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Australia is both affluent and highly vulnerable to anthropogenic climate change. Despite climate change loss and damage – impacts that cannot or will not be adapted to – science and policy focusing on the Global South, the IPCC recently showed Australia is already experiencing losses and damages. Australian governments and other actors centre building resilience to climate change. In this research I ask the question: How does the material manifestation of resilience discourse influence adaptation limits and vulnerability to climate change loss and damage in regional Australia? To answer this question, I identify examples of existing and emergent adaptation limits, historical-structural, intersectional, and psychosocial determinants of vulnerability, and explore the material manifestation of climate resilience governmentality. I demonstrate the ways in which material manifestations of resilience discourse interacts with and reproduces vulnerability to climate change loss and damage in regional Australia. I identify an overwhelming focus on physicalist interventions and subjects’ psychological dispositions instead of underlying vulnerability. These, among other, factors are contributing to the formation of unresilient subjects – subjects who are unable to cope and bounce forward from loss and damage. In the era of loss and damage, not even affluence will shield people from escalating losses.

With development displacing more people and planned relocation being espoused as an adaptation strategy in response to climate change, research that explores the experiences of those who have been resettled is needed. The Maldives has a history of resettlement based on an ongoing policy of consolidation of dispersed populations to ensure access to services. The paper explores the history, politics, and perceptions and experiences of Gaadhoo Islanders in the Maldives during their involuntary resettlement to Fonadhoo Island in January 2016. Through in-depth interviews and ethnographic fieldwork among the resettled, a range of subjective experiences is identified. Although only a small proportion of participants wanted to leave and the process was undemocratic and politically motivated, both positive and negative outcomes were identified. In line with existing research, greater access to services and employment were positive outcomes of the resettlement. However, the process led to non-tangible loss of identity, culture and community cohesion. It is suggested that transparency, consistency and open communication should be central to the process throughout, from pre-decision to the resettlement process itself, and during the compensation and post-resettlement stages. The lessons drawn from this case study may help mitigate potential negative impacts from resettlements which will likely continue and increase into the future.

Background Accidental awareness during general anaesthesia (AAGA) is a complex and rare outcome to investigate in surgical patient populations, particularly obstetric patients. We report the protocol of the Direct Reporting of Awareness in Maternity patients (DREAMY) study, illustrating how the research was designed to address practical and methodological challenges for investigating AAGA in an obstetric cohort. Methods This is the trial protocol of a prospective, multicentre cohort study of patients undergoing obstetric surgery under general anaesthesia. Accidental awareness during general anaesthesia will be detected using three repetitions of standardised direct questioning over 30 days, with responses indicating memories during general anaesthesia verified using structured interviews. Reports will be adjudicated, then classified, in accordance with pre-defined and pre-validated structures, including the Michigan Awareness Classification tool. Quantitative data will be collected on general anaesthesia conduct for all participants. This descriptive study is being conducted in England and aims to recruit a minimum of 2015 patients. Results The DREAMY study was prospectively registered (ClinicalTrials.gov Identifier: NCT03100396) and ethical approval granted. Participant recruitment began in May 2017 and one year follow up concluded in August 2019. Publication of the results is anticipated in 2020. Conclusions The DREAMY study will provide data on incidence, experience and implications of AAGA for obstetric patients, using a robust methodology that will reliably detect and translate subjective AAGA reports into objective outcomes. In addition, the study is expected to improve vigilance for AAGA in participating hospitals and encourage adoption of recommendations for support of patients experiencing AAGA.

