This video will cover the following objective from respiratory physiology, outline the process of gas exchange and summarize the process of oxygen and carbon dioxide transport within the respiratory system, define and contrast the process of external and internal respiration, define the Bohr effect, describe how pH and temperature affect the oxygen hemoglobin dissociation curve. Dalton's law states that the total pressure of a mixture of gases is equal to the sum of the individual partial pressures for each gas. For example, if the total pressure of the atmosphere at sea level is 752 millimeters mercury and the concentration of nitrogen in the air is 79 percent, the partial pressure of nitrogen is 593 millimeters of mercury. You could calculate that by multiplying the total pressure of 752 millimeters mercury by 0.79. Similarly, if we wanted to calculate the partial pressure of oxygen, well, we could, because if nitrogen and oxygen are the only gases in that mixture, we could just take the total pressure and subtract 593 to get 159 or we could multiply the 752 by 0.21 because 21 percent of the air is oxygen and so the air is normally around 79 percent nitrogen and 21 percent oxygen. Other gases are in much lower concentrations. Understanding how the partial pressures of gases will contribute to the diffusion of gases is important to help us understand the forces driving gas exchange and to understand how gas exchange will be influenced by changes in the atmospheric pressure. For example, at high altitude, such as on top of Mount Everest, the atmospheric pressure is only 253 millimeters of mercury. The concentration of oxygen and nitrogen in the air is not different. There's still 21 percent oxygen and 79 percent nitrogen. However, the partial pressures are much lower and so the partial pressure of oxygen would only be around 53 millimeters of mercury on top of Mount Everest and this would greatly decrease the rate of diffusion of oxygen into the blood. External respiration is gas exchange between the blood in the pulmonary capillaries and the air in the lungs within the alveoli and the partial pressure gradients are driving simple diffusion of oxygen and carbon dioxide across the respiratory membrane. The respiratory membrane is the wall of the alveolis and the wall of the pulmonary capillary, which are held together by a fused basement membrane of loose connective tissue. Oxygen moves from a relatively high partial pressure in the alveolis where the partial pressure is around 100 millimeters of mercury in the normal circumstance at sea level and it's moving into the blood of the pulmonary capillary where the partial pressure of oxygen is normally around 40 millimeters mercury. In contrast, carbon dioxide is moving out of the blood in the pulmonary capillaries where there's a relatively high partial pressure of carbon dioxide. The partial pressure of carbon dioxide in the pulmonary capillaries is around 46 millimeters of mercury and the partial pressure of carbon dioxide in the air in the alveoli is around 40 millimeters of mercury. So after external respiration the partial pressure of oxygen in the blood that's flowing back in pulmonary veins is up around 100 millimeters of mercury and the partial pressure of carbon dioxide is decreased down to around 40 millimeters of mercury. So when oxygen dissolves in the plasma it can then diffuse across the plasma membrane of erythrocytes and enter into the cytoplasm of the red blood cell where it can bind to the protein hemoglobin. In this way hemoglobin drastically increases the oxygen carrying capacity of the blood by removing oxygen from the plasma. This enables continued diffusion of oxygen from the air of the alveoli into the blood plasma as hemoglobin can become saturated with oxygen. Similarly there's a mechanism to increase the efficiency of carbon dioxide transport in the blood. Some carbon dioxide can bind to hemoglobin also some carbon dioxide will react with water in order to form carbonic acid that dissociates to form bicarbonate and bicarbonate is the primary source of transport for carbon dioxide in the blood. Then when the blood reaches the pulmonary capillaries bicarbonate can react with hydrogen ions to form carbonic acid and carbonic anhydrase can inter-convert the carbonic acid into produce carbon dioxide in water and this allows more carbon dioxide to move out of the blood into the alveoli as carbonic anhydrase is continually converting carbonic acid into carbon dioxide the carbon dioxide is then diffusing out of the red blood cell into the plasma and then carbon dioxide diffuses from the blood plasma into the air in the alveoli across the respiratory membrane. Internal respiration refers to gas exchange between the blood within the systemic capillaries and the interstitial fluid of tissues throughout the body as cells throughout the body use oxygen for aerobic cellular respiration the partial pressure of oxygen in the interstitial fluid decreases and as these cells produce ATP from aerobic cellular respiration they also produce the metabolic waste product carbon dioxide and so carbon dioxide concentration of the interstitial fluid increases and the partial pressure of carbon dioxide in the interstitial fluid increases so normally the partial pressure of carbon dioxide increases to around 46 millimeters of mercury in the interstitial fluid and the partial pressure of carbon dioxide in the pulmonary or in the systemic capillaries is initially around 40 millimeters of mercury coming in from the arteries but as carbon dioxide diffuses into the blood the blood carbon dioxide partial pressure rises to around 46 millimeters mercury and the the blood oxygen partial pressure is normally around 100 millimeters mercury in the blood coming from the arteries into the systemic capillaries then the partial pressure of oxygen in the interstitial fluid is usually below 40 millimeters of mercury and oxygen will diffuse out of the blood into the interstitial fluid until the partial pressure of oxygen in the blood arrives at around 40 millimeters of mercury in the blood that's deoxygenated blood draining into the venules to return back to the to the right atrium of the heart through veins carbon dioxide is transported in the blood some of that carbon dioxide is dissolved in plasma but the only around 40 millimeters of mercury partial pressure of carbon dioxide can dissolve in the plasma and that's only a small percentage of the total carbon dioxide that's transported in the blood so around 7% of the carbon dioxide transported in the blood is just dissolved in the plasma but carbon dioxide can diffuse into erythrocytes and within the erythrocyte it can bind to hemoglobin and around 23% of the carbon dioxide transported in the blood is bound to hemoglobin the carbon dioxide binds to a different site on hemoglobin than oxygen binds to but we'll see that carbon dioxide binding to hemoglobin will have an important influence on the affinity of hemoglobin for oxygen then the majority of carbon dioxide will react with water within the red blood cell and a reaction catalyzed by the enzyme carbonic anhydrase forming carbonic acid then carbonic acid will lose a hydrogen ion forming carbonate and this will have the effect of lowering the pH of the blood and the bicarbonate ion ends up being the primary transport form of carbon dioxide around 70% of the carbon dioxide that's being transported in the blood has been converted into bicarbonate the majority of oxygen transport in the blood is being carried bound to hemoglobin there are four heme groups one within each of the globin polypeptide subunits of the hemoglobin protein so one hemoglobin protein can carry four oxygen molecules here we can see a graph of the oxygen hemoglobin dissociation curve on the x-axis we can see the partial pressure of oxygen within a tissue and on the y-axis we can see the oxygen saturation of hemoglobin represented in percentage and so in the lungs where there's a high partial pressure of oxygen the hemoglobin in the blood of the pulmonary capillaries becomes a hundred percent saturated where four molecules of oxygen bind to each hemoglobin protein then as that blood is delivered out through the systemic circuit in the systemic capillaries oxygen diffuses out of the blood and then oxygen is released from hemoglobin we can see at a partial pressure of 40 millimeters of mercury about 75 percent of the hemoglobin is bound to oxygen meaning there's about three molecules of oxygen for every hemoglobin protein and so about 25 percent of the oxygen that was being transported by hemoglobin was released into the tissues and this means that there's still 75 percent of the oxygen carrying capacity after oxygen has been released to tissues under normal circumstances and this helps provide some security against hypoxia so that there's a reserve of oxygen available for strenuous activity that requires an increase in the metabolic activity and increased rate of oxygen consumption here we see the effect of pH on the oxygen hemoglobin dissociation curve and so the pH of the blood influences the affinity of hemoglobin for oxygen as we see the shift between a pH of 7.4 which is shown in the pink line if the pH falls down to 7.2 you can see the the curve shifts down into the right as we can see with the blue line this represents a decrease in the affinity of hemoglobin for oxygen because at the same partial pressure there's a lower oxygen saturation of hemoglobin if we look at 40 millimeters of mercury oxygen concentration or partial pressure of oxygen that's typical of the systemic capillaries we can see that at a pH of 7.2 there would only be 60 percent oxygen saturation of hemoglobin in comparison with at a pH of 7.4 there would be 75 percent oxygen saturation of hemoglobin then we can see at a higher pH at 7.6 the curve shifts up into the left as we can see represented with the orange line at the same partial pressure of 40 millimeters of mercury now at 7.6 at a pH of 7.6 the oxygen saturation of hemoglobin would be increased to around 80 percent and so this effective pH on the affinity of hemoglobin for oxygen is also known as the Bohr effect so the Bohr effect is a decrease affinity of hemoglobin for oxygen in response to a low pH or the opposite would be an increase in the affinity of hemoglobin for oxygen in response to an elevated blood pH similarly carbon dioxide causes a decrease in the affinity of oxygen for hemoglobin which helps to stimulate the delivery of oxygen in tissues where the carbon dioxide concentration is increasing and the pH is decreasing the affinity of hemoglobin for oxygen decreases helping to release oxygen into those tissues