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A 31-year-old woman with a history of stillbirth due to placental abruption at 29 weeks’ gestation and one first trimester miscarriage documented a continuous record of her perceived fetal movements from 28 to 38 weeks’ gestation. Repeated ultrasound examinations confirmed a viable pregnancy, with normal growth, liquor volume and Doppler profile. She delivered a healthy male infant at 38 weeks and 3 days’ gestation. The data collected give a detailed record of fetal activity in a healthy pregnancy. Perceived fetal activity increased as pregnancy progressed and was greatest in the evenings. We also found that clusters of movements, which have previously been reported as protective against stillbirth, were felt earlier on in pregnancy.

Background While the use of robotic-assisted surgery is now mainstream for procedures such as robotic prostatectomy, its role in general surgery is less well established. Access to training in robotics for general surgery trainees in the Republic of Ireland is variable. Further, there is no data on attitudes of Irish trainees towards the role of robotics. We aimed to establish attitudes of Irish general surgery trainees towards the perceived utility of robotic surgery as well as access and satisfaction with training. Methods A survey was disseminated to trainees in the Republic of Ireland enrolled in a General Surgery training scheme via email and social media. Data collected included stage of training, intended subspecialty, interest in developing robotic skills, previous exposure to robotic surgery, satisfaction with current access to robotic training and opinion on formally incorporating training in robotics into the general surgery curriculum. Results The response rate was 44.8%. Of these, 83% reported interest in training in robotics and 69% anticipated using the technology regularly in consultant practice. Previous exposure to robotic-assisted surgery was significantly predictive of interest in developing the skillset (p = 0.014). Over 71% of trainees reported that they were not satisfied with access to robotic training. Of those satisfied with access, 40% felt there was a role for incorporating robotic training into the curriculum, compared to 68% of those dissatisfied. Conclusion Irish general surgery trainees perceive robotic-assisted surgery to be highly relevant to their future practice. There is an unmet need to provide additional training in the skillset.

Background Robotic-assisted minimally invasive surgery (MIS) for rectal cancer is a relatively new technique. Studies to date suggest that short term outcomes including TME quality, margin status, lymph node retrieval and 30-day morbidity and mortality are equivalent in robotic-assisted and laparoscopic MIS for rectal cancer. By contrast, there is a paucity of data on the medium and long-term oncologic safety of robotic-assisted comparative to laparoscopic surgery for rectal cancer. Methods A retrospective review was conducted of all robotic-assisted (n = 31) and laparoscopic (n = 23) rectal cancer cases performed at our institution between January 2016 to December 2018. Inclusion criteria were patients scheduled electively for a laparoscopic or robotic-assisted resection of rectal cancer (anterior resection or abdomino-perineal resection). Patients with distant metastases at presentation, those who proceeded to surgery as an emergency and those with a non-colorectal primary were excluded from analysis. Results A total of 54 (n = 54) cases met the inclusion criteria and were included in the final analysis. The median follow-up was 34 months. Of the 54, 21 patients received neoadjuvant chemoradiotherapy prior to definitive surgery. No significant difference was detected in local recurrence rates (p = 0.5), overall survival (p = 0.7) or disease-free survival (p = 0.8) between the robotic-assisted and laparoscopic cohorts. Conclusion In this series, robotic-assisted rectal cancer resections were associated with equivalent medium term oncological outcomes as laparoscopic procedures. However, given the small numbers in this cohort, outcomes from larger scale datasets will be required to confirm these results.

Laparoscopic Cholecystectomy (LC) is currently considered the gold standard for the management of symptomatic gallbladder stones disease. Specific complications remain challenging, particularly postoperative bleeding, bile leak, and bile duct injury. We report a rare case of a giant intrahepatic subcapsular haematoma (ISH) complicating LC. Case Presentation A 59-year-old female presented with symptomatic biliary colic. Her past medical history was noted for obesity (BMI>50). She underwent an elective LC with an uncomplicated intraoperative course; however, post-operatively she developed hypovolaemic shock with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. Emergency CT revealed a massive subcapsular haematoma measuring 21cm×3.1cm× 17cm at the right liver margin without evidence of ongoing bleeding. She was managed conservatively- as per a tertiary hepatobiliary surgery centre’s advice- with meticulous clinical observations, serial monitoring of haemoglobin, and repeat CT to assess for interval progressions. She progressed well with conservative management and did not require surgical or radiological intervention. A follow-up liver sonography performed eight weeks post-discharge confirmed a complete resolution. Conclusion Giant ISH is an exceedingly rare but life-threatening complication following LC which merits special attention. Our case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH in those who experience refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post-LC ISH.