The exposure of vulnerable food systems to hazards often leads to outcomes such as food insecurity. In order to prevent such food insecurity, it is critical to understand the causal factors – or root causes – of vulnerability, particularly in a world of increasing risk. As such, this paper develops and implements a food system causal disaster vulnerability framework within the Bedamuni tribe of Papua New Guinea. Although changing, Bedamuni livelihoods remain centred on subsistence swidden agriculture, hunting, and gathering. The framework developed here considers food systems as socioecological systems that through, for example, ecosystem use, provision, and social institutions should ideally provide food security along with other forms of social and cultural welfare. As detailed in the paper, disaster vulnerability is considered a function of exposure (temporal and spatial), susceptibility (as historical, socio-human, psychological, economic, environmental, physical, cultural, and governance dimensions), livelihood resilience (as knowledge, power and participation, capabilities, assets, and social capital) and absorptive, adapttive, and transformational capacities. The study is based on in-depth mixed methods fieldwork undertaken in 25 villages throughout the Bedamuni territory and incorporates established ethnographic approaches (e.g., participant observation, garden and disaster transect walks, and interviews) and a novel culturally appropriate approach (e.g., 31 “longhouse stories” lasting 1–3 h). The study reveals the main drivers of increasing vulnerability relate to historical, ecological, social, and psychological dimensions of susceptibility and declining adaptive capacity. The need for transformational change is suggested but is hindered by declining self-efficacy, inertia and a lack of knowledge of how to address factors such as population growth, declining land productivity, climate change, and increasing garden pests and diseases. Taken together with high exposure to El Nino droughts (e.g., 1971/2, 1982/3, 1997, 2015/16) and earthquakes (e.g., ~1950, 2018), disaster vulnerability is concerningly high and participants suggest is increasing. This paper is an empirically grounded argument for using causal approaches that look beyond outcomes to identify drivers of vulnerability in food systems. The framework and empirical evidence presented provides researchers, NGOs, and policy makers guidance and entry points for reducing vulnerability and increasing the resilience of marginalised Indigenous food systems in Papua New Guinea and potentially beyond.

Loss and damage is the “third pillar” of international climate governance alongside mitigation and adaptation. When mitigation and adaptation fail, losses and damages occur. Scholars have been reacting to international political discourse centred around governing actual or potential severe losses and damages from climate change. Large gaps exist in relation to understanding the underlying power dimensions, rationalities, knowledges, and technologies of loss and damage governance and science. We draw from a Foucauldian-inspired governmentality framework to argue there is an emerging governmentality of loss and damage. We find, among other things, that root causes of loss and damage are being obscured, Western knowledge and technocratic interventions are centred, and there are colonial presupposed subjectivities of Global South victims of climate change, which are being contested by people bearing the brunt of the climate crisis. We propose future directions for critical research on climate change loss and damage.

Emergency food aid is the dominant humanitarian response to food insecurity precipitated by disasters. There is a significant literature on food aid effectiveness (e.g., bolstering food security, targeting, modality selection) in various disaster contexts. Additionally, there are some studies on the potential disincentive effects on agricultural production among other unintended consequences. However, there has been no explicit research on the possible effects of emergency food aid on the causal disaster vulnerability of Indigenous food systems. This research, based within the remote Bedamuni tribe of Western Province, Papua New Guinea, addresses this gap. The Bedamuni first received emergency food aid in response to the 1997 El Nino drought, followed by the 2015/16 El Nino and February 2018 Highlands earthquake. We identify first sustained contact (1962), the subsequent establishment of a mission (1968), and the societal changes that followed as more pronounced drivers of vulnerability. However, emergency food aid exacerbates several key determinants of vulnerability such as declining self-efficacy and adaptive capacity, in addition to encouraging unsustainable food system practices. This paper argues for a more holistic understanding of causal vulnerability in food systems and renewed critique regarding the use of emergency food aid in rural Indigenous contexts.

