Debate Article Research Articles

Virtual reality simulation for facilitating critical reflection and transformative learning: pedagogical, practical, and ethical considerations

There is growing recognition that preparing health professionals to work with complex social issues in the delivery of healthcare requires distinct theoretical and pedagogical approaches. Recent literature highlights the significance of employing simulated environments which aim to immerse learners in the experiences of diverse populations and bridge the gap between academic learning and lived realities across a diverse society. Virtual Reality (VR) is gaining traction as a promising pedagogical approach in this context. VR has been argued to offer distinct advantages over traditional educational methods by allowing learners to see the world through the eyes of diverse populations, and to learn about social injustices while immersed in a mediated environment. It also has practical benefits in its capacity to expose large number of students to these topics with relatively modest resources compared to other approaches. This debate article explores VR as an innovative pedagogical approach for facilitating critical reflection, dialogue and transformative learning about social issues in health professions education (HPE). It examines the potential affordances as well as risks and dangers of integrating VR into educational programs and highlights key pedagogical, practical, and ethical considerations. Emphasis is placed on the importance of these considerations in efforts toward ethical, safe, and respectful use of VR in educational settings. This paper contributes to the ongoing dialogue on VR simulation as an innovative approach to HPE and highlights the importance of creating conditions that maximize its educational benefits and minimize potential harms.

Encounters with otherness and uncertainty: a response to Frieman

I find myself largely in agreement with the argument presented in Frieman's debate article (2024) on knowing and narrativity in archaeology, and I share the author's view of feminist epistemology as key to embracing the conditions of the discipline (see e.g. Pétursdóttir & Sørensen 2023; Sørensen et al. 2024). Here, I consider some of the perspectives that Frieman leaves slightly underexplored.

From proof and unproof to critical fabulation: a response to Frieman

In her debate article, Frieman's (2024) reflections on the idea of unproof are a welcome and elegant addition to current debate on the nature of archaeological evidence, how we construct the stories we tell about the past, and the role of archaeology in the contemporary world. Frieman draws on both feminist and anarchist theory to argue that the value of archaeology is the way it allows us to grasp worlds different from our own and suggests that this can allow us to pre-figure better future worlds. This chimes closely with other recent work on the subject (e.g. Barton 2021; Cipolla et al. 2024; Schofield 2024)—clearly, archaeologists are considering the radical potential of our own discipline to change the world.

Language support for academic writing: exploring the use of hedges and boosters in student research and designing language interventions

Research has been embraced in the Philippines for many years now. In education, due to its importance among college students, the researcher aimed at knowing how far students know about devices that they use in research writing. The researcher had used descriptive interpretation by employing frequency count and independent sample t-test to compare the significant difference in the use of hedges and boosters between the two programs. Hedges and boosters were sourced out from a total enumeration of 41 research papers from both programs, 31 from BSED and 10 from BEED. The most frequently used hedging devices in the research papers both introduction and conclusion sections of BSED Program are Type III. “This study” ranked as first, “It” ranked as second, “The study” ranked as third, and “may”, a Type I hedging device, ranked as fourth whereas in BEED program, “It” ranked as no. 1, “This study” ranked as no. 2, and “The study” ranked as no. 3. The most used boosting device in both BSED and BEED programs is “should”. The most used hedging device across all programs is “This study”. The boosting device, “should”, gained the highest number of use and ranked as the most frequently used booster. This study rejects the claim that there is significant difference in the frequency of the use of hedges and boosters when grouped according to program. The language intervention activities constructed by the researcher were directly compared against the result of the study. These activities are as follows: lecture about metadiscoursal devices, scouting hedges and boosters in authentic materials, debate, essay writing, and feature article writing. In conclusion, the study of hedges and boosters helps to portrait an important component of academic argument since claims and argumentation are tried to be included by writers in their academic writing (Bruce, 2005, as cited in Tran, 2013). The language intervention activities might be of big help to these students after all both programs will mandate their 4th year students to write research paper, an academic write-up, as a requirement for graduation.