Background and objectives Neoadjuvant chemoradiotherapy (nCRT) induces a pathological complete response (pCR) in 25–85% of oesophago-gastric cancer. As surgery entails morbidity and mortality risks and quality of life (QL) impairment, its avoidance in patients without residual disease is desirable. This study aimed to compare quality of life of patients with a cCR who chose surveillance with those who chose surgery. Methods Four groups of patients were studied. Group 1(n = 31) were controls; Group 2 (n = 26) had chemoradiotherapy only; Group 3 (n = 31) had oesophagectomy after nCRT; Group 4 (n = 26) had gastrectomy alone. A 33-point novel questionnaire was administered at two 3 month time points. Participants were also interviewed with a validated questionnaire. Results Mean(±sd) quality of life scores in cCR patients offered surveillance (28.9 ± 4.5) were superior to patients undergoing oesophagectomy (32.3 ± 58. p=0.042) or gastrectomy (33.19 ± 5.9, p=0.004). This result was replicated in the validated questionnaire (p=0.017). There was a trend towards increased reflux-related respiratory symptoms in the oesophagectomy group (7.3 ± 2.2 vs 6.5 ± 1.9; p=0.396) and towards early dumping (8.2 ± 1.4 vs 7.1 ± 1.; p=0.239) and vagotomy-related symptoms (1.82 ± 0.9 vs 1.4 ± 0.6; p=0.438) in the gastrectomy group. Conclusions Avoidance of surgery in cCR patients is rewarded with a superior quality of life to those undergoing surgery.

Inflammatory bowel disease (IBD) is a chronic relapsing-remitting immune-mediated disorder affecting the gut. It is common in Westernized regions and is increasing in incidence in developing countries. At a molecular level, intrinsic deficiencies in epithelial integrity, mucosal barrier function, and mechanisms of immune response and resolution contribute to the development of IBD. Traditionally two platforms have been utilized for disease modeling of IBD;in-vitromonolayer cell culture andin-vivoanimal models. Both models have limitations, including cost, lack of representative cell types, lack of complexity of cellular interactions in a living organism, and xenogeneity. Organoids, three-dimensional cellular structures which recapitulate the basic architecture and functional processes of the organ of origin, hold potential as a third platform with which to investigate the pathogenesis and molecular defects which give rise to IBD. Organoids retain the genetic and transcriptomic profile of the tissue of origin over time and unlike monolayer cell culture can be induced to differentiate into most adult intestinal cell types. They may be used to model intestinal host-microbe interactions occurring at the mucosal barrier, are amenable to genetic manipulation and can be co-cultured with other cell lines of interest. Bioengineering approaches may be applied to render a more faithful representation of the intestinal epithelial niche. In this review, we outline the concept of intestinal organoids, discuss the advantages and disadvantages of the platform comparative to alternative models, and describe the translational applications of organoids in IBD.

We report on a 59-year-old female with symptomatic cholelithiasis on a background of morbid obesity who underwent an elective LC with an uncomplicated intraoperative course; however, she experienced a refractory hypotension within one hour postoperatively with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. A triphasic computed tomography scan revealed a large intrahepatic subcapsular haematoma (ISH) measuring 21 cm × 3.1 cm × 17 cm surrounding the lateral surface of the right hepatic lobe without active bleeding. She was managed conservatively with serial monitoring of haemoglobin and haematoma size. A follow-up ultrasound scan after eight weeks confirmed complete resolution of the haematoma. Giant ISH is a fairly rare, but life-threatening complication following LC which merits special attention. This case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH, although being rare event, in those who experience a refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post LC-ISH.