Pacific Island countries are already experiencing severe impacts from climate change and these will likely increase in the future. In response, a plethora of climate change adaptation projects have been implemented across the region with the aim of assisting those most affected. Yet these projects have largely failed to reduce vulnerability to climate change in a meaningful way. This chapter addresses a commonly overlooked, but argued here to be crucial, reason for failure: how religion shapes local perspectives of climate change, and the lack of acknowledgement with these by external actors. We address this gap through exploring the changing ontological and epistemological understandings of climate change and hazards among two distinct cultural groups from the Pacific Islands—the Bedamuni of Western Province, Papua New Guinea and the I-Kiribati. To structure our diachronic investigation, we explore the drivers of socio-cultural change across three periods: pre-contact, colonial and missionary, and contemporary. A complex story of interaction with exogenous ideas and syncretism is portrayed within both societies. Yet today we find the Bedamuni continuing to draw heavily from traditional belief systems, especially the presence and influence of spirits, to explain hazards while simultaneously being devout Christians. Despite noting changes in weather and seasonality, Bedamuni people have had little exposure to global climate change discourses. Conversely, the I-Kiribati, as the occupants of one of the countries most exposed to climate change, have had relatively high exposure to scientific climate change discourses. Notwithstanding this, I-Kiribati mostly draw from Christian beliefs to explain natural phenomena while maintaining traditional beliefs in gods, spirits and magic. Like others in the Pacific, these cultures have unique histories, ontologies and epistemologies so, for climate change adaptation to be successful in the region, governments, agencies, and NGOs must acknowledge that no two places are alike and that understanding recipients’ ontological worldviews and accommodating these into adaptation strategies is an essential starting point for the development of effective future strategies.

Disasters are the result of a vulnerable socioecological system interacting with a hazard. Causal – or the root causes of – vulnerability relates to historical and contemporary social, economic, political, cultural, and biophysical processes and factors, and human and institutional actors that increase the susceptibility of socioecological systems. Indigenous cultures throughout Papua New Guinea survived and flourished over millennia despite recurrent exposure to hazards such as El Nino-caused droughts and frosts, earthquakes, and flooding, which indicates high resilience. However, over the last century these same hazards are leading to reports of widespread hunger and the distribution of emergency food aid. The distribution of emergency food aid feeds into an existing narrative that Indigenous cultures’ food systems are, and have always been, vulnerable to disasters. However, the survival of these cultures over thousands of years suggests otherwise. It is therefore critical to explore whether the causal disaster vulnerability of Indigenous food systems is increasing over time and what processes and factors are, or are not, driving this vulnerability.In addition to identifying the wider historical and contemporary drivers of disaster vulnerability, this thesis aims to explore how emergency food aid influences the causal disaster vulnerability of Indigenous food systems. This is achieved through a case study of the extremely remote Bedamuni of Western Province, Papua New Guinea. Fieldwork took place over three months in mid-2018 within 25 Bedamuni villages. I used a variety of established (e.g., ethnographic observation and notetaking, interviews) and novel (e.g., 31 ‘longhouse stories’ lasting 1-3h) qualitative data gathering methods with the assistance of local research assistants. Despite limited interaction with colonial government patrols in the 1940s and 1950s, first sustained contact with the Australian Territory of Papua and New Guinea occurred in 1962. As such, many elders who were young men and women at first contact contributed to this research. Emergency food aid was first distributed after the 1997 El Nino and has been distributed after two major events since then. This case study provides an opportunity to empirically explore the influences of colonisation, missionisation, capitalism, and emergency food aid on the causal disaster vulnerability of the Bedamuni food system.The thesis first develops and justifies the core concepts utilised throughout. This includes conceptualising food systems as a form of socioecological system, developing a framework to understand the causal disaster vulnerability of Indigenous food systems, and demonstrating how emergency food aid can be considered as a potential driver of vulnerability. Drivers, including but beyond emergency food aid, are taken to be any exogenous or endogenous processes which intentionally or unintentionally durably alter food system activities and outcomes. Before turning to the Bedamuni case study, the multidisciplinary literature is reviewed to identify the changing contours of vulnerability in remote Papua New Guinea food systems from pre-history through to the modern day. The drivers associated with, for example, prehistorical migrations and agricultural development, colonial ‘law and order’, Christianity, and capitalism are shown to be instrumental to understanding the contemporary disaster vulnerability of remote food systems.Drawing from the fieldwork explored in detail in Chapter 3, the thesis investigates changes to the Bedamuni food system from first Western contact to mid-2018. From this analysis I show there have been significant changes to population, land use and settlement patterns, agricultural practices, and political economy (e.g., social relations, power, property). Colonial contact and the establishment of an Evangelical mission in 1968 are found to be the major initial drivers of changes that continue to influence current sustainability and food security concerns.The thesis couples the socioecological conceptualisation of food systems with disaster vulnerability expressed as a function of exposure (temporal and spatial), susceptibility (as historical, socio-human, psychological, economic, environmental, physical, cultural, and governance dimensions), livelihood resilience (as knowledge, power and participation, capabilities, assets, and social capital), and absorptive, adaptive, and transformational capacities. By implementing this framework, it is demonstrated that the main drivers of vulnerability relate to historical, social, economic, environmental, and psychological dimensions of susceptibility and declining adaptive capacity. Taken together with high exposure to El Nino droughts (e.g., 1971/2, 1982/3, 1997, 2015/16) and earthquakes (e.g., 1954, 2018), disaster vulnerability is concerningly high and participants suggest is increasing. Therefore, some entry points to reduce vulnerability and increase resilience in Indigenous food systems are outlined. The development and empirical testing of a nomothetic framework was a major outcome of this thesis.Emergency food aid, while a lesser driver compared to, for example, colonisation and capitalist political economy, has nonetheless affected several key determinants of vulnerability. These include exacerbating already declining self-efficacy traced to colonial and missionary led narratives of helplessness and a transition away from Indigenous knowledge and practice. Additionally, through encouraging increasingly unsustainable food system practices, emergency food aid was also found to undermine the motivation for urgently needed incremental and transformational changes to address escalating disaster vulnerability. The identified socioecological consequences of emergency food aid lead me to argue for a renewed critique of its distribution in remote Indigenous contexts.Overall, the exploration of the causes and consequences of change in the Bedamuni food system showed that much contemporary vulnerability can be traced back to colonial and missionary contact. The framework developed and implemented to understand the causal disaster vulnerability of Indigenous food systems proved highly effective at looking beyond outcomes and identifying root causes of vulnerability, which are multi-scalar historical, social, economic, political, cultural, and biophysical processes and factors. The overarching finding was that emergency food aid, which is now universally expected among the Bedamuni, was found to be influencing and exacerbating the causal disaster vulnerability of the food system through further undermining their collective capacities and by encouraging a socioecological trajectory that is proving increasingly unsustainable.

