starch, the production of SCFA decreased with subject age at 4 h but not at 24 h. With both substrates at 4 h, toddler stools produced significantly more CO(2) than infants or adults, but there were no statistical differences at 24 h. Methane was detected in three adults only. Lactate was detected mainly at 4 h in children. CONCLUSIONS: The results suggest that fermentation, particularly of raw starch, is a more rapid process in young children than in adults. A highly efficient energy salvage process may occur in the colon of young children.

Mind over grammar: reasoning in aphasia and development.

Research on propositional reasoning (involving 'theory of mind' understanding) in adult patients with aphasia reveals that reasoning can proceed in the absence of explicit grammatical knowledge. Conversely, evidence from studies with deaf children shows that the presence of such knowledge is not sufficient to account for reasoning. These findings are in keeping with recent research on the development of naming, categorization and imitation, indicating that children's reasoning about objects and actions is guided by inferences about others' communicative intentions. We discuss the extent to which reasoning is supported by, and tied to, language in the form of conversational awareness and experience rather than grammar.

Severe impairment in grammar does not preclude theory of mind.

Debates about the role of language in human thinking are increasingly prominent in the cognitive sciences. There are claims that certain forms of reasoning can only be performed through access to the resources of the language faculty. In particular, a component of social cognition involving the representation of the mental states of others ('theory of mind' reasoning) has been claimed necessarily to involve propositions of natural language. A recent case study reported a man (SA) with severe agrammatic aphasia who was unable to understand or produce language propositions in any modality of language use, but who was able to complete theory of mind tasks. We report a replication of this finding using a modified picture theory of mind task with a second patient (MR). Despite severe aphasia and impaired performance on a test of executive function, MR demonstrated retained theory of mind reasoning. These results reveal the functional autonomy of theory of mind from the capacity for propositional/grammatical language, and support its independence from executive function.

Contribution of finger tracing to the recognition of Chinese characters.

Finger tracing is a simulation of the act of writing without the use of pen and paper. It is claimed to help in the processing of Chinese characters, possibly by providing additional motor coding. In this study, blindfolded subjects were equally good at identifying Chinese characters and novel visual stimuli through passive movements made with the index finger of the preferred hand and those made with the last finger of that hand. This suggests that finger tracing provides a relatively high level of coding specific to individual characters, but non-specific to motor effectors. Beginning each stroke from the same location, i.e. removing spatial information, impaired recognition of the familiar characters and the novel nonsense figures. Passively tracing the strokes in a random sequence also impaired recognition of the characters. These results therefore suggest that the beneficial effect of finger tracing on writing or recall of Chinese characters is mediated by sequence and spatial information embedded in the motor movements, and that proprioceptive channel may play a part in mediating visuo-spatial information. Finger tracing may be a useful strategy for remediation of Chinese language impairments.

Evidence for cognition without grammar from causal reasoning and 'theory of mind' in an agrammatic aphasic patient.

Understanding the inter-relationship between language and thought is fundamental to the study of human cognition [1] [2] [3]. Some investigators have proposed that propositions in natural language serve to scaffold thinking, by providing, for example, a sequential structure to a massively parallel process [4]. Others have maintained that certain thoughts, such as inferring the mental states of others, termed 'theory of mind' (ToM) reasoning, and identifying causal relationships, necessarily involve language propositions [5]. It has been proposed that ToM reasoning depends upon the possession of syntactic structures such as those that permit the embedding of false propositions within true statements ('Mary knows that John (falsely) thinks chocolates are in the cupboard') [6]. The performance on reasoning tasks of individuals with severe agrammatic aphasia (an impairment of language following a lesion of the perisylvian areas of the language-dominant hemisphere) offers novel insights into the relation between grammar and cognition. We report the unusual case of a patient with agrammatic aphasia of such severity that language propositions were not apparently available at an explicit processing level in any modality of language use. Despite this profound impairment in grammar, he displayed simple causal reasoning and ToM understanding. Thus, reasoning about causes and beliefs involve processes that are independent of propositional language.

A reconceptualisation of apraxia of speech: a synthesis of evidence.

This paper presents a reconceptualisation of apraxia of speech (AOS) and reviews a range of acoustic and articulatory data which have been reported on apraxia of speech. Data from both domains, and previous theoretical debate are discussed as support for this cognitive-based reconceptualisation.

A reassessment of the cost-effectiveness of water and sanitation interventions in programmes for controlling childhood diarrhoea.

Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are highly cost-effective for the control of diarrhoea among under-5-year-olds, on a par with oral rehydration therapy. These are relatively inexpensive "software-related" interventions such as hygiene education, social marketing of good hygiene practices, regulation of drinking-water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programmes are not a cost-effective use of health sector resources has arisen from three factors: an assumption that all WSS interventions involve construction of physical infrastructure, a misperception of the health sector's role in WSS programmes, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure ("hardware") is generally built and operated by public works agencies and financed by construction grants, operational subsidies, user fees and property taxes. Health sector agencies should provide "software" such as project design, hygiene education, and water quality regulation. Cost-effectiveness analysis should measure the incremental health impacts attributable to health sector investments, using the actual call on health sector resources as the measure of cost. The cost-effectiveness of a set of hardware and software combinations is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year (DALY) saved.