Great debate: pre-diabetes is not an evidence-based treatment target for cardiovascular risk reduction.

With the increasing burden of diabetes as a cause of macro- and microvascular disease linked to the epidemics of obesity, attention is being paid to dysglycaemic states that predict and precede the development of type 2 diabetes. Such conditions, termed pre-diabetes, are characterized by fasting plasma glucose, or plasma glucose levels on an oral glucose tolerance test, or values of glycated haemoglobin intermediate between 'normal' values and those characterizing diabetes. These last are by definition associated, in epidemiological terms, with a higher incidence of microvascular disease-mostly retinopathy. Pre-diabetes overlaps with the components of the 'metabolic syndrome'-among which are excess visceral adiposity; hypertension; hypertriglyceridaemia; high levels of small, dense low-density lipoproteins; and metabolic-associated fatty liver disease. There is little doubt that pre-diabetes has important prognostic implications, especially for the occurrence of myocardial infarction, ischaemic stroke, and peripheral arterial disease. It is disputed, however, whether pre-diabetes is itself an actionable disease entity, in addition to the risk factors characterizing it. Because of this uncertainty, the latest European Society of Cardiology guidelines chose not to include pre-diabetes as a treatment target for atherosclerotic cardiovascular disease, at variance from the three previous editions of such guidelines. This is spurring a debate, the Pro and Contra arguments featured in the present debate article.

On cultural traditions and innovation: finding common ground

We appreciate the respondents’ comments on our debate article ‘Cultural evolution as inheritance, not intentions’ (Bentley & O'Brien 2024). We all agree that traditional cultural practices—such as manufacturing Acheulean handaxes—often take considerable amounts of time to learn; as Gladwell (2008) popularly proposed, it takes 10 000 hours of practice to make an expert. We also appear to agree that cultural practices are intergenerational. As Frieman (2024: 1421) notes, ideas and practices persist because they are “valued, recreated, manipulated, instrumentalised and enacted generation after generation”; and as Ingold (2024: 1417) puts it, traditional tasks “are not subject to the free will of the individual but fall upon practitioners as part of their responsibilities” to their communities. Drawing on the practice of Bronze Age metallurgy, Pollard (2024) asks the million-dollar questions: how does innovation occur, and what causes it? As both Prentiss (2024) and Pollard note, for example, the pace of technological change is often punctuated, an observation common across the natural and social sciences, but one that defies easy explanation (e.g. Duran-Nebreda et al. 2024; O'Brien et al. 2024).

Debate article: Management of breast cancer in patients with pre-existing bilateral breast augmentation-a snapshot of global practice and call for international guidelines

Breast cancer (BC) is the most common female cancer, and as bilateral breast augmentation (BBA) increases, more women are presenting with BC within an augmented breast. No international guidelines exist on how to manage such a situation, so this group undertook a global survey to provide a snapshot of current surgical practice.The key finding was the variable oncoplastic management of BC after BBA: most surgeons responded that when oncologically safe, breast conservation with implant preservation was appropriate as radiotherapy was not a contra-indication to preserving implants. Immediate symmetrisation could be considered but was not always available.We propose a large multicenter observational study to support the development of international guidelines. This will help patients, healthcare funders, providers, and surgeons to optimize care and reduce inequity of access to appropriate oncoplastic surgery options for the increasing number of women with BBA and BC.

A call for theory-inspired analysis in qualitative research: Ways to construct different truths in and about healthcare.