that have the highest demand because they have a high metabolic rate producing large amounts of carbon dioxide similar to the effect of pH and carbon dioxide temperature also has an influence on the affinity of hemoglobin for oxygen we can see that increasingly temperature has the effect of decreasing the affinity of hemoglobin for oxygen and this should make sense that as a tissue is working hard with a high metabolic rate has a high demand for oxygen there's heat being produced by that increased metabolic rate and that heat then further stimulates a decrease in the affinity of hemoglobin for oxygen enabling more efficient delivery of oxygen to that tissue that has a high metabolic rate two three bisphosphoglycerate commonly just abbreviated two three BPG is a molecule that has the influence of decreasing the hemoglobin affinity for oxygen two three BPG is a side product of glycolysis and the normal intermediate of glycolysis one three bisphosphoglycerate would be converted to three phosphoglycerate by the enzyme phosphoglycerate kinase but if the rate of glycolysis is very high one three bisphosphoglycerate can accumulate faster than phosphoglycerate kinase can convert it to three phosphoglycerate and the enzyme bisphosphoglycerate mutase converts some of the extra one three BPG into two three BPG and then two three BPG it can be converted by a two three BPG phosphatase into three phosphoglycerate providing another pathway to get through glycolysis although with a less efficient pathway because we would not get the ATP that's generated by phosphoglycerate kinase if we took this alternate pathway however the the benefit of producing two three BPG is that two three BPG will then bind to hemoglobin in erythrocytes and decrease the affinity of hemoglobin for oxygen and so as two three BPG is accumulating it stimulates the release of oxygen in a tissue that has a high metabolic demand


A life threatening situation that I have no control over. That's very difficult. That's hard She's been a survivor for 10 years and you tell that story as if she got diagnosed yesterday Do you it's always present? What what what does that mean? It's always present. What does that mean? Well, it's the the thought of When you talk about about our marriage We had got to a point. We've been married so long that we got to a point that I Did my thing she did her thing and business and Sometimes we saw each other before we went to bed most time we didn't and Then when you face with the Possibility that one of you may not be there and especially her that she may not be there that


In this talk of techniques of endoscopic pituitary surgery, a beginner's perspective, I am going to discuss the tricks of the trade. Now endonational transitional surgery using an endoscope as a sole visualizing tool is in place of microscope. It has emerged as a better alternative to microscopic TNTS because the visualization and volume of exposure is superior. It permits the complete removal of tumor from the hidden angles and preserves the normal pituitary, so giving a comfortable postoperative course and the less complications. How we do it? In the position, it's same like any trans microscopic TNTS that patient is put supine with hips and knee flexed, trunk elevated to 20 degrees for the less bleeding and it allows the easy access to the middle turbinate. Now head is rested in neutral position on a horseshoe or fixed in a three pin when you use the neuron navigation. The chin forehead line is maintained parallel to the floor. It's 15 degree turn towards the surgeon and 15 degree counter lateral tilt. So that is the ideal position we use. And hemostatic aids are that adrenaline one in one thousand, the five ampoules are diluted in 30 ml of one percent silo cane and the propofol infusion is used to reduce the bleeding and keeps the BP around 90 or pulse around 60. Now all the cables of the endoscope that is the light, camera or irrigation are tied together to the shaft of the endoscope and the rest on the table away from the patient surgical field.  You can hold it like a pen other ways but it doesn't really matter. But holding it like this makes your these two fingers to manipulate the zoom and focus. Now the surgical stages are nasal stage, synodal stage, cellular stage or reconstruction stage and the recognition of important landmarks during each of these stages is important for the safe exposure. Now when you start endoscopy first have a overall bird's eye view or overall view of the area then endoscope is inserted parallel to middle terminate at an angle of 25 degrees inferiorly to see the koana first. The inferior terminate points to eustachian tube ultimately when you follow the inferior terminate will take you to the eustachian tube. The koana is the most important anatomical reference point then you go with the scope in between the inferior terminate and septum and then in between the middle terminate and septum into the sphenoidal recess. Now is the super selective packing of 2 to 4 cotton patties which are soaked in the decongestant and then squeezed they are left in this eustenoidal recess and they are pushed from lower down to up and from anterior to posterior and they are left for 5 to 10 minutes to widen this eustenoidal recess. Now this is how you put these patties there. Now once this space is created the fresh cotton patties are pushed back in the sphenoidal recess and to the rostrum of the sphenoid and again left for 2 to 5 minutes and middle terminate is now lateralized with the shaft not the tips because the tips may injure the mucosa. So with the shaft of a freed sector you just lateralize the middle terminate. If it is bulky then another way is that you first you medialize it and then out fracture it so that it will give you a lot of space and I can assure you that investment of 10-15 minutes in these procedures of putting and packing of patties and all that makes your life very comfortable and your operation very safe in the later stages of the surgery. Now avoid injury to nasal mucosa by insertion of the instrument under endoscopic guidance. Don't just put the instrument like that but it will injure the nasal mucosa and keep the suction at low setting and if there is any bleeding from the mucosa the better way to control is you just infiltrate it rather than coagulating. Now the ostium is identified medial and posterior to superior terminate in the lateral corner of the rostrum of the spinoid. In 30 percent of patients you may not see the ostium but it is always there and to look it sometimes you may see some air bubble or probe. You can just probe it about 1.5 centimeter from the roof of the koana if you just probe it you will find it and still if you are not able to find it then there is a part just immediately below this a very thin part of spinoid anterior part which is called fontanelle. So you just put your any instrument gently there it will go into the spinoid sinus and it will perforate it and now this is the ostia this is how it looks like when you take it into the spinoid model resist. Now mucosa over the spinoid sinus is coagulated and nasal septum is gently pushed medially and fractured and is pushed to the other side. Now some mucosal dissection is further carried out along the contralateral side of spinoid rostrum visualizing the ostium of other side. So other side of stium now you see some mucosal and this gives a classical owl eye appearance and this is this is two or the eye and this is the nose of the owl which is the woma. Now avoid mucosal coagulation in upper part of the nasal septum to avoid post-op anosomia and now this is how you see from the both sides you see and these are the ostia and this is a V shaped osteotomy is performed spinoid osteotomy and now again a lot has been said about this posterior septal artery which is branch of sphinopolitan artery which in turn is branch of internal migratory artery that it lies supereolateral to koana inferior lateral corner of its spinoth model recess and medial posterior corner of inferior margin of middle turbinate and this is in the sphinopolitan posa and this artery can be coagulated when excess is made between the middle turbinate and nasal septum for NTS spinodotomy to prevent bleeding during surgery and after all so even in post-op epistexis the commonest cause is bleeding from this artery and usual advice is that this artery when you encounter bleeding bipolar it rather than monopolar but you can use monopolar also at low setting but better to bipolar it. Now sphinodosteum is enlarged medially and inferiorly and V shaped NTS spinotomy is done from the inferior margin of middle turbinate to the sphinodosteum for 15 mm length the rostrum of sphinoid is removed now by doing this and now you can remove this rostrum. The posterior one-third of nasal septum is now removed by backbiter along with the contralateral mucosa of the nasal septum so as to make it approach a binostril or binaris approach and this is how we use this backbiter. Now the techniques differ here it may be a uninostril or binostril it may be a 2 or 3 or 400 surgeon techniques which is preferred which provides you a 3D vision and it depends and differs on extent of middle turbinate lateralization or resection whether partial or complete or the type of cellar floor and one should know all these possible modifications of these techniques so as to tailor according to the specific requirements in a particular patient. So for example a uninostril approach throw a capacious nostril in a adenoma which is confined to the cellar in a patient with DNF is a good option you need not to go by near and then if you are able to do a wide anterior wide sphinodotomy you can take out this tumor by uninostril approach. Now what are the limits of this sphinodotomy is cranially the superior limit is up to sphinodosteum cordially the vomer is drilled up to the pterigo sphinoid synchondrosis or the canal for median nerve which is further lateral seen at 5 and 7 o'clock position creating a space of more than one or two tips of the suction passing through the permitting instrument manipulation under the cellar floor otherwise your instruments will get stuck you will not be able to reach there so when you see the floor of the cellar under the floor of cellar there should be a space of about at least 4 to 6 millimeter so that your instruments can pass there and lateral limit is up to the crest which marks the junction of sphinoid with the ethmoids after sphinodotomy the endoscope may be mounted on a holder or another surgeon holds it who acts as a navigator that is called a co-pilot and with the main dissecting surgeon is known as pilot and this provides a 3D