758 research outputs found

    Application of intraoperative quality assurance to laparoscopic total mesorectal excision surgery

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    Introduction: The role of laparoscopy in the surgical management of rectal cancer is debated. Randomised trials have reported contrasting results with inadequate specimens obtained in a minority of patients. The reasons behind these findings are unclear. Complex surgical interventions and human performance are prone to variation, which may account for outcome differences, but neither are robustly measured. Application of quality assurance (QA) to the intraoperative period could explore surgical performance and any relationship with subsequent outcomes. The overarching aim of this thesis is the promotion of oncological and patient safety through application of QA to laparoscopic TME surgery. Methods: Evidence synthesis of QA tools was obtained through a systematic review to identify reported objective laparoscopic total mesorectal excision (TME) assessment tools. Development of novel QA tools for laparoscopic TME was performed and applied and validated using case video from two multicentre randomised trials with reliability and validity of the laparoscopic TME performance tool (L-TMEpt) assessed. A multicentre randomised trial comparing 3D vs. 2D laparoscopic TME was performed incorporating objective performance analyses. Scores divided surgeons into quartiles and compared with histopathological and clinical endpoints. A novel intraoperative adverse event classification was developed and piloted. Results: 176 cases from 48 credentialed surgeons were analysed. L-TMEpt inter-rater, test-retest and internal consistency reliabilities were established. Substantial variation in surgical performance were seen. Scores were strongly associated with the number of intraoperative errors, plane of mesorectal dissection and short-term patient morbidity. Upper quartile surgeons obtained excellent results compared with the lower quartile (mesorectal fascia 93% vs. 59%, NNT 2.9, p=0.002; 30-day morbidity 23% vs. 48%, NNT 4, p=0.043). Conclusions: Intraoperative QA using assessment tools can objectively and reliably measure complex cancer interventions. Laparoscopic TME surgical performance assessment showed substantial variation which is strongly associated with clinical outcomes holding implications for surgical trial design and interpretation.Open Acces

    In need of a hero? the creation and use of the legend of General George S. Patton, Jr.

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    During WWII, General George Patton became the hero Americans needed through the creation of a self-crafted brand and with help from journalists. After Patton’s death, opportunists forwarded a legend narrative that developed into a collective memory that morphed over time to meet contemporary challenges. Stakeholders of that collective memory commemorated and memorialized the dead hero for monetary and political gain, to promote patriotism, make military doctrinal changes, and even promote peace. Today, this collective memory has potential for the U.S. Army as it transforms civilians into soldiers and officers. This study contributes to history and memory studies by linking representations of an historical figure to targeted audiences, arguably, the first of its kind. As an interdisciplinary study utilizing empirical historical and qualitative sociological methods, it adds to extant literature for multiple disciplines by providing explanatory insight into the use of hero narratives by individuals undergoing a transformational process. The dissertation is divided into two parts. Using archival and material culture evidence, Part 1 discusses the creation and promulgation of the Patton collective memory and applicable theories and research on memory, ultimately relating it to the legacy of leader development and operational doctrine Patton left for the Army. Part 2 defines the Army as a subculture and introduces the importance of heroes in general. Evidence from in-depth individual interviews with 27 Reserve Officer Training Corps cadet volunteers from a single university in the spring of 2020 forms the basis for a proposed grounded theory, the Transformative Hero Model. The model is informed by several orienting theories including Affective Disposition Theory, Sense-making Theory, and Self-efficacy Theory. Cadets undergoing the Army’s transformational process used hero narratives to develop themselves and understand their place within an organizational subculture. Whom cadets found inspirational and how they connected to and used those narratives centered on their sense of self. They also used hero stories in their socialization process by adopting a shared heritage and internalizing value structures. Furthermore, they began to differentiate themselves from out-group members while simultaneously increasing identification with their subgroup. Organizations that use transformational processes may leverage hero narratives by using this model

    The Effect of Serratus Anterior Fatigue on Scapular Kinematics

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    Background: Shoulder pain is a common occurrence in the general population. Pain has been associated with shoulder impairments and pathology. Associations between shoulder limitations, impairments, and mechanisms of injury and altered scapular motion appear in the literature. Fatigue of the scapular stabilizing muscles resulting from repeated arm motion has been reported to alter scapular kinematics, which could result in shoulder pathology, especially impingement. Purpose: The purpose of this study was to examine the effects of fatigue of the serratus anterior muscle on scapular kinematics. The hypotheses were that there would be decreased posterior tilt and decreased upward rotation during arm elevation after selective fatigue of the serratus anterior. Methods: Thirty participants (20 females, 10 males) were included in the investigation. Scapular kinematics and shoulder strength were measured prior to and immediately following a serratus anterior fatigue protocol. A two factor (Fatigue x arm elevation angle) repeated measures ANOVA was used to determine the effects of serratus anterior fatigue on scapular kinematics. Results: There was no statistical significance in upward rotation of the scapula between pre- and post-fatigue conditions (ascending: p=0.188; descending: F p=0.798). Less scapular posterior tilt was found following the fatigue protocol between 60° - 90° and between 90° - 120° of arm elevation, during the ascent (p=0.004) and the descent (p=0.013). A statistical significance of fatigue by arm elevation angle was also found for clavicular elevation during the ascent (p=0.050) between 90° - 120° of arm elevation. A statistical significance of fatigue on internal rotation was found during the ascent (p=0.027). There was no statistical significance in clavicular protraction between pre- and post-fatigue conditions (ascending: F p=\u3c0.001; descending: F p=\u3c0.001). Conclusions and Practical Relevance: Fatigue of the serratus anterior resulted in decreased scapular posterior tilt, and greater clavicular elevation at higher arm elevation angles along with greater scapular internal rotation. These findings are consistent with the scapular kinematic patterns associated with shoulder pain. Improving the endurance of the serratus anterior might reduce the scapular kinematics associated with mechanism of injury for the shoulder complex

    Exploring Forecast Models for Day of Launch Winds

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    Castlereagh at the Congress of Vienna: Maintaining the Peace, Political Realism, and the Encirclement of France

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    At the Congress of Vienna from September 1814 to June 1815, Stewart, the second Marquees of Londonderry and Viscount Castlereagh, succeeded in encircling France with a cordon of strong states that could better resist the possibility of future French military aggression. He conceived these goals with an eye towards European balance of power, strategically resettling European borders and placating allies when necessary. He guarded against the advances of France and Russia through the strengthening of the Low Countries, resettlement of Norway from Denmark to Sweden, the restructuring of a more resilient Italian Peninsula, and the division of Poland and Saxony along the convoluted borders between Russia, Austria, and Prussia. Castlereagh, of course, held ideological leanings, but his principle purpose was neither the preservation of absolute monarchy or ancien regime, nor a more liberal sentiment for self-determination. His goal was to bring peace to Europe through strategic realism in the peacemaking process
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