Over the last 50 years, there has been significant development of qualitative research and related methods in healthcare. Theoretical frameworks support researchers in selecting appropriate research approaches, proceduresand analytical tools. However, the implications of the choice of theory are sparsely elucidated. Based on a text excerpt from a public debate article, the study aimed to show how different theory-inspired analytical perspectives produced varied understandings of the same text. The study presented three subanalyses inspired by Bourdieu's sociological theory, Lazarus and Folkman's psychological theoryand utilitarian ethics, respectively. The analyses showed that by using different theoretical analytical perspectives in inductive processes, an immediate interpretation of the text was not obvious. It became possible to spot the underlying meta-theoretical assumptions, as the interpretations were not taken for granted or indisputable. Our analyses suggest that different theoretical lenses lead to different interpretations of the same empirical material, recognising the existence of multiple truths or realities. Thus, utilising a theoretical perspective in inductive analyses can enhance transparency and rigour because the analytical optics are made explicit to the reader. This allows the reader to follow the analysis processes and comprehend from which theoretical starting point a truth arises.

To mesh or not mesh "apical prolapse," that is the question!

The management of pelvic organ prolapse (POP) involves both nonsurgical and surgical management. Views on best surgical approach for apical prolapse is an evolving field based on recent evidence and events related to transvaginal mesh. At the 97th Annual Meeting of the North Central Section of the American Urological Association (Scottsdale, AZ, USA), this topic was discussed and debated. The following article summarizes the concepts presented that day as well as the interactive debate with three perspectives on apical prolapse surgeries. The authors were asked to support their approach in various scenarios including: extremes of age, prior hysterectomy and intact uterus, desire to avoid mesh, sexual activity, and presence of comorbidities. Surgical approaches for POP have evolved and is a popular topic for debate, particularly when discussing apical prolapse. Transvaginal native tissue repairs remain the mainstay of POP surgeries; however, transabdominal approaches continue to evolve. Use of interposition material, such as synthetic polypropylene mesh, is the standard when performing an abdominal sacrocolpopexy, however, use of autologous fascia can be considered. Small series have demonstrated the safety and efficacy of autologous fascia-based repairs; however, larger studies with longer follow-up are needed. There are a variety of surgical strategies to repair POP. Ultimate decision making on specific surgeries should be determined by patient preference and goals after appropriate counseling on all options.

Placemaking in the Post-Pandemic Context: Innovation Hubs and New Urban Factories

This debate article explores the potential of urban manufacturing to rejuvenate Italian cities through the productive reuse of disused industrial heritage. It emphasizes the need for transformative placemaking approaches that integrate diverse activities, fostering economic and functional diversity within ecosystems. The paper addresses key policy considerations and the impact of dedicated spaces or hubs in engaging specialized communities of workers. It acknowledges the emergence of new professional demands due to Industry 4.0 and highlights potential polarization toward highly skilled profiles. The ongoing pandemic crisis and the rise of gig and platform economies also pose challenges to traditional services and lower-skilled professionals. The paper raises questions regarding attracting makers and their contribution to urban employment growth. It underscores the importance of inclusive learning and shared prosperity by promoting the hybridization of technical, cultural, and social functions within productive-cultural sectors. The governance of hubs and innovation ecosystems necessitates a shared vision and responsibility, fostering partnerships with stakeholders at national and international levels. The examples of BASE and the Technopole of Bologna demonstrate placemaking practices that prioritize the construction of proximate relationships, extending beyond physical improvements. These practices are applied in industrial settings, research, cultural production, and education, with low barriers to entry and targeted approaches to diverse user groups.

To err is human: assessing failure and avoiding assumptions

We thank the respondents for their thoughtful replies to our debate article (Price & Jaffe 2023). Our main objective was to start a dialogue on failure and, in that, we have happily succeeded. The comments and critiques highlight the need for more discussion and thinking if we are to place failure in the archaeological interpretive toolbox. That said, the range of definitions, analytical perspectives, and unanswered questions will, we hope, provide a bulwark against turning ‘failure’ into yet another archaeological buzzword.

Debate: Intra-articular steroid injections for osteoarthritis – harmful or helpful?