perception and initially I was fixing the holder but now I just don't prefer in and I never do it and one should not do it for the reasons I will tell you later the role of the navigating or a co-pilot surgeon is that he holds the scope with fingers on backside or reverse of the pilot surgeon like you are holding this so the assistant or co-pilot is standing on that side so he holds it like this so that he can show you and his elbow should always be supported so that he can do it precisely the co-pilot stands on the left side of the surgeon and head end of the patient now try to make the path as straight as possible by passing the scope and instruments above the inferior turbulence move the scope in relation to the instruments like pilot and co-pilot they work in synchrony the espionage mucosa on entry of all of the cellar floor is coagulated and not stripped to avoid the bleeding the inner mucosa which is in the espionage sinus it should not be just pulled out because a lot of bleeding can occur so that should be coagulated now repeated warm saline irrigation stops bleeding from the mucosa and cleans the field but one word of caution you should not coagulate inside with the monopolar inside the espionage sinus because there may be bony dehiscence and you might be coagulating on the carotid so just never coagulate there a small bony hole is made in the center of the cellar floor and then the entry of all and floor is removed circumferentially and then the dura is coagulated with a single blade bipolar and there is a technique of a cavity and half so here what you do is you go between the superior terminate and middle terminate lateralize the middle terminate and to open the bull-eyes now here there is a Parsons ridge which separates the synodosteum from the superior terminate which is excites and now it is communicated with the spinoid cavities now communicated with the posterior and this posterior cavity is used to park or keep your scope there so that the spinoid cavity the full spinoid cavities available for the dissection for you and now keep checking the proper orientation for the beginners this is very important that at all the stage of surgery you must keep checking that the buttons of the scope are facing the screen and this is the proper orientation and particularly after each exit and insertion of the scope now if you see observe a semi lunar sign which means your scope is touching that issue so you just rotate it 90 degree will be okay and if there is a fogging it is usually due to humidity and if you irrigate the scope with a warm cell and this will go and this will improve now try and practice or execute in and out movements inside the nasal cavity to judge the depth and to fit the surgical landmarks for proper orientation and depth perception in the beginning you just take out in so that you are aware that how far deep are these structures introduce the scope slowly like going through a tube without touching its wall to prevent or avoid the soiling of your scope now while introducing the scope take advantage of elasticity of the Ella and lift or deform the Ella and keep the scope at 11 o'clock like you are pushing here so you lift this so you use the elasticity of the Ella and your scope should be at 11 o'clock position now instruments are introduced taking the advantage of rigidity of the floor and this gives you orientation you just go directly there and you see the Qana and this is a very basic anatomical reference point and along the nasal septum below the scope through the nostril the instrument should pass below the scope through the lower part of the nostril now distance between the tip of instrument and scope is kept about a centimeter and the instrument should be guided by the endoscope and they should not touch each other or crossover avoid quick movements in the proximity to the surgical target so go slowly and gently after this minute not to me once we have removed the spinoid phase now how to know that where is the midline so the remains of the rostrum that is the vomer inferiorly will guide you to the midline and you stay between the two carotid bulges now you can see the carotid bulges so stay in between the two carotid bulges for midline now when using a drill now drill is first taken close to the target when the tip can be seen in the screen and now you make the drill on and touch to the target and drill in bursts like a painting brush just don't press it against any structure remove the drill only then it has completely stopped otherwise it will injure your mucos on the way or some other structure now dry drilling with burr diamond burr stops the bleeding from the bone this is the one very important method and while drilling keep the endoscope away and zoom to avoid the soiling of the lens now remove the coffin effect by widening nice sometimes you feel that the space is very less so just widen your spinotomy and this will make your life comfortable and sometimes you will find during your surgery that lot of bleeding is coming there so it is nothing but it's a blocked koana so you just go down and suck the fluid from the koana and it will be okay now the paramedian septum they most often lead to carotid or optic nerve so remove them only when it is mandatory and don't remove by a forceps and pinching just you drill them with a diamond to make it flush with your other spinotomy cellar surface now the anatomical landmarks are identified in a panoramic view which mimic a fetal face like the center is the cellar the rostral is the tuber crumb celly at 12 o'clock position cordal clivalent indentation at 6 o'clock position and literally optic protuberance at 10 and 2 o'clock position carotid protuberance at 5 and 7 o'clock position and cavernous sinuses at 3 and 9 o'clock position so this is what you see like a fetal face and this is the classical picture of this here you see this is the area of interest and this is the lateral optical carotid recess and this is how it gives the appearance and this is a live during surgery a photograph just to show you and here you see this septum is paramedic so these septums are hardly ever midline the spinotomy septum now a medium size 3 to more millimeter diamond bar is used to drill the cellar and the drilling of the cellar should be very gentle lazy drilling with diamond bar under low speed then the egg shell which is produced is a dissected and broken with a fine spade sector or a kerosene were up cut punch without taking any bite you just hold the kerosene there and just break it it will just break it without taking any punch and it should be done till you see the four blue lines of superior and inferior intercavernous and both the cavernous sinuses laterally and now this is the initial hole is made in the cellar and then it and then cellar interval and floor is removed circumferentially and these till the four blue lines are seen now the dura is open transfers it may be a straight line it may be cruciate or whatever way you can open but what we find best is that first you make a transfers incision and then you give them five and eight o'clock position creating a inferior flap of the Dura so the advantage is that this part of the Dura supports the upper part of the tumor and restricts doesn't allow the arachnoid to bulge down so that it hinders your view of the tumor within the posterior inferior part now endoscope knife is used for opening the Dura to cut the Dura in the center first and then from very free to midline because it's a copper bank a knife of endoscope knife is a long instrument so you don't have a precise control on this so you should never open it from midline to periphery because you may injure the cavernous so better is from periphery to midline so open it from periphery to and then you can extend it laterally with the seizures if later on it is required and now this is how it's being done the transfers incision is given and this is the five and eight o'clock position we give the incision and now the first the basal and first a part of the tumor is removed through the opening in the inferior flap in posterior trajectory towards clivus dorsal junction in cordal to rostral direction the superior dural flap holds the superior anterior part of the tumor and prevents the premature arachnoid bulge that tumor should first be mobilized free and then taken in a holding forceps or suction in a peacemapes now do not hold any tissue if you cannot see the tips of the instrument and do not pull there's no place for blind defection in this type in endoscopic surgery because the whole idea of endoscopic that you visualize everything next the lateral and lastly the superior part of the tumor is removed with upward angled curates now the tumor decompression is done with bimanual dissection that is the curate in the right hand and suction in the left hand or double suction method where two sections are each hand and the left section delivers the tumor and right section sucks it now the take advantage of the endoscope that take the endoscope inside the cellar close to the target for detailed study and this is what is called the flashlight effect because when you take it close you study the anatomy in detail and you see whether it's a tumor or diaphragm or arachnoid or normal pituitary and then only you tend to remove it and then if you see that this is a tumor then withdraw the endoscope little bit take your instrument and then remove the tumor the removal of the tumor is a dynamic process the arachnoid may bulge down to the diaphragm in front of a thin pituitary stalk so always caution if you see arachnoid don't try to open it the last piece of the tumor is often located at the insertion of the pituitary stalk and the two most common sites which are found to retain tumor is the angle between the optic nerve and carotid artery at medial OCR and under the anterior lip of the dura at level of superior intercavenous sinus and this is how the arachnoid bulge looks like now a 30 degree endoscope visualizes opposite to the cable of the light if the cable is here it means you are visualizing opposite to the cable of the light so when cable is down the scope is kept in the lower part of the nose because you want to dissect superiorly so now a scope comes to the lower part of the nose and your instruments pass in the upper part of the nose so angled endoscope is taken in the cellar to examine the tumor remanence which are removed with a curved or a angled suction to examine the medial cavernous wall you rotate a 30 degree endoscope and ask the assistant to rotate the camera also to maintain the orientation and always again as I said keep the buttons facing the screen now the space between the