V-OG03 Robotic Epiphrenic Diverticulectomy, Myotomy And Hiatus Hernia Repair

Abstract Background Oesophageal epiphrenic diverticulum’s are rare; reported in less than 0.5 per cent of the population. They are noted however in 1–3 per cent of patients complaining of dysphagia. They are almost always associated with a motility disorder of the oesophagus. Surgery is generally the only solution to help with the symptoms of dysphagia and reflux. Methods This video highlights a case of a moderate sized diverticulum causing dysphagia and significant reflux. The procedure was performed on the DaVinci X system; to my knowledge, this is the first time this technique has been performed on the DaVinci X in the UK. A 4 arm technique was used, utilising two right arms and one left. Instruments used were cadiere forceps, hook and sureform stapler. The 12 mm port was docked with arm 3 and sited on the patients left. A stapled diverticulectomy was performed with the Sureform blue cartridge. An endoflex was used to retract the liver. Results The procedure was successfully performed in 150 minutes and involved resection of the diverticulum, hiatal repair and short myotomy up to the neck of the diverticulum. Conclusion The robotic platform allows for better visualisation of the hiatal structures and vagal nerves and the enhanced magnification make for a safer myotomy. The articulating instruments permit safer dissection of the diverticulum. A 4 arm technique makes the myotomy easier and safer to perform.

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To bee or not to beet with neonicotinoids

Environmental Law Review ◽

10.1177/14614529211021194 ◽

2021 ◽

Vol 23 (2) ◽

pp. 103-109

Author(s):

Lynda M. Warren

Keyword(s):

Sugar Beet ◽

Weather Conditions ◽

The European Union ◽

Environmental Standards ◽

Economic Interests ◽

Precautionary Approach ◽

The United Kingdom ◽

Commercial Sugar ◽

The Uk ◽

First Time

In January 2021 the UK government granted an application for authorisation to use thiamethoxam, a neonicotinoid pesticide, to protect commercial sugar beet crops from attack by viruses transmitted by aphids. This was the first time such an authorisation had been granted in the United Kingdom (UK) and there were concerns that it signalled a weakening of environmental standards now that the UK was no longer part of the European Union. In fact, similar authorisations had been granted by several European Member States in the last 2 years, despite the ban on the use of neonicotinoids introduced in 2018. Nevertheless, the reasons for granting the authorisation do suggest that the balance between adopting a precautionary approach to environmental protection and taking emergency action to protect economic interests may have shifted. It was acknowledged that the proposed mitigation to safeguard bees and other wildlife was not entirely satisfactory. In the end, due to unforeseen weather conditions it meant that the pesticide is not necessary, which in itself demonstrates that short-term emergency measures are unsuitable for dealing with the problem. If the sugar beet industry is to continue to prosper in the UK, it will need to be managed in a way that provides resistance to virus infection without the use of controversial chemicals.

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Spontaneous oesophageal perforation after laparoscopic hiatus hernia repair

ANZ Journal of Surgery ◽

10.1111/ans.12560 ◽

2014 ◽

Vol 85 (11) ◽

pp. 887-888

Author(s):

Martyn L. Humphreys ◽

Bevan Jenkins ◽

Jason Robertson ◽

Michael Rodgers

Keyword(s):

Hernia Repair ◽

Hiatus Hernia ◽

Oesophageal Perforation

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657 ROUTINE ESOPHAGRAMS FOLLOWING HIATUS HERNIA REPAIR MINIMISES REOPERATIVE MORBIDITY: A MULTICENTER COMPARATIVE COHORT STUDY

Diseases of the Esophagus ◽

10.1093/dote/doab052.657 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

David Liu ◽

Melissa Wee ◽

James Grantham ◽

Bee Ong ◽

Stephanie Ng ◽

...

