The social, psychological, emotional morbidity and adjustment techniques for women with anal incontinence following Obstetric Anal Sphincter Injury: use of a word picture to identify a hidden syndrome

BACKGROUND: To identify the emotional, social and psychological consequences and recovery process of anal incontinence (AI) following obstetric anal sphincter injuries (OASIS) and explore if this can be identified as a recognisable syndrome with visual representation. METHODS: A qualitative approach was adopted for this study. Data derived from case studies (n = 81) and interviews (n = 14) with women with AI after OASIS was used to identify the emotional, social and psychological consequences of AI after OASIS. Keywords and synonyms were extracted and the power of these statements displayed as a ‘word picture’. The validity and authenticity of the word picture was then assessed by: a questionnaire sent to a group of mothers who had experienced this condition (n = 16); a focus group attended by mothers (n = 14) and supported by health professionals (n = 6) and via interviews with health professionals (n = 12) who were involved with helping mothers with AI following OASIS. RESULTS: Women with AI resulting from OASIS have a specific syndrome – the ‘OASIS Syndrome’ - which we have uniquely visualised as a ‘word picture’. They feel unclean which results in dignity loss, psychosexual morbidity, isolation, embarrassment, guilt, fear, grief, feeling low, anxiety, loss of confidence, a feeling of having been mutilated and a compromised role as a mother. Coping relies on repetitive washing (which may become a ritual), planning daily activities around toiletry needs, sharing, family support, employment if possible and attention to the baby. Recovery and healing is through care of the child and hope generated by love within the family. CONCLUSIONS: This study has identified a previously unrecognised ‘OASIS Syndrome’ and, by way of a new and unique ‘word picture’, revealed a hidden condition. There should be greater awareness by the public and profession about the ‘OASIS Syndrome’ and a mechanism for early identification of the condition and referral for management. This, if successful, would overcome the barrier of silence which surrounds this currently unspoken taboo

Security Scenario Generator (SecGen): A Framework for Generating Randomly Vulnerable Rich-scenario VMs for Learning Computer Security and Hosting CTF Events

Computer security students benefit from hands-on experience applying security tools and techniques to attack and defend vulnerable systems. Virtual machines (VMs) provide an effective way of sharing targets for hacking. However, developing these hacking challenges is time consuming, and once created, essentially static. That is, once the challenge has been "solved" there is no remaining challenge for the student, and if the challenge is created for a competition or assessment, the challenge cannot be reused without risking plagiarism, and collusion. Security Scenario Generator (SecGen) can build complex VMs based on randomised scenarios, with a number of diverse use-cases, including: building networks of VMs with randomised services and in-thewild vulnerabilities and with themed content, which can form the basis of penetration testing activities; VMs for educational lab use; and VMs with randomised CTF challenges. SecGen has a modular architecture which can dynamically generate challenges by nesting modules, and a hints generation system, which is designed to provide scaffolding for novice security students to make progress on complex challenges. SecGen has been used for teaching at universities, and hosting a recent UK-wide CTF event

Lithology and Internal Structure of the San Andreas Fault at Depth Based on Characterization of Phase 3 Whole-rock Core in the San Andreas Fault Observatory at Depth (SAFOD) Borehole

We characterize the lithology and structure of the spot core obtained in 2007 during Phase 3 drilling of the San Andreas Fault Observatory at Depth (SAFOD) in order to determine the composition, structure, and deformation processes of the fault zone at 3 km depth where creep and microseismicity occur. A total of approximately 41 m of spot core was taken from three separate sections of the borehole; the core samples consist of fractured arkosic sandstones and shale west of the SAF zone (Pacific Plate) and sheared fine-grained sedimentary rocks, ultrafine black fault-related rocks, and phyllosilicate-rich fault gouge within the fault zone (North American Plate). The fault zone at SAFOD consists of a broad zone of variably damaged rock containing localized zones of highly concentrated shear that often juxtapose distinct protoliths. Two zones of serpentinite-bearing clay gouge, each meters-thick, occur at the two locations of aseismic creep identified in the borehole on the basis of casing deformation. The gouge primarily is comprised of Mg-rich clays, serpentinite (lizardite ± chrysotile) with notable increases in magnetite, and Ni-Cr-oxides/hydroxides relative to the surrounding host rock. The rocks surrounding the two creeping gouge zones display a range of deformation including fractured protolith, block-in-matrix, and foliated cataclasite structure. The blocks and clasts predominately consist of sandstone and siltstone embedded in a clay-rich matrix that displays a penetrative scaly fabric. Mineral alteration, veins and fracture-surface coatings are present throughout the core, and reflect a long history of syn-deformation, fluid-rock reaction that contributes to the low-strength and creep in the meters-thick gouge zones