posterior and the carotid siphon which is like a reverse S represents the ideal entry point for removal of the tumor from the posterior segment of the cavernous sinus and finally inspection of cellar is done in clockwise fashion starting at six o'clock position and using a 30 degree angled endoscope now failure of diaphragm to descent indicates retained tumor in the supracellar space and pulsations visible in the diaphragm is a robust finding of a total tumor removal now normal pituitary should be preserved now how you preserved it that you always predict in preoperatively in MRI that where it is shifted and usually it is posteriorly and superiorly right but you always see it because the posterior pituitary doesn't have blood-brain barrier so it enhances brilliantly so this is the white thing you always look and preoperate MRI and you predict that where is the pituitary shifted it's a normal pituitary is a yellowish in color firm in consistency and there is vasculature on it so this is how you identify it and a thinned out residual normal pituitary appears as a apron plastered to the under surface of diaphragm and should be identified and preserved in functioning a micro adenoma a thin shell of normal pituitary is also removed or shaved along with the tumor cavity to enhance the chances of cure now in the end you ask the anesthetist to give ball cell work to check for CSF leak and always use a large single piece of fat instead of multiple small pieces and use a bath plug technique that you push the fat first and just gently pull it so that it will seal the hole of the dural defect the fat graft must pulsate it shows that it's proper to avoid the over enthusiastic packing of the cellar now medial middle terminate is now medialized back to normal position to keep the maxillary drainage patent and no nasal pecs are required after this and this is just a one edited video of a pituitary adenoma you see this is the Kwanha and this is the ispinoid of Stia as you go up in the ispinoid matrices now you coagulate the mucosa here and now you see this is the austere and this is the boomer and then the fracture the septum has been fractured and now I am dissecting sub mucosaline and that is the other side austere and now we see the anterior ispinoid Rome is done and this is the cellar and this is the septum is leaving to move this cell is opening is widened gradually circumferentially now you see this is the dural opening so earlier we were using the opening like this but now we do the way I showed you and this is that the tumor so first make it free and then then you remove it and it also should be a very gentle traction we never call pull because there's no place for pull in this so it's just gently put a traction and then remove it and now you can see the normal pituitary there and in small pieces or in stages gently and this whole of the tumor is removed and now you can see that I from bulging and then the user and and a pad of fat which is pushing there and you gently withdraw it so that it seals it completely and then use a glue see in in endoscopic surgery the problem is there is no bone to support this graft so this is when you put the fat you have to put some sealing agent so that it is there and then the middle terminates which are medialized they will support it now no foreign material should be left behind in the spinoff sinus cavity because it's postoperatively because there's a lot of crusting intact residual mucosa keeps spinoff sinus as a air filled cavity which is more physiological so you remove the mucosa only covering the cellar and a simple pituitary you need not to remove whole of the mucosa if whole of the spinoff sinus is packed suppose the CSF leak occurred now you want to pack the spinoff sinus then you have to remove whole of the mucosa to prevent mucosil formation and leave minimal raw surface a steep learning curve exists during the change from microscopic to endoscopy and this is the time when complications can occur so a sudden change from microscopic to endoscopic may be difficult and discouraging so the transition should be slow and progressive a steep progressive learning curve can be reduced and by slow progression you gain confidence and you gain ability to tackle the complications if any occurs now you may have a frustrating experience in first 2030 cases because of difficulties in the initial phase of the procedure because we are not used to this initial phase so this can be minimized or overcome or avoided by the knowledge of endoscopic equipment by detailed understanding of endoscopic perception of the anatomy or learning the endoscopy skulls or taking help of your ENT colleagues it's great to be at your own but if you have some difficulties take help of your ENT colleagues follow the techniques step by step knowing the tips and tricks of the trade by assisting and watching the videos of the experts and by practicing in labs on models attending courses and live or cadaver workshops and not only one see one workshop will just orient you so now you go back do some cases come back then learning would be more and more and this is how we always attend old endoscopy workshops and I definitely learned some points from that so for a beginner and selection of cases is also important so the best patient for a beginner is a known functioning adenoma which is well nematized synod sinus and the tumor is confined to cellar so it is the best case for a beginner and the worst is when there is a conical or pre-cellar type of synod nomatization when patient has acromegaly or cushions because they bleed more because the mucosa is fragile hypertrophy then it's more and when if it is a recurrent or dumbbell or a giant pituitary adenoma so do not select these cases in the beginning always review the pre-op MRI and CT scan for assessment of nasal airway for the presence of any DNS or concavulosa and concavulosa is that the middle terminate may be nematized itself so it would be large and bulky so anatomy of paranasal sinus like extent of nematization and presence of intra or interstinal septum that how many septums are there and where they end like in cellar if there is any anatomical variation if there is any bone adhesions or presence of kissing carotids and these are the three types of the cellar so this is the most difficult so avoid in the beginning in doing this type of cellar these are cellar pre-cellar or conical type now a use of neuro navigation is important for the beginners in few cases I always use this just to get oriented to this later on you don't need it like if your anatomy is clear you don't need a navigation when the synod anatomy is not straight like if it is a concal or pre-cellar it's better to have a neuro navigation when it is a re-operation use neuro navigation when there is kissing carotids again use no navigation and when you are doing a extended transitional surgery for dumbbell or giant tumors I always use this now use extended approach for large or giant dumbbell tumors with narrow waist and extended here means is that you just remove the tuberculum celli and medial OCR because this is considered that this is the part of the bone which is making this narrow isthmus so if you remove this then whole tumor you can access it so this permits the retraction of Dura like with the suction then you can retract the Dura and see more tumor which allows the maximum tumor removal under vision so in the beginning the complications of CSF leak is more because when you shift from microscopic to endoscopic there is the visualization is super so there is a aggressive tumor removal tendency then you see the more tumor and you just pull it and then a arachnoid has come and the CSF leak has started so because of superb visualization you have a tendency for more aggressive removal so tend to restrict yourself now there is hardly any bone to support fat graft so the CSF leak may be there if you don't use some glue and all that or if you use the fixed microscope or static microscope because here I must tell you that a fixed endoscope is worse than microscope because it is just 2d only so for visualization and tumor dissection you need 3d vision 3d perception so do not fix the scope because it's worse than microscope 2d only no depth perception 400 or 2 surgeon that is the pilot covalent technique is good for 3d perception which allows you to use the flash light effect dynamic dissection and which helps you to differentiate between the tumor and normal pituitary and between the diaphragm and arachnoid and we have seen that with increasing experience there is improvement in endocrine remission extent of tumor a section preoperative visual deficits improve better post-op high perpetrator in is less because we are able to preserve more and more normal pituitary and there is reduction in duration of surgery mucosal trauma or post-op discomfort hospital stay and CSF leak so to conclude in the beginning one must select cases properly the transition should be gradual from microscopic to endoscopic use extended approach in large fibrotic solid tumors with supra-cellar extension with narrow waist that is the dumbbell or in giant pituitary adenomas spend time in widening of the spinoid model recess recognition of important landmarks during each stage of surgery stay oriented always the buttons must be facing the screen use neuro navigation in complicated cases by manual dissection and sequential tumor removal is the key use flash light effect and preserve normal pituitary avoid arachnoid tear and I tell you if you can avoid arachnoid tear your 90% complications are over because arachnoid tear only causes CSF leak meningitis it only causes damage to the perforators blood goes causes spying if you do intradural dissection you will pull some perforator or something so if you can avoid arachnoid tear 95% of problems are over thank you very much


Which is the biggest problem they have? Price rise is a big problem for them. Earlier they got 500 rupees per day. Now a days they are getting maximum 300. A week ago, 60 rupees per person got the petrol. Now it is 90-60 rupees. Our lives are in a very bad condition. Our problems are in a very bad condition. No one can bring any kind of life to them. The biggest problem is that there is no one to take care of us. There is no one to take care of us. The interest rate is 26-25. The interest rate is 26-25. How many children do they have? I have two children. Does he feel that they will be able to educate their children easily? I don't think they will be able to educate their children easily. The change that we expect from the doctors is that they have to show what is going on. They have to show what is going on.


