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From their experience in the National Science Teachers Association's Project for an Energy-Enriched Curriculum, the authors discuss short-range and long-range energy problems and the multidisciplinary responses that education must make to these problems. Energy/environment/economics topics should be infused into the curriculum and vocational students prepared for environmental conservation careers. (MF)

Summary Introduction Over the past 25 years, Pediatric Urology fellowship programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) have more than doubled. This increase may lead to a significant decrease in the number of operative cases per surgeon and therefore impact the current practice of pediatric urology. Objective The objective in conducting this study is to try and predict the effect of the current number of pediatric urology fellowship training positions on future case volume per surgeon using a mathematical model and to discuss future management of the pediatric urology workforce. Design The current study employed a mathematical model to predict the effect of the number of fellowship graduates on future “case volume per surgeon”. We incorporated population growth rates, to calculate incidence rates of key procedures/conditions and the anticipated retirement rate of the current pool of pediatric urologists to help calculate this. Results There is a possibility to increase the number of practicing board-certified pediatric urologists in the next 30 years from approximately 325 to 900 (figure). There will be a twofold reduction in case volume per surgeon compared to the present in model 1. In model 2 the decrease in case volumes is less significant. The annual number of fellows needed to obtain a future-to-current ratio equal to 1 is 16 for model 1, and 26 for model 2. Discussion Our study demonstrates, by using two different models that the current number of pediatric urology fellowship training positions in the United States will ultimately lead to a significant decrease in the case volume per surgeons. Our model has limitations as it relies on multiple assumptions. We are assuming that all fellowship positions would be filled every year and that all fellows would graduate, establish their practices in the United States, and devote 100% of their assumed 30-year professional career to pediatric urology. We also made assumptions of disease occurrence and need for surgical correction. The final assumption we made was that the birth rate would stay static over the next 30 years even though it has been declining for many decades. Conclusion This exercise, even with its inherent limitations, is still sufficient to demonstrate that fellowship expansion warrants thoughtful discussion. Figure The projected changes in pediatric urology manpower, eventually leading to a steady-state of 900 pediatric urologists in 30 years, a point where the number of retiring pediatric urologists will be replaced by an equivalent number of fellowship graduates on an annual basis. [ABSTRACT FROM AUTHOR]

The complete primary repair of bladder exstrophy (CPRE) aims to restore normal anatomy through complete mobilization and reapproximation of the bladder neck and proximal urethra. The Peña stimulator has previously been used to identify musculature in the pelvis. The device is now used to distinguish intersymphyseal bands from pelvic floor and urethral sphincteric musculature during CPRE. The ability to distinguish the levator ani muscles from fibrotic bands assists the surgeon in identifying the appropriate extent of deep pelvic dissection during CPRE. During the anatomic bladder neck recreation, the muscle stimulator demonstrated the striated muscle at the level of the bladder neck and urethral sphincter. Localization of the muscles at the bladder neck and proximal urethra corroborates the concept that pelvic floor physical therapy could enhance the strength of the pelvic floor in children with bladder exstrophy. [ABSTRACT FROM AUTHOR]

The P.A.D.U.A. technique is a method of addressing congenital urethral narrowing. It involves passive dilation with a series of progressively larger indwelling catheters. Utilization is limited by scant literature, particularly regarding technical details and long-term durability. Tools for achieving safe and reliable urinary drainage are critical in these patients, who require careful stewardship of their kidney and bladder function. To describe long-term urethral patency and urinary function following P.A.D.U.A., and to provide sufficient technical detail to reproduce the technique. Patients with congenital urethral narrowing managed with P.A.D.U.A. were identified and chart review was performed. Details of catheter exchange sequences were compiled and described. The primary outcome was the attainment of adequate urethral caliber by successful completion of P.A.D.U.A., and the secondary outcome was voiding per urethra at most recent follow-up. P.A.D.U.A. achieved adequate urethral caliber in 9/11 (82%) of patients. This included seven patients with Prune Belly Syndrome, one with isolated urethral atresia, and one with a cloacal anomaly. P.A.D.U.A. failed to achieve urethral patency in one patient with urethral duplication, who was unable to progress through the catheter sequence, and one patient with Prune Belly Syndrome, who completed P.A.D.U.A. but developed recurrent narrowing one week later. There were no delayed failures of urethral patency. Patients who achieved patency underwent a median of seven catheter placements over 92 days. Median (range) initial and final catheter sizes were 3.5F (1.9–8F) and 14F (8–16F). While 82% achieved patency, only 3/11 (27%) were voiding spontaneously per native urethra at most recent follow-up. This series of patients undergoing P.A.D.U.A. for primary treatment of congenital urethral narrowing is the largest to date and provides granular technical details. It aligns with prior reports suggesting that P.A.D.U.A. achieves urethral patency in most patients with Prune Belly Syndrome or isolated urethral atresia, but has limited application in the hypoplastic duplicated urethra. Despite high rates of urethral patency in this select population, many patients will not achieve and maintain spontaneous voiding without catheterization. This is likely due to ongoing deterioration of bladder function caused by the prenatal developmental insult, paralleling the phenomenon seen in posterior urethral valves. P.A.D.U.A. is an effective and durable technique for achieving urethral patency. However, due to complicating factors such as the underlying bladder pathology present in many patients, urethral patency achieved with P.A.D.U.A. does not guarantee long-term safe and reliable spontaneous emptying per urethra. [Display omitted] [ABSTRACT FROM AUTHOR]