Keyword(s):

Hernia Repair ◽

Hiatus Hernia ◽

Functional Outcomes ◽

Gastric Resection ◽

Postoperative Morbidity ◽

Early Complications ◽

Esophageal Obstruction ◽

Comparative Cohort Study ◽

One Year

Abstract Hiatus hernia repairs are common. Early complications such as re-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Here, we determine whether routine postoperative esophagrams following hiatus hernia repair may expedite the surgical management of these complications, reduce reoperative morbidity, and improve functional outcomes. Methods Analysis of a prospectively-maintained database of 1829 hiatus hernia repairs undertaken in 14 hospitals from 1 January 2000 to 30 September 2020. 1571 (85.9%) patients underwent a postoperative esophagram which was reviewed. An early (<14 days) reoperation was performed in 44 (2.4%) patients. Results Compared to those without an esophagram, patients who received one prior to reoperation (n = 37) had a shorter time to diagnosis (2.4 vs. 3.9 days, p = 0.041) and treatment (2.4 vs. 4.3 days, p = 0.037) of their complications. This was associated with decreased open surgery (10.8% vs. 42.9%, p = 0.034), gastric resection (0.0% vs. 28.6%, p = 0.022), postoperative morbidity (13.5% vs. 85.7%, p < 0.001), ICU admission (16.2% vs. 85.7%, p < 0.001), and length-of-stay (7.3 vs. 18.3 days, p = 0.009). Furthermore, patients who underwent early reoperations for asymptomatic re-herniation had less complications and superior functional outcomes at one-year follow-up than those who needed surgery for symptomatic recurrences later on. Conclusion Postoperative esophagrams decreases the morbidity associated with early and late reoperations following hiatus hernia repair, and should be considered for routine use.

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The duties of impartiality, disclosure, and confidentiality: lessons from a London-seated arbitration

Arbitration International ◽

10.1093/arbint/aiab013 ◽

2021 ◽

Author(s):

Samuel Yee Ching Leung ◽

Alex Chun Hei Chan

Keyword(s):

United Kingdom ◽

Important Case ◽

Careful Examination ◽

International Arbitration ◽

The United Kingdom ◽

Key Concepts ◽

The Uk ◽

First Time

Abstract Halliburton Company v Chubb Bermuda Insurance Ltd (formerly known as Ace Bermuda Insurance Ltd [2020] UKSC 48 is an important case not only to the UK but also to the international arbitration community for several reasons: first, it examines indispensable duties in international arbitration and for the first time recognises and explicates upon the duty of disclosure at the highest court of the United Kingdom; secondly, it addresses and clarifies key concepts in international arbitration; thirdly, it confirms the objective nature of the test of justifiable doubts which has wider implications for other arbitral forums; fourthly, it illustrates how the duties of impartiality, disclosure, and confidentiality interact with and affect each other and how the key concepts should be applied to this interaction; and finally, it lays down useful guidance for arbitrators. For these reasons, this case deserves close and careful examination. This article aims to explain the significance of the aforesaid and suggests that, in addition to what has been addressed, further judicial explanations are warranted in what other aspects.

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Defence Medical Services’ REBOA training course

BMJ Military Health ◽

10.1136/bmjmilitary-2021-001926 ◽

2021 ◽

pp. bmjmilitary-2021-001926

Author(s):

Max E R Marsden ◽

C Park ◽

J Barratt ◽

N Tai ◽

P Rees

Keyword(s):

Training Programme ◽

Balloon Occlusion ◽

Medical Services ◽

Skill Retention ◽

Training Course ◽

Challenges And Opportunities ◽

Haemorrhage Control ◽

Surgical Teams ◽

The Uk ◽

First Time

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors’ perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation.

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Do we need medical leadership or medical engagement?

Leadership in Health Services ◽

10.1108/lhs-03-2014-0029 ◽

2015 ◽

Vol 28 (3) ◽

pp. 173-184 ◽

Cited By ~ 22

Author(s):

Peter Spurgeon ◽

Paul Long ◽

John Clark ◽

Frank Daly

Keyword(s):