The next item of business is a member's business debate on motion 6107, in the name of Rachel Hamilton, on supporting mental health in rural communities. The debate will be concluded without any questions being put, but I'd ask members who wish to participate to press the request-to-speak buttons now or as soon as possible. I call Rachel Hamilton to open the debate around 7... Point of order, Finlay Carson. Thank you, Presiding Officer. I'm struggling to hear. I wonder whether we could have the volume in the chamber. Your mic's very quiet. I will speak up, and hopefully that will improve the situation, Mr Carson. With that, I call Rachel Hamilton to open the debate around 7 minutes, Ms Hamilton. Thank you, Presiding Officer, and it is a privilege to be able to bring forward this motion for debate today. On a topic that I know members and colleagues joining me in the chamber are incredibly supportive of, and I thank them for that. During yesterday's rural question sessions, we heard the Cabinet Secretary speak genuinely about Rasby and the National Rural Mental Health Forum in response to a question from my colleague Alexander Stewart. Her response to my colleague's question showed that we can discuss this issue without scoring political points. This is an issue on which politicians can agree, and that is exactly what I hope to achieve from today's debate. Last May, alongside my colleague Craig Hoy, we hosted a round table on this issue with a wide group of stakeholders from rural industries and third sector organisations such as SLE, Age Scotland, the Poverty Alliance, the Countryside Alliance and the Alliance attended. It was clear from this meeting that there was so much more that we could do to support their work. We identified the need to tackle the stigma around mental health, as well as the importance of early intervention. However, those issues are universal. The key takeaway from the discussion for me was that rural communities face entirely different challenges in terms of their mental health than cities, and our response to those challenges must be sensitive to that. There is also a growing recognition that rural contexts can be overlooked in the design of mental health services. That led to the creation of the National Rural Mental Health Forum, and I welcome Jim Hume to the gallery today. The Cabinet Secretary outlined the £50,000 worth of support that the Scottish Government was providing them, but we all got the sense that she wished that she could go further with that. People living in rural areas, farmers, crofters and agricultural workers often find it difficult to access mental health care. Like others across Scotland, they experience depression, suicidal thoughts and feelings, self-harming behaviour and anxiety, no matter their age, gender or location. On top of that, remoteness, isolation and small-town stigma can exacerbate those problems. As can the occupational challenges of rural workers, big gamekeepers, for example, who face vitriol and abuse on a daily basis for simply doing their jobs, looking after the countryside. They must also contend with the threat of losing their livelihoods looming over their head as a result of the strict but necessary management of gun licences. All the while, their working life could see them go days without seeing another person. It is those challenges that led us to call the Government to establish a rural workers task force to look at ways of supporting those workers with their mental health. I was encouraged, as I think we all were, when the former First Minister, Nicola Sturgeon, committed to looking again at those proposals. I know that things have changed a little in government since then, and such commitments come full by the wayside. However, the last few years have been tough for people living in rural areas. I will give way. I am most grateful to Rachael Hamilton for what she said thus far. Does she also recognise that the work of the Royal Scottish Agricultural Benevolent Institution, our SABI, is critical and very practical and carried out by volunteers who really help to provide assistance to farmers and crofters, in particular, who live remotely and may not see anybody for weeks at end, and provide invaluable support to people in those predicaments throughout rural Scotland? I thank Fergus Ewing for his intervention, and I completely agree that RASB does such good work. I will mention it a little bit later, because it is some of the work that they are doing that has formed the basis for some of the proposals that I will be talking about today. I was just talking about the challenges that farmers and rural workers have been facing, not only through Covid, making sure that we have got food on our plates, but also having to work every single day and not be able to take a day off. They have also faced increasing energy costs and input costs due to Putin's invasion in Ukraine. Those costs have had to be absorbed by people working in the agricultural sector, which has caused a huge financial strain on the balance sheet. That is why I and my party have taken the initiative and produced our own detailed proposals to establish a Scottish rural mental health task force. I will explain a little bit more as I go through, but our plan is going to be able to ensure that rural GP provision is placed on a sustainable footing to bolster mental health services in rural communities. It will create a network of mental health first-aiders by training residents, neighbours, local clubs, professionals such as vets, feed merchants and rural sales representatives, so that farmers and rural workers with whom they frequently engage can get the best and maximum benefit from that interaction. The mental health first-aiders would be able to be trained to identify signs of poor mental health and encourage mental health training among rural workers. We have established a short-term working life group to launch a viable and collaborative way to deliver that ambition. I would, of course, be delighted to discuss those proposals further with the Cabinet Secretary and her colleagues in Government. For all that we disagree on, I know that mental health is a matter that this Government does take seriously, but the Government is only one piece of the puzzle. At the NFU's annual dinner earlier this year, I was fortunate enough to be sat next to Mark Gascoing, who is the original founder of Farmstrong from New Zealand. Of course, that has been established in Scotland now, but I talked to him at length about his organisation's work in supporting farmers' wellbeing. I also want to thank Virgin Money, which might sound slightly unusual and an unlikely contributor to a parliamentary brief on this particular debate, but they were a partner with Farmstrong and funded the roadshow throughout Scotland. Undoubtedly, that was fostered through their relationship with the previous bank, the Clydesdale bank, who had a very strong relationship with the agricultural sector and worked across the countryside. It was the conversation with Mark Gascoing that strengthened my resolve to bring this debate to the chamber today to discuss what more we can do to tackle the issues of which we are discussing. We are also joined today by representative from Raspberry, from Change Mental Health, from the NFUS and the SLE, who have also undertaken fantastic work to tackle this issue. Their role and the role of the third sector and rural organisations cannot be understated. Whether it is specific services, signposting or simply the presence of someone to talk to, their work is absolutely vital. I am delighted that they have joined us today for the debate. I have talked at length about the issue at hand on our plan to tackle, but I want to finish on a more personal note. The British Association for Counseling and Psychotherapy were kind enough to prepare a briefing for this debate today, which drew attention to the higher burden of depression amongst women working in agriculture compared to men. Before entering politics, I was an agronomist visiting farms across Scotland and the north of England. For many of the farmers that I worked with, there is no doubt that I was the only person that they had spoken to in any given day. Can you imagine that? Poor things. For me, they must have been literally the only person that I spoke to, perhaps for that week. I was one of two women in my role out of 100 across the UK, which brought its own challenges. I had long days with little interaction with others and dealing with the odd throwaway comment about being a woman in agriculture. It is so easy to see how these things can build up to the point where it becomes difficult to cope. I am sorry that I do not have any more time to mention young farmers. I hope that some of my colleagues will mention that today, because they too are their challenges with social isolation as well. I was thankful to have a fantastic support network around me from anything happening to me, but not everybody is so lucky. I hope that we can work together to make things better. I congratulate Rachel Hamilton on securing this debate. It is a really important issue and Ms Hamilton has highlighted that very well. As an MP covering a large rural area, Dumfries and Galloway and the Scottish Borders, I am aware of the challenges that rurality can pose to positive mental health but also the benefits that it can bring. I am also aware, as the motion states, of the increased challenges that our farming community faces, the Ukraine war and the cost crisis. They have all added increased stress, as well as leaving the EU. That has already been said, but it is worth repeating that the evidence does show us that people in rural Scotland are more likely than others to experience depression, suicidal thoughts and feelings, self-harm and behaviour and anxiety, no matter their age, gender or location. It is worth repeating that. They are at a higher risk of becoming isolated and worsened by remoteness, stigma and fear, and stigma is a huge issue that needs to be addressed. It is right that we take all action possible to support the health and wellbeing of our rural communities. 