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Foliar pathogens such as Zymoseptoria tritici and Puccinia striiformis causing septoria leaf blotch and yellow rust respectively can cause serious yield reduction in winter wheat production, and control of the diseases often requires several fungicide applications during the growing season. Control is typically carried out using a constant fungicide dose in the entire field although there may be large differences in crop development and biomass across the field. The objective of the study reported in this paper was to test whether the fungicide dose response curve controlling septoria leaf blotch and other foliar diseases in winter wheat was dependent on crop development and biomass level. If such a biomass dependent dose response was found it was further the purpose to evaluate the potential to optimize fungicide inputs in winter wheat crops applying a site-specific crop density dependent fungicide dose. The study was carried out investigating fungicide dose response controlling foliar diseases in winter wheat at three biomass densities obtained growing the crop at three nitrogen levels and using variable seed rates. Further the field experiments included three fungicide dose rates at each biomass level, an untreated control, and 75%, 50% and 33% of the recommended fungicide dose rate and the experiments were replicated for three years. Crop biomass had a significant influence on occurrence of septoria and yellow rust with greater disease severity at increasing crop biomass. In two of three years, the interaction of crop biomass and fungicide dose rate had a significant influence on disease severity indicating a biomass-dependent dose response. The interaction occurred in the two years with high yield potential in combination with severe disease attack. If the variation in crop density and biomass level obtained in the study is representative of the variation found cultivating winter wheat in heterogeneous fields, then there seems to be scope for optimizing fungicide input against foliar diseases site-specific adapting the dose according to crop density/biomass. [ABSTRACT FROM AUTHOR]

Introduction: The recovery model has influenced mental health services and fostered new standards for best practice. However, knowledge about how mental health care professionals (HCPs) experience recovery-oriented programs is sparse. Aim/Question: This paper explores HCPs' experiences when facilitating a recovery-oriented rehabilitation program. The research question is how do HCPs experience a change in their attitude and practice when applying recovery-oriented programs? Methods: This paper draws on semi-structured in-depth qualitative interviews conducted with 16 HCPs experienced in facilitating a recovery-oriented rehabilitation program in either the USA or Denmark. Results: Three themes emerged from the HCPs' reflections on changes in attitudes and practices: "Hopeful Attitude" captures a change in the HCPs' attitude toward a more positive view on the future for clients' living with mental illness; "A New Focus in the Dialogue With Clients" thematizes how the HCPs focus more on the individual's own goal for recovery rather than disease-induced goals in the dialog with clients; "A Person-Centered Role" comprises a shift in the professional role whereby the HCPs value the client's own ideas in addition to the professional's standards. Conclusion: This study supports the theory of the recovery model by its empirical findings and indications that when facilitating a recovery-oriented program, HCPs experience recovery-oriented changes in their attitude toward life with mental illness, and it alters their professional practice toward a stronger focus on client's own goals during treatment. More studies are needed to further clarify how changes in HCPs' attitudes translate into changes in mental health practices. [ABSTRACT FROM AUTHOR]