One Health Determinants of Escherichia coli Antimicrobial Resistance in Humans in the Community:An Umbrella Review

To date, the scientific literature on health variables for Escherichia coli antimicrobial resistance (AMR) has been investigated throughout several systematic reviews, often with a focus on only one aspect of the One Health variables: human, animal, or environment. The aim of this umbrella review is to conduct a systematic synthesis of existing evidence on Escherichia coli AMR in humans in the community from a One Health perspective. PubMed, EMBASE, and CINAHL were searched on “antibiotic resistance” and “systematic review” from inception until 25 March 2022 (PROSPERO: CRD42022316431). The methodological quality was assessed, and the importance of identified variables was tabulated across all included reviews. Twenty-three reviews were included in this study, covering 860 primary studies. All reviews were of (critically) low quality. Most reviews focused on humans (20), 3 on animals, and 1 on both human and environmental variables. Antibiotic use, urinary tract infections, diabetes, and international travel were identified as the most important human variables. Poultry farms and swimming in freshwater were identified as potential sources for AMR transmission from the animal and environmental perspectives. This umbrella review highlights a gap in high-quality literature investigating the time between variable exposure, AMR testing, and animal and environmental AMR variables.</p

A series of three cases of severe Clostridium difficile infection in Australia associated with a binary toxin producing clade 2 ribotype 251 strain

Three patients with severe Clostridium difficile infection (CDI) caused by an unusual strain of C. difficile, PCR ribotype (RT) 251, were identified in New South Wales, Australia. All cases presented with severe diarrhoea, two had multiple recurrences and one died following a colectomy. C. difficile RT251 strains were isolated by toxigenic culture. Genetic characterisation was performed using techniques including toxin gene profiling, PCR ribotyping, whole genome sequencing (WGS), in-silico multi-locus-sequence-typing (MLST) and core-genome single nucleotide variant (SNV) analyses. Antimicrobial susceptibility was determined using an agar incorporation method. In vitro toxin production was confirmed by Vero cell cytotoxicity assay and pathogenicity was assessed in a murine model of CDI. All RT251 isolates contained toxin A (tcdA), toxin B (tcdB) and binary toxin (cdtA and cdtB) genes. Core-genome analyses revealed the RT251 strains were clonal, with 0–5 SNVs between isolates. WGS and MLST clustered RT251 in the same evolutionary clade (clade 2) as RT027. Despite comparatively lower levels of in vitro toxin production, in the murine model RT251 infection resembled RT027 infection. Mice showed marked weight loss, severe disease within 48 h post-infection and death. All isolates were susceptible to metronidazole and vancomycin. Our observations suggest C. difficile RT251 causes severe disease and emphasise the importance of ongoing surveillance for new and emerging strains of C. difficile with enhanced virulence

A one-stop perineal clinic: our eleven-year experience.