Care Quality ◽

Current Evidence ◽

Organisational Performance ◽

Content Type ◽

Care Quality Commission ◽

The Uk ◽

Medical Leadership ◽

First Time ◽

Practical Implications ◽

A Current

Purpose – The purpose of this paper is to address issues of medical leadership within health systems and to clarify the associated conceptual issues, for example, leadership versus management and medical versus clinical leadership. However, its principle contribution is to raise the issue of the purpose or outcome of medical leadership, and, in this respect, it argues that it is to promote medical engagement. Design/methodology/approach – The approach is to provide evidence, both from the literature and empirically, to suggest that enhanced medical engagement leads to improved organisational performance and, in doing so, to review the associated concepts. Findings – Building on current evidence from the UK and Australia, the authors strengthen previous findings that effective medical leadership underpins the effective organisational performance. Research limitations/implications – There is a current imbalance between the size of the databases on medical engagement between the UK (very large) and Australia (small but developing). Practical implications – The authors aim to equip medical leaders with the appropriate skill set to promote and enhance greater medical engagement. The focus of leaders in organisations should be in creating a culture that fosters and supports medical engagement. Social implications – This paper provides empowerment of medical professionals to have greater influence in the running of the organisation in which they deliver care. Originality/value – The paper contains, for the first time, linked performance data from the Care Quality Commission in the UK and from Australia with the new set of medical engagement findings.

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Quantifying the prevalence of assortative mating in a human population

10.1101/848911 ◽

2019 ◽

Author(s):

Klaus Jaffe

Keyword(s):

Assortative Mating ◽

Genetic Relatedness ◽

Random Mating ◽

Human Populations ◽

Genetic Composition ◽

Genetic Studies ◽

Maintenance Of Sex ◽

Animal Populations ◽

The Uk ◽

First Time

AbstractFor the first time, empirical evidence allowed to construct the frequency distribution of a genetic relatedness index between the parents of about half a million individuals living in the UK. The results suggest that over 30% of the population is the product of parents mating assortatively. The rest is probably the offspring of parents matching the genetic composition of their partners randomly. High degrees of genetic relatedness between parents, i.e. extreme inbreeding, was rare. This result shows that assortative mating is likely to be highly prevalent in human populations. Thus, assuming only random mating among humans, as widely done in ecology and population genetic studies, is not an appropriate approximation to reality. The existence of assortative mating has to be accounted for. The results suggest the conclusion that both, assortative and random mating, are evolutionary stable strategies. This improved insight allows to better understand complex evolutionary phenomena, such as the emergence and maintenance of sex, the speed of adaptation, runaway adaptation, maintenance of cooperation, and many others in human and animal populations.

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Treatment of first-time traumatic anterior shoulder dislocation: the UK TASH-D cohort study

Health Technology Assessment ◽

10.3310/hta23180 ◽

2019 ◽

Vol 23 (18) ◽

pp. 1-104

Author(s):

Jonathan L Rees ◽

Anjali Shah ◽

Katherine Edwards ◽

Maria T Sanchez-Santos ◽

Danielle E Robinson ◽

...

Keyword(s):