Marginalised agrarian societies are suggested to be the most vulnerable to environmental hazards and other perturbations. There are competing explanations for this phenomenon, which include: a lack of development, global environmental change, and the development process itself, or capitalism more specifically. All three causal arguments are compelling, but typically offer only partial explanations. With most societies experiencing significant capitalist-driven agrarian change over the last few centuries (e.g., depeasantisation, dispossession, proletarianisation), the critical agrarian change literature is biased tou will see those people which youowards these studies. Here I explore one of the most marginalised societies in Papua New Guinea, the Bedamuni People of Western Province. After 60 years of Western contact, at the time of fieldwork (2018), they remained shifting horticulturalist who had not been disposed of their land, had no commodity production and very limited opportunities for paid work. By exploring agrarian change within Bedamuni society since first Western contact (1962) and the arrival of missionaries (1968), and employing the concept of critical junctures, I critically unpack some of the root causes of heightened socioecological vulnerability. In the Bedamuni case study, and likely in many other societies, it is not just lack of development, environmental change, or the development process itself, it is all these things, and more, concomitantly. With the resource and commodity frontier almost upon them, and many Bedamuni desiring it to come, it is critical to understand the root causes of growing hunger. I argue that the development approach being driven by powerful actors will not meaningfully address this crisis and, in fact, may exacerbate the processes and factors that have produced heightened socioecological vulnerability. This paper problematises essentialist, universal narratives about the drivers of vulnerability in marginalised Indigenous societies in the global South. Whilst universal explanations can be insightful, we must not forget the centrality and specificity of space and place in development research.