Intra-articular corticosteroids injections are a widely used treatment for pain from symptomatic osteoarthritis. Systematic reviews show that the treatment effect is modest compared with intra-articular saline (often considered as placebo) and lasts for 2-4 weeks on average. Potentially as a consequence of limited therapeutic duration, repeated injections are often given up to 4 injections annually. In this context of repeat injections, recent evidence has emerged that intra-articular corticosteroids might be associated with more MRI-assessed quantitative cartilage thickness loss than saline injections. Guidelines vary in the recommendation for use of intra-articular corticosteroids. Given the frequency with which intra-articular corticosteroids injections are used, the size and scale of the population with osteoarthritis, it is critical to fully understand the benefits and drawbacks of intra-articular corticosteroids injections. That is the focus of this debate article.

Walled in: borderlands, frontiers and the future of archaeology

For archaeology to survive in the present and for critical discourse on the past to thrive, archaeologists must advocate for the discipline's continued relevancy. In this Debate article, the authors illustrate the potential and challenges of such advocacy by examining contemporary perceptions of the Roman period Hadrian's Wall and how it relates to modern border landscapes—namely the US/Mexico border. They argue that archaeologists have not addressed the imagined continuity of socio-political narratives surrounding borderlands, calling for wider recognition of border materiality. The authors contend that the uncritical portrayal of the past, particularly in politically charged spaces such as border zones, can contribute to inequality and oppression in the present.

Disentangling the messiness of natural experiments to evaluate public policy.

Disentangling the messiness of natural experiments to evaluate public policy.

Forest Therapy for Women with Gynaecological Cancer—A Feasibility Study to Find New Alternatives in Cancer Rehabilitation

Cancer can have a significant impact on one’s life situation, with many patients reporting psychosocial discomfort, worry, anxiety, fear of recurrence, depression, tiredness/fatigue, sleep problems, pain and numerous other problems even long after active medical treatment. Psychosocial support during cancer rehabilitation has proven to be insufficient. In a recent debate article, the scientific committee of CancerRehabFund, Sweden, demands more rehabilitation alternatives for individuals living with cancer. Nature-based treatment is one of the alternatives mentioned as the way forward, but more research is needed. Therefore, we want to evaluate the patient’s experience of a ten-week forest bathing intervention, as an add-on to the standard care, and whether it can improve general health and well-being in women suffering or recovering from gynaecological cancer. The study will run between the autumn of 2022 and until the end of 2023. It is a prospective single-case study, including quantitative and qualitative approaches using validated self-administered instruments (pre–post measurements) and semi-structured interviews (post) on women’s lived experience of the 10-week forest bathing intervention. The quantitative outcome measurements will be the quality of life, fatigue and depression/anxiety. There will also be a questionnaire on perceived sensory dimensions experienced in the forest environment. The study will include 24 participants, divided into four groups of 6 participants. Once a week for ten weeks, the participants will be offered a session of a 2.5-hour stay in the forest with breathing exercises, slow movement, time in silence and privacy and a social gathering to conclude each session. Before and after each session, the participants will be invited to fill in the Profile of their mood state to describe their mood/feelings. There will be three different forest locations with varied forest cover types, i.e., evergreen, deciduous and mistands. Participation in this study will be voluntary, and all results will be anonymously presented on a group level. This paper is a protocol paper describing in detail the venues/forest sites, the forest therapy intervention and the scientific methodological approach for evaluating the ten-week intervention. To our knowledge, this is the first study on forest bathing for cancer survivors in Sweden. The Swedish Ethical Review Authority has approved the study [Dnr 2022-02083-01].

Debate: Should academics collaborate with digital companies to improve young people's mental health?

Should academics collaborate with social media and gaming companies to identify and reduce mental health impacts on children and young people? While opinions on this question sharply diverge within the academic community, in practice collaboration is already widespread. As digital platforms increasingly dominate the time and attention of many young people and are the source of both considerable concern as well as offering innovative opportunities for beneficial interventions, researchers are recognising the potential for collaboration to accelerate positive impact. However, concerns over the independence and transparency of collaborative research have received little institutional or collective response. Recognising both the promise and the pitfalls, this debate article calls for multidisciplinary deliberation within the academy to support the co-development of clear guidelines on the principles and processes by which collaboration is best undertaken, as well as the basis for ensuring that some research remains independent.