Risk Factors ◽

Shoulder Dislocation ◽

Recurrent Dislocation ◽

Incidence Rates ◽

Anterior Shoulder Dislocation ◽

Traumatic Anterior Shoulder Dislocation ◽

The Uk ◽

First Time ◽

Residual Confounding ◽

Age And Sex

Background Shoulder dislocations are the most common joint dislocations seen in emergency departments. Most traumatic cases are anterior and cause recurrent dislocations. Management options include surgical and conservative treatments. There is a lack of evidence about which method is most effective after the first traumatic anterior shoulder dislocation (TASD). Objectives To produce UK age- and sex-specific incidence rates for TASD. To assess whether or not surgery within 6 months of a first-time TASD decreases re-dislocation rates compared with no surgery. To identify clinical predictors of recurrent dislocation. Design A population-based cohort study of first-time TASD patients in the UK. An initial validation study and subsequent propensity-score-matched analysis to compare re-dislocation rates between surgery and no surgery after a first-time TASD. Prediction modelling was used to identify potential predictors of recurrent dislocation. Setting UK primary and secondary care data. Participants Patients with a first-time TASD between 1997 and 2015. Interventions Stabilisation surgery within 6 months of a first-time TASD (compared with no surgery). Stabilisation surgery within 12 months of a first-time TASD was also carried out as a sensitivity analysis. Main outcome measure Re-dislocation rate up to 2 years after the first TASD. Methods Eligible patients were identified from the Clinical Practice Research Datalink (CPRD) (1997–2015). Accuracy of shoulder dislocation coding was internally validated using the CPRD General Practitioner questionnaire service. UK age- and sex-specific incidence rates for TASD were externally validated against rates from the USA and Canada. A propensity-score-matched analysis using linked CPRD and Hospital Episode Statistics (HES) data compared re-dislocation rates for patients aged 16–35 years, comparing surgery with no surgery. Multivariable Cox regression models for predicting re-dislocation were developed for the surgical and non-surgical cohorts. Results Shoulder dislocation was coded correctly for 89% of cases in the CPRD [95% confidence interval (CI) 83% to 95%], with a ‘primary’ dislocation confirmed for 76% of cases (95% CI 67% to 85%). Far fewer patients than expected received stabilisation surgery within 6 months of a first TASD, leading to an underpowered study. Around 20% of re-dislocation rates were observed for both surgical and non-surgical patients. The sensitivity analysis at 12 months also showed little difference in re-dislocation rates. Missing data on risk factors limited the value of the prediction modelling; however, younger age, epilepsy and sex (male) were identified as statistically significant predictors of re-dislocation. Limitations Far fewer than the expected number of patients had surgery after a first-time TASD, resulting in an underpowered study. This and residual confounding from missing risk factors mean that it is not possible to draw valid conclusions. Conclusions This study provides, for the first time, UK data on the age- and sex-specific incidence rates for TASD. Most TASD occurs in men, but an unexpected increased incidence was observed in women aged > 50 years. Surgery after a first-time TASD is uncommon in the NHS. Re-dislocation rates for patients receiving surgery after their first TASD are higher than previously expected; however, important residual confounding risk factors were not recorded in NHS primary and secondary care databases, thus preventing useful recommendations. Future work The high incidence of TASD justifies investigation into preventative measures for young men participating in contact sports, as well as investigating the risk factors in women aged > 50 years. A randomised controlled trial would account for key confounders missing from CPRD and HES data. A national TASD registry would allow for a more relevant data capture for this patient group. Study registration Independent Scientific Advisory Committee (ISAC) for the Medicines and Healthcare Products Regulatory Agency (ISAC protocol 15_0260). Funding The National Institute for Health Research Health Technology Assessment programme.

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Chapter I. The Home Economy

National Institute Economic Review ◽

10.1177/002795018712100102 ◽

1987 ◽

Vol 121 ◽

pp. 6-20

Keyword(s):

Growth Rate ◽

Current Account ◽

Peak Level ◽

Balance Of Payments ◽

Capacity Utilisation ◽

The Uk ◽

First Time ◽

The Current Account

For the first time in more than a decade the question is being asked whether the growth of the UK economy this year may be, in some sense, too rapid. Fears have been expressed of ‘overheating’ leading to a rise in inflation and excessive growth in imports. Comparisons have been made with the ‘boom’ conditions of 1972 and 1973. In our view these fears are exaggerated and the comparisons misleading. Nevertheless some increase in the rate of inflation is to be expected, and the underlying position on the current account of the balance of payments seems already to have moved from surplus into deficit. We now expect the rate of the economy this year to be around 3½ per cent, compared with about 3 per cent in 1986. Thus, if we are correct, the acceleration year on year is very slight, well within the error margins of measurement. This contrasts with 1972 and 1973 when the growth rate averaged 4½ per cent for two years. Moreover unemployment was only about 1 million at the beginning of 1972 and about 1/2 million at the end of 1973 whilst last year it at over 3 million and is not expected to fall as low as 2½ million even next year. Even if inflation next year does rise from about 3½ per cent a year to about 5 per cent, as we expect, this is still not comparable with the rates of 7½ and 9 per cent experienced in 1972 and 1973. The CBI index of capacity utilisation is now not far below its peak level in 1973, but we doubt whether an index of this kind is reliable for comparision between periods so far apart in time.

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