The societal costs of disasters around the world are continuing to increase and Pacific Island countries are considered some of the most vulnerable. This is primarily due to a combination of high hazard exposure coupled with a range of social, economic, physical, and political vulnerabilities. This article contributes to the growing body of work that aims to understand the causal factors of disaster vulnerability, but with a specific focus on small island developing states. The article first develops a framework for understanding disaster vulnerability, drawing on extensive literature and the well-established Methods for the Improvement of Vulnerability in Europe (MOVE) framework, and second, applies this adapted framework using empirically-derived data from fieldwork on Emae Island, Vanuatu to provide a working understanding of the causal elements of disaster vulnerability. Drawn from a significant body of scholarship at the time, the MOVE framework was primarily developed as a heuristic tool in which disaster vulnerability is considered to be a function of exposure, susceptibility (socially, economically, physically, culturally, environmentally, institutionally), and a lack of resilience. We posit that this adapted framework for small islands should also include historical susceptibility, and we prefer livelihood resilience (as capabilities, social capital, knowledge, participation, and human rights) over lack of resilience. We maintain that understanding disaster vulnerability holistically, which is inclusive of both strengths and drawbacks, is crucial to ensure that limited resources can target the causal factors that produce vulnerability and help safeguard and improve livelihoods in both the short and long term.

Anthropogenic climate change is leading to widespread losses around the world. While the focus of research over the last decade has largely been on economic or tangible losses, researchers have begun to shift their focus to understanding the non-economic or intangible dimensions of loss more deeply. Loss of life, biodiversity and social cohesion are some of the losses that are beginning to be explored, along with Indigenous and local knowledge (ILK) and cultural heritage. These latter two form the basis of this systematic review of 100 studies to take stock of what we know about climate-driven losses to ILK and cultural heritage, how such losses manifest and how they are overcome, revealing gaps in our knowledge and carving a path for future research.

Disasters are typically conceptualised as extreme events that disrupt the “normal” functioning of a society. Dominant framings imply temporal boundedness and nature as primarily responsible for environmental disasters. Yet, many critical investigations into the root causes of disasters have taken aim at their eventfulness and naturalness through convincing analysis of the historical construction of vulnerability. Relatively underexplored, however, is the examination of the lived experiences and perceptions of disaster temporalities, which are mediated through culture and institutions. This paper explores the perceptions of disaster temporalities within two Indigenous societies in the Southwest Pacific: the Bedamuni of Western Province, Papua New Guinea and Emae Island, Vanuatu. Additionally, disaster management actors’ perceptions are explored within Vanuatu. Based on two separate research projects utilising ethnographic methods to understand disaster vulnerability, the findings suggest different perceptions of disaster temporalities. The Bedamuni have historically normalised periods of food insecurity, and even though hazards are of great concern they were, and to some extent still are, considered a cyclical feature of life caused by spirits and human conjuration. They also tied major recent disasters to their eschatological beliefs, which pre-date introduced Christian teachings. Emae islanders, with far longer sustained contact with Western societies (including aid and development activities), appear to now experience and perceive large-scale disasters (e.g., cyclone Pam) as abnormal, natural, and discrete events that are tied to climate change. Both cultures understand many aspects of their disaster vulnerability but are more likely to focus on response, similar to disaster management actors in Vanuatu.