Purpose For bladder exstrophy repair it is universally accepted that successful initial surgery is paramount to achieve the optimal outcome. Gaining the necessary surgical experience is challenging due to the rarity of bladder exstrophy. We report preliminary findings of a multi-institutional collaboration created to increase experience and proficiency with the care of bladder exstrophy. Materials and Methods Our 3 institutions alternatively served as the host site for scheduled surgeries with observation, commentary and critique by visitors from the other sites. The technique was complete primary repair with bilateral iliac osteotomy. The timing of complete primary repair at age 1 to 3 months facilitated collaboration. We recorded patient demographics and outcomes, and the impact of this collaboration on our technique and experience. Video recording was used for real-time observation and teaching, and future analysis, editing and review. Results A total of 16 site visits occurred from February 2013 through May 2014. Complete primary repair was performed in 9 males and 7 females with bladder exstrophy. Median age at complete primary repair was 2 months (range 0.1 to 28.8). Median followup was 8.9 months (range 2.8 to 18.2). All closures were successful with no dehiscence. Complications included urethrocutaneous fistula in 2 patients, 1 episode of pyelonephritis in 3 each and urethral obstruction in 2 females, of whom 1 required clean intermittent catheterization. Conclusions We report a multi-institutional collaboration to standardize the surgical management of bladder exstrophy. This effort increased the annual experience of each institution involved from threefold to ninefold and it has accelerated the physician knowledge base to ultimately benefit patient care. [ABSTRACT FROM AUTHOR]

Classic bladder exstrophy in the female results in an exstrophic bladder and urethra, an anterior introitus with a bifid clitoris and short labia minora. During closure, the lower abdominal wall is closed and the bifid clitori are brought into close apposition, but are often not completely closed to prevent injury to the clitoral bodies, thus leaving a persistent gap between the clitoral bodies that grows over time. We demonstrate a vertical z plasty closure to provide a 2 layer closure of the mons that decreases tension and improves cosmetic appearance by recreating a clitoral hood that provides a more normal appearance of the external genitalia for girls with bladder exstrophy. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) during pregnancy is an effective and safe way to improve maternal health in uncomplicated pregnancies. However, compliance with PA recommendations remains low among pregnant women. Objective: The purpose of this study was to evaluate the effects of offering structured supervised exercise training (EXE) or motivational counseling on PA (MOT) during pregnancy on moderate-to-vigorous intensity physical activity (MVPA) level. Additionally, complementary measures of PA using the Pregnancy Physical Activity Questionnaire (PPAQ) and gold standard doubly labeled water (DLW) technique were investigated. The hypotheses were that both EXE and MOT would increase MVPA in pregnancy compared with standard care (CON) and that EXE would be more effective than MOT. In addition, the association between MVPA and the number of sessions attended was explored. Methods: A randomized controlled trial included 220 healthy, inactive pregnant women with a median gestational age of 12.9 (IQR 9.4-13.9) weeks. A total of 219 women were randomized to CON (45/219), EXE (87/219), or MOT (87/219). The primary outcome was MVPA (minutes per week) from randomization to the 29th gestational week obtained by a wrist-worn commercial activity tracker (Vivosport, Garmin International). PA was measured by the activity tracker throughout pregnancy, PPAQ, and DLW. The primary outcome analysis was performed as an analysis of covariance model adjusting for baseline PA. Results: The average MVPA (minutes per week) from randomization to the 29th gestational week was 33 (95% CI 18 to 47) in CON, 50 (95% CI 39 to 60) in EXE, and 40 (95% CI 30 to 51) in MOT. When adjusted for baseline MVPA, participants in EXE performed 20 (95% CI 4 to 36) minutes per week more MVPA than participants in CON (P =.02). MOT was not more effective than CON; EXE and MOT also did not differ. MVPA was positively associated with the number of exercise sessions attended in EXE from randomization to delivery (P =.04). Attendance was higher for online (due to COVID-19 restrictions) compared with physical exercise training (P =.03). Adverse events and serious adverse events did not differ between groups. Conclusions: Offering EXE was more effective than CON to increase MVPA among pregnant women, whereas offering MOT was not. MVPA in the intervention groups did not reach the recommended level in pregnancy. Changing the intervention to online due to COVID-19 restrictions did not affect MVPA level but increased exercise participation. Trial Registration: ClinicalTrials.gov NCT03679130; https://clinicaltrials.gov/ct2/show/NCT03679130 International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2020-043671 J Med Internet Res 2022;24(7):e37699 doi:10.2196/37699 [ABSTRACT FROM AUTHOR]