98 per cent of Scotland's land mass is rural, 17 per cent of Scotland's population lives in rural Scotland and just under 1 million people live in rural Scotland. A lack of anonymity has been identified as a barrier to people seeking help at early stage in rural areas. Evidence from change mental health, formally supported in mind, shows that people in rural Scotland want support to be low-level in non-clinical and informal settings and be delivered by people who are trusted and local networks. Services need to be close to the place of need, designed to include mobile and digital services and outreach. The outreach approach must recognise the significant stress of travelling to appointments for those with poor mental health. I would therefore ask the cabinet secretary if further targeted advertising and engagement across rural Scotland can take place to promote means through which people can access support and to promote the wider message of it's okay, not to be okay. I am aware of the research from Rosabrie, which shows that the Scottish index of multiple deprivation struggles to identify people living in deprivation in rural areas. That can lead to some believing that living in rural Scotland is a rural ideal, which in fact deprivation and poverty exist and is becoming increasingly exacerbated. Low-swage economies are in rural areas of Scotland and 9 out of 10 people who are income deprived do not live in a recognised deprived area. Evidence suggests that people living in rural areas experience deprivation differently from those living in towns and cities. Particular issues in rural areas include higher consumption of fuel for heating and transport. I am a member of the British Irish Parliamentary Assembly. We are doing an economy committee inquiry at the moment. It is absolutely highlighting that one of the main challenges is the fuel for oil heating, which is a major issue that can contribute to poorer mental health. Emma Harper agrees that we need to do a lot better at creating the parity that should exist between physical and mental health services, because that does not exist in rural areas for sure, but it does not exist in much of Scotland. Does she agree that we should unite to see improvement rapidly? I am also a member of the Health and Sport Committee and I am a nurse. A lot of the work that I do as former co-convener of the mental health cross-party group talks about parity that we need to do. There is a lot of work going on, so I would support what the member is asking for, but I know that there is a lot of work under way right now, especially in the work that I am doing in Parliament. We know that less accessibility to key services such as childcare, broadband and transport links can also be a challenge. Limited opportunities to earn adequate income compared to urban areas is part of the issue. I am conscious of time, but I am aware from my own case work that there are many issues that need to be supported. I also want to give a nod to former MSP Jim Hume and Keira McDermott, who are in chamber this afternoon from Change Mental Health, so I welcome them to the gallery today. There is so much work that I could talk about as well, and I know that Rosabi has been highlighted already, and there is another fantastic charity operating to support those in our agricultural communities. We must collectively work to tackle that in all our areas, including our rural areas. I thank Rachel Hamilton for bringing such an important topic to the chamber today, and I thank her for shining a light on what is often a hidden epidemic. Both Rachel Hamilton and I represent areas with large remote and rural populations. More than half of Aberdeenshire's population live in rural areas, and that compares to around only 17% for the rest of Scotland. The reality is that mental health interventions have often been developed through the lens of urban populations. What works in Glasgow will not necessarily work in Glenburby. It is vital that policy makers recognise the unique nature of mental health in rural and farming communities so that we can better respond to it. That is why the advocacy of organisations such as the National Farmers Union Scotland, the Farm Safety Foundation and the Countryside Alliance, as well as the work of academic institutions such as Robert Gordon University in my region, are so important. In the north-east, more than 22,000 people are employed in the food, drink and agricultural sectors, but the awful reality is that agricultural workers are amongst the highest suicide rates in the UK, and sadly one farmer dies every week by suicide. Farmers often work, as we've heard today, in isolation with loneliness frequently affecting their mental health. Finance worries, especially with the input-price inflation, can weigh heavily on their minds. The 2021 documentary, Anurthing Farming Lives, which was conceived by several organisations in north-east Scotland, thoughtfully examines these issues. The north-east has also suffered from the recent avian flu outbreak, resulting in the deaths of thousands of hens, a devastating loss for businesses. While spring heralds the lambing and carving season, there are associated pressures and stresses for farmers. Lifestop worrying can have a devastating impact on the mental health of farmers, with the horrendous case recently of one dog mawling 17 lambs to death in five and four lambs in Murray. Farming, as we've heard today, can be both physically and psychologically tough. We must continue to work to break down barriers, of course. Emma Harper. I thank Tess Wight for giving way. You mentioned livestock worrying. It's great that we raise awareness at any opportunity about livestock attacks. Would she agree that the changes to the legislation that I brought forward in the member's bill will help to raise awareness of livestock worrying so that we can try to reduce those incidences? I thank Emma Harper for raising that. I think that anything to stop this from happening is to be applauded. I'd also like to say that the behaviour of dog walkers is also very important to keep dogs on leads at this time of year. We must continue to break down barriers such as loneliness, as I've said, that might prevent farmers and agricultural community from accessing help. It's good to know, as we've heard today, that young farmers are doing a lot of good work and they're piloting a Thrive Mental Well-being app that provides live access to qualified therapists who can give advice. They can give advice on many things and especially mental health. We need to look more closely at those kind of initiatives. Two final comments, Presiding Officer. Accessing appropriate NHS services to support their mental health can be challenging for people residing in rural and remote communities. We know, sadly, that there's a shortage of GPs and other clinicians in rural areas, something the Scottish Government urgently needs to address to prevent the collapse of rural health care. It's good today that Mary Gougeon MSP is here to hear my next comment because Angus mental health patients have also been badly let down by the closure of the Mulbury unit at Strathrow hospital in 2018, meaning that patients have had to travel and do have to travel miles to a facility in Dundee where the Strang report has revealed serious systemic issues with mental health services. Residents in Angus feel deeply let down by that decision and I hope that the minister will address those points in her closing. I thank Rachael Hamilton for bringing this important debate forward. I was aware of Rachael Hamilton's knowledge and thoughts in that area, but your contribution was really good and well received. I am grateful for the opportunity to speak in this debate on behalf of Scottish Labour. Like many in the chamber, I represent a rural region in South Scotland and I recognise much of what is in the motion for debate today. The agricultural industry is undoubtedly one of the most challenged out there, whether it is the weather, supply chain issues, uncertainty following the war in Ukraine or soaring energy prices. Farmers, farm workers and crofters are constantly battling the various factors that affect their livelihood and businesses. With long hours, financial pressures and often isolated workplaces, farmers and the agricultural workforce are more susceptible to their mental health being under strain. According to the Office for National Statistics, as we have heard, the suicide rate for the male farm workers is three times the male national average. That is a worrying figure and I believe that one that has persisted over a long period of time and it shows the importance of giving particular focus to improving rural mental health. It is a devastating statistic that we must all take very seriously. Many of the studies that we have heard that I came across while I was preparing for today's debate highlight the wide range of mental health challenges that are facing people in rural Scotland. Alarmily, in this area, there is the false conclusion of the idyllic countryside lifestyle that is moving to the country for a better life, the kind of thing that we see on the TV, which is just not a reality for so many people. I welcome the fact that mental health in rural communities is receiving more attention and it appears that we are beginning to turn the corner in recognising its vital importance to the wellbeing of countryside communities. However, let me be clear that recognition on its own will not push the needle forward. It will require considerable and targeted campaigning, as we have heard, and investment over a long period of time. It is a long-term commitment that we need to this issue. Indeed, although investment in mental health services is necessary, that will not deliver the changes that we need to see alone. We do require a strong economy that delivers for rural areas and improves the likelihood of not only mental wellbeing but physical and social and economic wellbeing—absolutely essential, of course. She is making a very important point about the needs for us to revitalise rural life in the rural economy. One of the key infrastructure projects around that is the extension of full coverage of 5G and full fibre broadband. That one infrastructure project in itself has the power to transform not just the rural economy and rural life but tackle also the issues of isolation and loneliness. Does she agree? I absolutely agree. I was fully behind a commitment in 2019 from the Labour Party, when we talked about internet being the equivalent of libraries of the early 20th century. It opens up opportunities for people, both for business but absolutely for that isolation. Of course, we all would agree that the pandemic proved that without a doubt. We need to get that infrastructure work done and we need to prioritise areas that would make the biggest difference. For too long, we have focused overly on urban areas. Tess brought forward a very good point about how we manage services in that way while we have forgotten some of our rural economies. In the interests of time, I have some of the points that Emma Harper has raised around how we make sure that we have good services for people and that people can see the benefit of meeting up in places to go. I believe that good public services in rural areas is so important. To conclude, I want to thank everybody for their contribution. The notion that we should be working together to make that happen is so important. Thank you, Ms Mocken. I now call Donald Cameron to be followed by Beatrice Wishart in four minutes, Mr Cameron. Thank you, Deputy Presiding Officer. Can I refer to my register of interests and farming, crofting and shooting and deer stalking therein? Can I also thank Rachel Hamilton for securing this debate? There have been many excellent speeches so far, each looking at this issue slightly differently. Rachel Hamilton mentioned young farmers and how right she was to focus on them. Of course, it goes without saying that young farmers are the future of farming, and it is absolutely right that their mental health, in particular, should be a focus of this debate. In every rural debate that we have, we often rightly pay tribute to the ways in which farmers, crofters, growers, gamekeepers and others manage the land, and we talk about how they have adapted to the need to reduce carbon emissions and to do things more efficiently to meet the new environmental challenges. We applaud the ingenuity of those in rural Scotland who have driven diversification in agricultural business to become more sustainable. However, we rarely acknowledge the individuals behind all of this and, more importantly, their own wellbeing. As others have said, the Royal Agricultural Benevolent Institution's big farming survey found that 36 per cent of the UK's farming community are probably or possibly