Background The utility and acceptability of preformed metal crowns (PMC) for management of carious primary molars has been established in the literature and published guidance. The role of dental hygienist and therapists (DHT) in the evolving team model in primary care has been recognised as requiring further investigation. The importance of patient and parental acceptance is acknowledged in recent healthcare research. Method This study focuses on patient and parent acceptance of preformed metal crowns placed by DHTs. Prescription format is investigated and the availability of bitewing radiographs considered. Reflective assignments at the end of training gave an indication of DHTs views on increased professional autonomy and the issue of direct access. Patient and parent satisfaction following placement of PMCs by DHT vocational trainees (DHTVT) were evaluated. Data was collected in two audit rounds from 2013 to 2014 using a ‘faces’ scale for children and a Likert scale for parents following placement of PMCs on carious primary molars. Results 133 PMCs were placed (110 children) by 10 DHTVTs over an eight-month period. Overall, radiographs were available for 10.5% of cases. The data showed high levels of patient and parent acceptance of the use of PMCs. Conclusions Low availability of radiographs may represent a missed diagnostic opportunity. PMC placement by DHTVTs resulted in high patient and parent satisfaction, comparable to other studies. Although caries has been declining over the last decade in Scotland,1 evidence shows that inequalities and a social gradient2,3 in experience of caries in children remain. There is a need for tools and strategies for the prevention, recognition, risk assessment, diagnosis, and management of caries in the primary dentition. These must be accessible, acceptable to children and their parents/carers, cost effective, affordable and applicable in the primary care general dental practice environment where most families are likely to be registered. The emerging theme of dentistry being provided in a team model with dental care professionals (DCPs) taking on an expanded role is under continuing review4 following the General Dental Council (GDC) announcements5,6 on ‘direct access’. The Scottish Dental Hygiene and Therapy Vocational Training (DHTVT) programme is a one-year, elective, post-qualification training programme for Dental Hygiene and Therapy graduates run by NHS Education for Scotland (NES). In 2013–2014, DHTVTs were employed across six Scottish health board areas in hospital, salaried and independent settings in urban and rural locations. The elements of the programme involve a blend of clinical mentoring, web-based learning, case presentations, critical reading, reflective assignments and face-to-face theoretical and practical teaching across a number of modules. The aim of this project was to collect data to indicate patient and parental response following the placement of PMCs, collect data on the use of radiographs in children having PMCs placed and to investigate the role of dental therapists in the dental team. The data, once collated, was presented to DHTVTs to inform reflection on the management of carious primary molars and to raise awareness of issues relating to cost effectiveness of providing treatment in a primary care environment and critically appraise perceived barriers to the use of PMCs in the treatment of carious primary molars. Collated data has been presented to trainers in future cohorts to inform discussion amongst the group of trainers at induction days around dental team working, effective detection, diagnosis, risk assessment and prescription to DHTs.

PURPOSE: Emerging data indicate a colonoscopist-controlled method is needed to avoid missing proximal colon pre-malignant lesions. Screening colonoscopy does not prevent all proximal colon cancers. Even diminutive lesions in the proximal colon harbor dysplasia. In addition to adenomas (presumptive cancer precursors), recent proposals to reevaluate proximal colon hyperplastic polyps as serrated polyps which could be pre-malignant or harbingers of interval neoplasia dramatize the importance of attending to these lesions. The finding that the water method increased yield of proximal diminutive adenomas prompted assessment of the hypothesis that the water method increases yield of all proximal diminutive lesions (adenoma and hyperplastic polyp) in screening cases. METHODS: Two RCT assessed the water method with primary outcome of completion of unsedated colonoscopy when the option of scheduled, unsedated or sedation on demand was used. Diminutive (

Summary Consent is relevant to all areas of anaesthetic practice, but labour ward presents one environment where consent can be particularly problematic. This article investigates issues surrounding the timing, content and delivery of information prior to anaesthetic procedures as well as the capacity to consent in labour and the emergency setting.

Background Intermittent warm-water infusion in lieu of air insufflation permitted 52% of patients who accepted sedation on demand to complete colonoscopy without sedation. Objective To test the hypothesis that the water method enhances cecal intubation and increases the proportion of patients who report willingness to repeat a scheduled unsedated colonoscopy. Design Observational study. Patients Two consecutive groups of veterans. Interventions From June 2005 to May 2006, the usual air insufflation method was used to aid colonoscope insertion. From June 2006 to October 2007, the water method was used. Main Outcome Measurements Cecal intubation; report of willingness to repeat unsedated colonoscopy. Results Sixty-two and 63 veterans were examined by the air method and the water method, respectively. Intention-to-treat analysis revealed that the cecal intubation rate with the water method (97% [61/63]) was significantly higher than that with the air method (76% [47/62]). The proportion of patients who reported willingness to repeat unsedated colonoscopy was significantly higher with the water method (90% [57/63]) compared with the air method (69% [43/62]). Limitations Single site, nonrandomized, unblinded, small number of elderly male veterans. Conclusion The effects of the water method in the group for scheduled unsedated colonoscopy were sufficiently provocative to warrant calling for their confirmation by a randomized controlled trial.