INTRODUCTION AND HYPOTHESIS: The perineal clinic is a dedicated setting offering assessment for various childbirth-related presentations including obstetric anal sphincter injuries (OASIs), perineal wound complications, pelvic floor dysfunction and other conditions such as female genital mutilation(FGM). We describe the clinical presentation and outcomes of women from a tertiary perineal clinic based on data collected over an 11-year period. METHODS: This is a retrospective observational study. A one-stop outpatient service was offered to all women who sustained OASIs (postnatally and antenatally in a subsequent pregnancy), perineal complications (within 16 weeks postpartum), FGM and/or peripartum symptoms of urinary/anal incontinence or prolapse. Assessment included history with validated questionnaires, examination and anal manometry and endoanal ultrasound when appropriate. Outcomes were compared among different grades of OASIs. Management of each type of presentation was reported with outcomes. RESULTS: There were 3254 first attendance episodes between 2006 and 2016. The majority (58.1%) were for OASIs, followed by perineal wound complications. Compared to the lower grades, the higher grades of OASI were associated with poorer outcomes in terms of symptoms, investigations and complications. Women with OASIs had unrelated symptoms such as urinary incontinence, perineal pain and wound infections that needed further intervention. A high proportion(42%) of wound complications required further specialist management. CONCLUSION: We describe a dedicated, one-stop perineal clinic model for antenatal and postnatal women for management of perineal and pelvic floor disorders. This comprehensive and novel data will enable clinicians to better counsel women regarding of outcomes after OASI and focus training to minimize risks of morbidities

High tie versus low tie of the inferior mesenteric artery: a protocol for a systematic review

In anterior resection of rectum, the section level of inferior mesenteric artery is still subject of controversy between the advocates of high and low tie. The low tie is the division and ligation to the branching of the left colic artery and the high tie is the division and ligation at its origin at the aorta. We intend to assess current scientific evidence in literature and to establish the differences comparing technique, anatomy and physiology. The aim of this protocol is to achieve a meta-analysis that tests safety and feasibility of the two procedures with several types of outcome measures

Comedy in Unfunny Times: News Parody and Carnival after 9/11

Comedy has a special role in helping societies manage crisis moments, and the U.S. media paid considerable attention to the proper role of comedy in public culture after the 9/11 tragedies. As has been well documented, many popular U.S. comic voices were paralyzed in trying to respond to 9/11 or disciplined by audiences when they did. Starting with these obstacles in mind, this essay analyzes early comic responses to 9/11, and particularly those of the print and online news parody The Onion, as an example of how “fake” news discourse could surmount the rhetorical chill that fell over public culture after the tragedies. By exposing the news as “mere” production and by setting an agenda for learning about Islamic culture and Middle East politics, The Onion avoided violating decorum and invited citizen participation. This kind of meta-discourse was crucial after 9/11, when shifting rules for decorum created controversy and as official voices in government and media honed frames and narratives for talking about the attacks

Management of obstetric anal sphincter injury: a systematic review & national practice survey

BACKGROUND: We aim to establish the evidence base for the recognition and management of obstetric anal sphincter injury (OASI) and to compare this with current practice amongst UK obstetricians and coloproctologists. METHODS: A systematic review of the literature and a postal questionnaire survey of consultant obstetricians, trainee obstetricians and consultant coloproctologists was carried out. RESULTS: We found a wide variation in experience of repairing acute anal sphincter injury. The group with largest experience were consultant obstetricians (46.5% undertaking ≥ 5 repairs/year), whilst only 10% of responding colorectal surgeons had similar levels of experience (p < 0.001). There was extensive misunderstanding in terms of the definition of obstetric anal sphincter injuries. Overall, trainees had a greater knowledge of the correct classification (p < 0.01). Observational studies suggest that a new 'overlap' repair using PDS sutures with antibiotic cover gives better functional results. However, our literature search found only one randomised controlled trial (RCT) on the technique of repair of OASI, which showed no difference in incidence of anal incontinence at three months. Despite this, there was a wide variation in practice, with 337(50%) consultants, 82 (55%) trainees and 80 (89%) coloproctologists already using the 'overlap' method for repair of a torn EAS (p < 0.001). Although over 50% of colorectal surgeons would undertake long-term follow-up of their patients, this was the practice of less than 10% of obstetricians (p < 0.001). Whilst over 70% of coloproctologists would recommend an elective caesarean section in a subsequent pregnancy, only 22% of obstetric consultants and 14% of trainees (p < 0.001). CONCLUSION: An agreed classification of OASI, development of national guidelines, formalised training, multidisciplinary management and further definitive research is strongly recommended