depressed, and many do not seek mental health support due to the stigma attached to it. The levels of depression vary among different farming sectors, but the second highest group in that study were grazing livestock farmers from quote less favoured areas, which is a particular concern to me representing the highlands and islands, where that land status predominates. The reasons for these figures are of course multifaceted, and many speakers have developed arguments about them today. Isolation in long working hours has been mentioned as a key reason for poor mental health in the agricultural sector, and NFUS Scotland has noted that farmers face increasing input costs, market volatility and so on. In another context, some rural workers experience threats and abuse. BASC Scotland has highlighted Scottish Government recent research, which found that 64 per cent—almost two thirds—of gamekeepers in Scotland experience threatening behaviour or abuse from members of the public at least once a year. We also have to be cognisant that access to mental health services remains difficult for many people across Scotland and especially in rural Scotland. Recent data shows that, in the NHS Highland area alone, almost three quarters of adults are waiting longer than 18 weeks for mental health treatment. Nearly half of those waiting to be seen have waited longer than a year. In our island communities, those waiting times are just as stark. In the western isles, half of adults are waiting longer than 18 weeks, and in Shetland almost 40 per cent are waiting longer than 18 weeks. We cannot sweep that under the carpet. Tess Wright was absolutely right to talk about this. There has to be swift, effective action to bring down these waiting times so that those who need specialist support can be seen in our rural communities as a matter of urgency. That is not just a role for the NHS to play. We know that there are many organisations who do fantastic work to support agricultural work, as they have been mentioned already. I will mention them again, because they absolutely deserve it. NFUS, BAS Scotland, Change Mental Health and Scottish Land in the States all do fantastic work to support the mental health of their members and others. Our agricultural workers and land managers are, as others have said, the custodians, the guardians of the Scottish countryside. They do fantastic work, often not recognised and without them Scotland would be a poorer nation, but warm words do little for those who often work in difficult conditions through long hours and with a multitude of challenges facing them. All of us here do more, much more, to support and nourish those in our rural workforce when it comes to their mental health. I thank and congratulate Rachael Hamilton for bringing this important debate to the chamber this afternoon. There is a mental health crisis in Scotland and there was long before the pandemic, and it affects people from all walks of life. In the early days of Russia's invasion of Ukraine, I think that we could all be forgiven for feeling anxious. While many of us have the option to focus on other matters, while the conflict continues, crofters, farmers and agriculture workers in Scotland are plowing on quite literally. As the motion highlights, there has been a vast rise in inflation on the products and services needed to provide food on our tables. And the conflict in Ukraine has contributed to inflation rise alongside the impact of Brexit and a slowdown of the world economy due to Covid-19. Farmers cannot escape the growing impact of inflation. They are doing all they can to cope with financial pressures, ensuring that high-quality produce is available at affordable prices and in fulsome supply. Business is at risk from multiple factors. Leaving Europe has not only meant an impact on inflation and that there are fewer workers coming forward to pick produce, but there is new uncertainty about the future of farming payments. We are also seeing increasing criminal behaviour that impacts financial stability, such as fly-tipping, theft and damage, and irresponsible access in the countryside, threatening the welfare of livestock, widog attacks and people leaving gates open. People do not seem to understand the impact of those actions. The pressure is on, and it is on those working to produce food, not just the physical toll of working all hours in all weathers, supporting the environment as well as their families and wider food supply chain, but the anxiety and worry about the increasing pressures that I have just described. More support is needed to address the underlying concerns that can contribute to poor mental health, while lack of anonymity in rural Scotland is known to be a barrier to people seeking help at an early stage. Crofters, farmers and agriculture workers often work alone too, increasing the impact of loneliness, which can be a major contributor to poor mental health. More widely in rural areas, one in 10 rural jobs is based on an estate business, and those businesses are also feeling the pressure. Any impact on them could see a knock-on effect of unemployment across a community, and those communities face unique challenges of rural deprivation such as higher fuel costs and poor public transport options. Scotland's islands are some of the places with highest levels of fuel poverty. The winter has been tough, and the weather does not necessarily allow for the heating to be turned off even in summer. The cross-party group on poverty has opened an inquiry into rural poverty and is encouraging people to share their experiences and views, and more information can be found on the poverty alliance website. Attracting local health and social care staff to live and work in rural and island areas, as I raised in the chamber yesterday, is challenging and impacts physical and mental health service provision. Poor connectivity, as others have said, makes seeking help or travelling to services more difficult. Communities in the north isles of Shetland, for example, face multiple ferry journeys to reach services on mainland Shetland, while poor broadband connections, or often a complete lack of any digital connectivity or mobile signal, make it impossible to access online therapeutic services, national infrastructure that should be available to all, regardless of geography. However, as the motion reminds us, there is support out there. Several organisations are working to provide tailored support for rural communities, and all those are mentioned in the motion. To conclude, Presiding Officer, I commend the groups that provide tailored and person-centred support to rural communities. The final speaker in the open debate, Finlay Carson, is widely accepted that people in rural Scotland are more likely to experience depression, suicidal thoughts and a higher risk of self-harming behaviour. No matter their age, gender or even location, there is every chance that they will feel isolated, often worsened by remoteness and fear of stigma. There is a need for more chances to engage before more individuals and there is a wider mental health crisis. That engagement that we need could simply take the form of a low-level, local, non-clinical setting with shorter waiting times and a mobile outreach to parts of Scotland, which would play a huge part in critical prevention of mental health. It is, after all, everyone's business to tackle mental health and the excellent work of the National Rural Mental Health Forum is vital in driving that forward. I am pleased to see some of the members of the forum in the chamber today, including Jim Hume, who served in the floor of the chamber and continues to champion rural Scotland. The forum is a dedicated network of over 230 organisations from third-sector, private and public sector, with an outreach of over half a million people living in rural Scotland, including my constituency of Galloway and Western Fries. Essentially, it drives change to enable rural people to be open about their mental health by creating a solid evidence base for that work, which is needed to improve people's lives. Importantly, the forum has developed a programme to influence policy makers to channel resources in a way that brings positive change through a network of rural organisations across Scotland. Any action to tackle mental health topics and issues in rural communities, I would strongly suggest, must also do in close and continued collaboration with the forum if we are able to seriously address the problem. Lack of anonymity has been identified as a barrier to people seeking help at an early stage, and that is something that we seriously need to tackle. We must create ways for people to connect with one another before their personal crisis occurs. As I have argued on a new unification, services need to be close to the place of need, designed to include mobile and digital services that we have already heard, as well as outreach. However, the outreach approach must also recognise the significant stress of travelling to appointments for those with poor mental health. Mental health care must be mainstreamed within the NHS and simply not a bolt-on, as it too often is, and there must be parity between mental and physical health. Crucially, there must also be an increased focus on the need of our children and young people by providing greater resources in order to reduce waiting times that we have heard in this debate already, especially in relation to self-harming. I think that we all recognise the important role that the forum has played in tackling mental health through sharing best practice, encouraging collaboration, raising awareness and informing policy and gathering research. It played a crucial role during the Covid-19 pandemic that had such a negative impact on the wellbeing, particularly on the Scottish rural population. Of course, it is now having to deal with the cost of living crisis, especially as the low-wage economy is so much the norm in rural areas. Evidence suggests that people face greater anxiety than most because of higher heating and transport costs and less accessible key services that include childcare and welfare broadband. There is also a limited opportunity to boost their income compared to urban areas. I would like to take this opportunity to highlight the scheme that was introduced in 2020 by the Stewartie Rugby Club. We have two members here today. A few years ago, two members tragically took their own lives. On the back of that scheme was set up and included engagement with Glasgow warriors to help coaches, players and members who were experiencing mental health issues or emotional distress. Good mental health is promoted on par with good physical health, and the players are encouraged to speak out even if they are just having a bad day. We have strived to ensure that everybody in the club is involved in recognising that health and the broadest sense is important, whether that be physical or mental health. On the back of what the club we are doing, I facilitated a meeting of what was very loosely called the Stewartie Mental Health Forum, a group made up of a range of mental health organisations to ensure that we could encourage people to have the covenants to be aware of the appropriate methods of first engagement and simply to be able to speak to someone who may be experiencing low mental health. We know how important the first responder is, and we know that research shows that someone with poor mental health may only take three chances to reach