Summary Cancer surgery can be complex and there is an associated risk of major haemorrhage. Haemorrhage during cancer surgery may result from vascular injury, cancer-related alterations to haemostasis or both and is frequently complicated by coagulopathy. In the last few years, our knowledge of normal haemostasis has evolved and ‘cell-based model of coagulation’ has been widely accepted. Optimal management of massive haemorrhage requires a good understanding of this model in order to facilitate administration of appropriate blood products and pharmacological alternatives. Successful outcome depends on good anaesthetic and surgical techniques, excellent communication (particularly with transfusion medicine colleagues) and appropriate postoperative intensive care management. In this article, the relevant issues regarding haemostatic resuscitation related to haemorrhage during major cancer surgery are discussed.

Turning from enunciation of sustainability to implementation, this paper focuses on the Local Agenda 21 (LA 21) policy envelope, emanating from the 1992 Rio Earth Summit. Agenda 21 challenges local authorities to adopt policy goals encompassing not only sustainable development but also to incorporate participative, collaborative processes, which involve local communities in defining their own sustainable futures. This can and should include tourism development as a significant environmental, economic and social agent. The impacts LA21 is having on tourism are assessed, using the UK as a case example, but with wider relevance. The paper evidences that while sustainable development in tourism practice is emerging, this remains largely outside the LA21 process, the significance of which and the relevance to tourism has been slow to be recognised. More attention to LA21's relevance to tourism is advocated and quintessentially sustainable forms of tourism development, such as cycle tourism initiatives, are use...

Objectives. This study was conducted to identify the determinants of Successful nonthoractomy cardioverter-defibrillator implantation.Background. Until recently, either sternotomy or thoracotomy was necessary to Implant the electrodes used for internal cardioverter-defibrillator systems. A number of manufactures have developed nonthoracotomy lead Systems comprising two transvenous coil electrodes and a subcutaneous patch electrode. At present, the factors associated with the success or feilure of a nonthoracotomy approach are unknown.Methods. A total of 101 consecutive patients requiring a cadioverter-defibrillator underwent an initial nonthoracotomy approach. Factors associated with successful nonthoracotomy implantation were prospectively determined.Results. A nonthoracotomy system was implanted in 72 (71%) of 101 patients. Twenty-nine patients (29%) required thoracotomy. Univariate of successful nonthoracotomy implantation included smaller cardiac size (p < 0.0001), smaller cardiothoracic ratio (p < 0.0002), QRS duration

Background An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy. Objective To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). Design Prospective RCT, intent-to-treat analysis. Setting Veterans Affairs ambulatory care facility. Patients Veterans undergoing scheduled unsedated colonoscopy. Interventions During insertion, the water and traditional air methods were compared. Main Outcome Measurements Discomfort and procedure-related outcomes. Results Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method ( P P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort ( t = −1.998, P = .049, R 2 = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. Limitations Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. Conclusions The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies.A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy.From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 well purged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications.This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a "sedation risk-free" procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers' willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.

Amongst the laudable aspirations of the Rio Earth Summit in 1992, the challenge of Local Agenda 21 (LA21) required local government globally to find ways of framing policy goals which would incorporate the central tenets of sustainable development and would also draw communities into a participative, collaborative policy making process. In assessing the extent to which we have realised these objectives, it is clear that tangible evidence is required that sustainable tourism as a policy goal can be translated into implementable policies, which will transform conceptually robust and well-rehearsed theory into action. More specific questions in the current context are whether LA21 is being adopted as such a policy mechanism, and to what extent it is impacting on tourism and generating community involvement.

Submammary pacemaker implantation offers women a cosmetically acceptable alternative to the standard pectoral implant. We present a novel method of submammary implantation performed on ten women aged 13-54 years. The lead electrodes are tunneled from the infraclavicular to the inframammary incision using a long needle, guidewire, and introducers/dilators in a manner analogous to the retained guidewire technique used for standard lead insertion. The procedure can generally be performed under local anesthesia. All patients tolerated the procedure well without acute complications. Over 2- to 23-month follow-up, there were no lead dislodgments. No patients developed mastitis or incisional complications, and all have been extremely satisfied with the cosmetic results. With proper technique, submammary pacemaker implantation can be performed under local anesthesia with minimal patient discomfort and optimal cosmesis.