PIP: Cost-effectiveness analysis indicates that some water supply and sanitation (WSS) interventions are very cost-effective in controlling diarrhea among children under age 5 years, as cost-effective as oral rehydration therapy. These include relatively inexpensive interventions such as hygiene education, the social marketing of good hygiene practices, regulation of drinking water, and monitoring of water quality. Such interventions are needed to ensure that the potentially positive health impacts of WSS infrastructure are fully realized in practice. The perception that WSS programs are not cost-effective has grown out of the assumption that all WSS interventions involve building physical infrastructure, a misperception of the health sector's role in WSS programs, and a misunderstanding of the scope of cost-effectiveness analysis. WSS infrastructure is usually built and operated by public works agencies and financed by construction grants, operational subsidies, user fees, and property taxes. Health sector agencies should provide project design, hygiene education, and water quality regulation. The cost-effectiveness of various water and sanitation interventions to control childhood diarrhea is estimated, using US$ per case averted, US$ per death averted, and US$ per disability-adjusted life year saved.

Hemispheric function in developmental language disorders and high-level autism.

Two groups of children with contrasting types of developmental language disorder (phonologic-syntactic and semantic-pragmatic) were compared with a group of children with high-level autism and with a control group of normal children on a broad battery of neuropsychological tests, known to be sensitive to left-right hemisphere damage. Significant differences found between the groups suggest contrasting forms of hemispheric dysfunction.

Social cognition in developmental language disorders and high-level autism.

Two groups of children with contrasting types of developmental language disorder (phonologic-syntactic and semantic-pragmatic) were compared with a group of children with high-level autism and with a control group of normal children on tests of social cognition (theory of mind; social comprehension; and detection of eye direction). The similarly poor performances of the semantic-pragmatic group and the autistic group suggest that semantic-pragmatic language disorder lies on the autistic spectrum.

Using electropalatography to treat severe acquired apraxia of speech.

This paper reports on the use of electropalatography (EPG) in the treatment of a patient with severe acquired apraxia of speech. At 2 years post-onset and after a period of conventional speech and language therapy, the patient, AD, presented with severe speech production problems affecting articulation, phonation and resonance. Treatment using EPG is described and both the patient's progress and his continued limitations are outlined. EPG provided a valuable form of visual feedback for the patient and revealed and clarified aspects of oral movements for speech and non-speech activity which had been difficult to capture via auditory perception.

Lexical-semantic deficits following right hemisphere damage: evidence from verbal fluency tasks.

The evidence of lexical-semantic deficits following right, non-language-dominant hemisphere injury was assessed using word (or verbal) fluency tests. Two groups of subjects (non-brain-damaged controls and right hemisphere-damaged patients) were indistinguishable in their performances on convergent lexical tasks. Subjects completed verbal fluency tasks by five semantic criteria. The brain-damaged subjects produced significantly fewer responses on two of the categories and demonstrated fewer lexical retrieval strategies. The results were interpreted as evidence that lexical-semantic knowledge is largely intact following right-hemisphere damage, and that apparent lexical deficits result from failure to use lexical knowledge flexibility, suggesting that right-hemisphere language disorders may stem from broader cognitive failures.

Mast cell ultrastructure in the adenoids of children with and without secretory otitis media.

This study was designed to compare the differences in morphology of the mast cells from the adenoid in children with otitis media with effusion (OME) and those from children with recurrent tonsillitis. Tissue for electron microscopy was prepared in the standard manner and between three and 10 blocks were examined for each child. All the mast cells with nuclei were photographed and the condition of the granules noted. The number of electron dense granules in each cell was assessed on a scale between zero and 10. Sixteen unselected children with OME were compared with 19 children with recurrent tonsillitis. There were no obvious differences in the degree of degranulation between the two groups although there was more vacuolation than previously described in the normal nose but less than in those patients with perennial allergic rhinitis. Allergy and mast cell reactions do not seem to predispose to OME. It was concluded that the adenoids are not the ideal tissue in which to study normal mast cells.

Deictic terms, lexical retrieval and utterance length in aphasia: an investigation of inter-relations.

This study quantified the number of deictic forms in the conversational speech of non-brain-damaged control, right hemisphere-damaged, and fluent and non-fluent aphasic subjects. The relationship between use of deictic terms and performance on single-word level lexical tests was examined, together with the number of deictics with increasing clause length. In the latter case, evidence of trade-off between lexical-semantic complexity and sentence length was sought. Fluent aphasics were found to use significantly more deictics than other groups, and non-fluent aphasics significantly fewer. No significant correlations were observed between deictic use and performance on the lexical tests. Analysis at the level of the group revealed no inverse relationship between deictic use and number of elements in the clause. However, this pattern could be observed in individual fluent aphasics.