Mixed urinary incontinence: Are there effective treatments?

The aim of this debate article is to discuss whether effective treatments are available for mixed urinary incontinence (MUI). Because patients with MUI have both stress and urgency urinary incontinence (SUI and UUI) episodes and current treatment guidelines currently recommend treating the predominant symptom first, this article presents standard and emerging treatments for both SUI and UUI before discussing how well these treatments meet the medical needs of patients with MUI. Standard treatments presented include noninvasive options such as lifestyle changes and pelvic floor exercises, pharmacological agents, and surgery. Treatment of all three types of urinary incontinence (UI) is usually initiated with noninvasive options, after which treatment options diverge based on UI subtype. Multiple pharmacological agents have been developed for the treatment of UUI and overactive bladder, whereas surgery remains the standard option for SUI and stress-predominant MUI. The divide between UUI and SUI options seems to be propagated in emerging treatments, with most novel pharmacological agents still targeting UUI and even having SUI and stress-predominant MUI as exclusion criteria for participation in clinical trials. Considering that current treatment options focus almost exclusively on treating the predominant symptom of MUI and that emerging pharmacological treatments exclude patients with stress-predominant MUI during the development phase, effective treatments for MUI are lacking both in standard and emerging practice. Ideally, agents with dual mechanisms of action could provide symptom benefit for both the stress and urgency components of MUI.

Russia Resurgent? Untangling the Role and Meaning of Moscow’s Proxies in West Africa and the Sahel

Growing international concern over Russia’s military and political resurgence in Africa and the possibility of creating a renewed Cold War has been rekindled by Russia’s invasion of Ukraine and the outbreak of war in Europe in February 2022. Russia’s growing influence in Africa through the re-establishment of old ties and the creation of new ones has been perceived as a quest to re-establish the geopolitical gains that the Soviet Union achieved before its collapse in 1989. Increasing demand for Russian weaponry and equipment, support for unpopular, illegitimate, or unconstitutionally elected leaders, and the targeting and interest in mining concessions and natural resources are considered by the West to be a threat to democratic gains and stability in an already fragile continent. Several questions arise as a result of the deepfake propaganda around occurrences on the continent. How has Russia’s resurgence or reemergence manifested on the African continent? What instruments does Russia utilise to exert its influence in Africa? What are the potential opportunities and threats of Russian presence in West Africa and the Sahel? And how will other global actors be affected? This debate article seeks to examine a particular aspect of Russia’s resurgence on the African continent, namely, the presence of Russian proxies in West Africa and the Sahel. It examines the multiple dynamics created by their presence, the potential threats that their proliferation and activities generate in an already fragile sub-region, and how such activities, if unconstrained, can impose other potential dangers on the continent and the globe.

'Seeing is believing': arguing for diagnostic laparoscopy as a diagnostic test for endometriosis.

Lay summaryEndometriosis is a benign disease that can cause pain and infertility in women. Debate exists over how endometriosis should best be diagnosed. On one hand, endometriosis can be diagnosed by directly examining pelvic anatomy via a surgical procedure known as diagnostic laparoscopy. On the other hand, the disease can be diagnosed via non-surgical means such as using medical imaging, the symptoms described by the patient and whether the patient responds to non-surgical therapies such as medication. In this debate article, we argue in favour of diagnostic laparoscopy. We review the safety of the procedure, compare the ability of diagnostic laparoscopy vs medical imaging to detect endometriosis and consider the benefits of formally diagnosing or ruling out the condition.

Diagnostic laparoscopy for unexplained subfertility: a comprehensive review.

Dealing with unexplained infertility is still non-guided, and patients are prone to different and sometimes discordant management strategies based on physician's preferences. However, much has been discussed in this matter, especially when it comes to the use of laparoscopy in patients with unexplained subfertility. In this debate article, we discussed data found in the literature concerning the utility of laparoscopy in these patients, leading us into establishing a new paradigm that will serve in orienting the physicians to when the procedure should be performed.