out. We must make sure that we get it right. The Scottish Conservatives want to see a network of trained mental health advisers created across Scotland and the heart of our rural communities to include any few members, young farmers, sales reps, auction mark workers, coach sports, just to name a few, trained to spot early signs and symptoms of poor mental health and assess the risk of suicide and self-harm while encouraging that person to access appropriate professional support on a confidential basis. I look forward to working with Rachel Hamilton and others to see how we can further support groups and individuals across Scotland. I thank Rachel Hamilton for bringing forward the debate, which has given us all an opportunity to talk about the hugely important issue of mental health in our rural communities. I also want to echo Carol Malkin's points about the genuine open approach that you have taken to the debate and the tone that you have set for the discussion today, which I very much welcome. I also welcome the chance to set out the Scottish Government's work on rural mental health and to discuss the challenges that people in rural areas face, because those are issues that I personally care about representing a rural constituency. Tess White mentioned in her contribution the Mulberry unit, and I know that she will no doubt be aware of the campaign that I had specifically on that, which is why that issue of equality of access for our rural communities is one that is particularly close to my heart. Rural Scotland and our agricultural community is based upon strength and the bonds of support. Farmers and crofters already know the value of supporting each other during the good times and at times of difficulty, but, as we have heard today, that is really difficult, given the isolation that people experience precisely because of where they live and where they work. As we have heard in the chamber today, particularly by Emma Harper and by Finlay Carson, mental health is everyone's business, and our rural economy is only as healthy as the individuals in communities who help to drive it forward. The motion mentions some of the issues impacting rural Scotland, and I know from my own work as Cabinet Secretary about some of the particular challenges that our land-based workers and communities have faced and those challenges that they continue to face. We cannot underplay the many challenges for Scotland's rural island and coastal communities and businesses, especially in the aftermath of the pandemic, Brexit and the cost of living crisis, and also in the wake of global trends such as climate change, biodiversity loss, food and energy insecurity. In trying to address those issues, the First Minister recently set out his vision for Scotland and the outcomes that we aim to achieve as a Government. We will use the powers that we have in Scotland to try and tackle poverty in all its forms and to protect people across our country as far as we possibly can from the impacts of the ongoing cost of living crisis. I want to briefly set out a couple of examples of how we are trying to address some of those challenges. One such example is the islands cost crisis emergency fund, which we launched last year, which recognises the distinct and particular challenges that are faced by our island communities, which were also highlighted by Rachel Hamilton in her comments and which Beatrice Wishart outlined in her contribution today. In relation to our agriculture sector and in response to war in Ukraine, we established a food security and supply task force together with industry, specifically to monitor and identify any potential disruption that there would be resulting from the impact of that. Recognising the challenges that our supply chains had also faced in recent years, pandemic, Brexit and the resulting vulnerabilities that were in turn exacerbated by that illegal war. That work produced a number of recommendations that we have taken forward and implemented, but I think that all of those challenges show us in the round. What they really do is call on us to act and they call on us to act now collectively and to really look across and beyond our policy boundaries. I really just want to turn now to the other substantive part of Rachel Hamilton's motion in relation to mental health and the support there. The motion recognises and welcomes the important work that is being done by NFUS, Countryside Alliance, the Mental Health Foundation, SLE, National Rural Mental Health Forum and the Poverty Alliance. As we have also heard from the various contributions around the chamber today, it is also vitally important that we recognise the role that organisations such as RSABI, the work that they do, the work that is being done by the Scottish Association of Young Farmers, the Scottish Crofting Federation and all those other agricultural organisations and businesses here too. The role of supporting businesses such as vet practices, marts, feed merchants and machinery rings all have an important role to play in providing that first line of mental health support to farmers and crofters. I think that we also need to recognise our own role here as Scottish Government as an organisation that operates in rural Scotland. Arpit offices, area offices and the sub offices, along with the APHA offices, exist to support farmers and crofters. I know that rural vets in particular do have a very demanding job with the pressures of providing a 24-hour emergency response service, and they are often working alone while helping farmers and crofters in a wide range of difficult situations. That has been recognised by the Royal College of Veterinary Surgeons' Mind Matters initiative, which provides that support to improve mental health in all parts of the veterinary profession, and it is currently introducing further support for vets in rural areas. A lot is already happening to support rural wellbeing, and we are proud to support a range of initiatives through RSABI and the National Rural Mental Health Forum. Last financial year, we committed £50,000 to supporting RSABI taking the total Scottish Government's support to over £500,000. I think that it is also really important to outline the kind of support that RSABI are able to offer. They provide that emotional support through a 24-7 helpline and web chat. They also provide a wide range of practical support, including on welfare benefits, business reviews, debt signposting and counselling in mediation services, and financial support, which can include monthly payments and potentially single grants for essential items, including food, heating, counselling, disability aids, funerals and retraining, as well as items for the home. They are also undertaking fantastic work with the development of a Thrive wellbeing app, which includes a live therapist function. I know that three young farmers clubs in Scotland are trialling this, and the initial results from that are really encouraging. The charity works with... I can give you the time back, cabinet secretary. Emma Harper. I will be really quick. If you mentioned the apps and work that has been done already, I know that you will be aware that NHS... To the chair, please, Ms Harper. I know that the cabinet secretary will be aware that NHS Inform has apps and web info, SilverCloud, Delight and Sleepio. Does she agree that, if we raise awareness of work that is already underway out there as well, that can help with early interventions? Yes, I do, and I appreciate the member raising that important point that she has covered, which means that I no longer have to. We need to do what we can to raise awareness of those apps and the support that is available to us. I also want to recognise, though, the work that the SAYFC has done. They run an establishment mental health support service for young people, which is called RUOK. Launched in 2016, the campaign was initially only to run for 12 months, but it was soon realised that it should become a permanent feature. It raises awareness on mental health and wellbeing with the SAYFC members sharing their own experiences. I also want to mention the National Rural Mental Health Forum. It has a wide reach, and it brings together over 230 organisations, charities, businesses, research organisations and individuals to focus on knowledge exchange and sharing experience and learning about mental health and wellbeing in rural areas and ensuring that that rural voice is heard in policy making. I know that Rachael Hamilton touched on that, and I am so glad that she did. That was to mention the work of Farmstrong, the farmer-led wellbeing programme. I was also delighted to get the opportunity to meet Mark Gaskell, the NFUSAGM, in February, while he was completing his tour of Scotland, supporting farmers to ultimately to live well, as well as to farm well. In drawing to a close, I want to reiterate my commitment to ensuring that rural communities have the on-going support that they need through the interventions that we have discussed here today. I think that we do have opportunities to do more through our plan for rural Scotland, which the First Minister had outlined, too. I also want to close by expressing my genuine and my heartfelt thanks to those organisations that we have talked about today. I know that Jim Hume is here from the National Rural Mental Health Forum. I can see Karen McLaren in the gallery as well from RSAPI, NFUS, SLE. I just really to say a huge thank you for the invaluable support that you provide and the work that you continue to do in our rural communities. And I suppose just a final word, I think, to anyone who feels that they are struggling at the moment, to really just encourage them to please talk and please reach out, because all of the organisations that we've mentioned here today and that we've discussed here today are here to listen and they are here to help. Thank you. Thank you, cabinet secretary. That concludes the debate, and I suspend this meeting in Parliament until 2.30.


What's going on everybody this is 1920 select team all china edition Two box break number nine random team sold out on jaz piece case breaks calm We're gonna roll the dice first thing we need to do is the early bird spot So all three after 11 times so here are the first 15 names in the break So top name wins a free spot one two three four five six seven eight nine ten 11 times Sean Mandel there you go. You are the early bird Sean nice So now let's randomize the list of customer names 11 times one two three four five six seven eight nine ten And eleven Ryan Shackleton down to Jacob K nice The names right there Title that sheet in a minute and now for the list of NBA teams 11 times one two three four Five that looks like a gummy worm six seven so love those eight nine ten eleven Wow pelicans on the top spot. Look at that and then look at the bottom Memphis and Lakers Ryan pelicans TJ Leonard Hornets Matthew Nets Zach Paul wizards Stephen K bulls Bretton Clippers Sean Mandel Kings and the early bird spot Sean Thunder EA Pistons Chell with the T-Wolves EA Pacers Ryan Rockets Knicks rich sons Ryan Spurs Cedric last by Modo Jazz Brick magic Zach Paul Mavs Derek heat Matthew S bucks Brian Warriors Rick Blazers Bretton Hawks Brian S Celtics Matthew Sixers Ray Nuggets Jacob Raptors David Tran with the Grizzlies Roger with the Lakers and Jacob with the Cavs So there you go. That was the randomizer portion of the break coming up next the actual break We'll see if there's any trades after a quick trade window