Introduction Tools for improving operative performance for surgical trainees are increasingly desirable, particularly in the context of EWTD and ‘run-through’ training programmes. In addition, positive direct trainer feedback to trainees can improve skill acquisition and motivation, whilst negative feedback may have the opposite effect.1 We aimed to examine the impact of targeted trainer feedback based on video analysis on trainee confidence and objective operative performance in laparoscopic cholecystectomy. Methods Selected procedures designated as training cases were recorded. These were assessed by the trainers using the Independence-Scaled Procedural Assessment Score for laparoscopic cholecystectomy. Targeted feedback based on video review of selected procedures was then delivered by the trainers to the trainees. Trainees completed a self-reported questionnaire based on their response to this feedback. Subsequent to the feedback intervention, further training procedures were recorded and assessed. Results A total of 6 trainees and 4 trainers participated in the study. For the pre-intervention assessment 15 cases were recorded, with a further 13 for the post-intervention assessment (total n = 28). The overall scores for the procedures performed post video feedback were improved, with a trend towards statistical significance (p = 0.08). However, there was a statistically significant improvement in the scores for performance of the triangle of Calot dissection after the feedback intervention (p = 0.009). The response rate to the questionnaire was 100%, with all trainees agreeing that they felt more confident and competent after the feedback intervention. Conclusion Targeted feedback to trainees based on post-procedure video review improves trainee confidence and may also improve performance. ACGME Core Competencies; Patient Care and Procedural Skills; Practice Based Learning and Improvement.

Highlights • Synovial chrondroma is a rare condition of which the aetiology remains unclear. Large palpable lesions represent an atypical presentation. • The diagnosis is often not immediately apparent. However it is usually suggested by radiologic investigation and confirmed on histology. • Disease recurrence is not infrequent after excision (15–23%) and patients should be counselled regarding this. • Malignant transformation whilst uncommon has been described. At present no definite criteria exist in order to make the diagnosis of malignancy. • Due to the above risks of recurrence and malignancy, long term follow up of affected patients is advised., Introduction Synovial chrondomatosis is a rare disorder characterised by the development of hyaline cartilage from the synovial membrane. Large isolated lesions in the Hoffa's fat pad are an uncommon entity. Presentation of case A 33 year old gentleman presented complaining of progressive knee pain associated with an enlarging lesion on the anterior aspect of the right knee, with associated locking and giving way. Examination revealed a firm 4 × 5 cm lesion adjacent to the patellar tendon. Subsequent CT and MRI demonstrated a lesion in the inferior aspect of Hoffa’s fat pad, with a second lesion adjacent to the proximal tibiofibular joint, in addition to advanced degenerative changes and a meniscal tear. He proceeded to excisional biopsy. Histological analysis was consistent with a solitary synovial osteochondroma. There were no atypical features suggestive of malignancy. Discussion Synovial chondromatosis is a rare disorder affecting the synovial joints. The underlying pathophysiology is thought to be metaplastic change of the synovium to hyaline cartilaginous tissue. Transformation to malignancy has been described but is uncommon with an estimated risk of 5%. It is 1.5–2 times as prevalent in males versus females. Symptoms which patients may complain of include pain;locking and giving way; and palpable masses. The management usually entails removal of the mass lesion with or without accompanying synovectomy. Recurrence of disease may occur in up to 15–23% of patients. Conclusion Synovial chrondromatosis is a rare but well recognised condition. Long term follow up is advised in view of the risk of recurrence and malignant transformation.

Background The mucus gel layer (MGL) lining the colon is integral to exclusion of bacteria and maintaining intestinal homeostasis in health and disease. MGL defects allowing bacteria to directly contact the colonic surface are commonly observed in ulcerative colitis (UC). The major macromolecular component of the colonic MGL is the secreted gel-forming mucin, MUC2, whose expression is essential for homeostasis in health. In UC, another gel-forming mucin, MUC5AC is induced. In mice, Muc5ac is protective during intestinal helminth infection. Here, we tested the expression and functional role of MUC5AC/Muc5ac in colitis patient biopsies and murine colitis. Methods We measured MUC5AC/Muc5ac expression in UC patient biopsies and during acute dextran sulphate sodium (DSS) colitis. We performed DSS-colitis in mice deficient in Muc5ac (Muc5ac−/−) to model the potential functional role of Muc5ac in colitis. To assess MGL integrity, we quantified bacterial–epithelial interaction and translocation to mesenteric lymph nodes (MLNs). Antibiotic treatment was performed to directly investigate the role of colonic bacteria in our murine colitis studies. Results Colonic MUC5AC/Muc5ac mRNA expression increased significantly in active UC and murine colitis. Muc5ac−/− mice experienced worsened injury and inflammation in DSS-colitis compared with controls. This was associated with increased bacterial–epithelial contact and translocation to the MLN. Antibiotic treatment normalised colitis severity in Muc5ac−/− mice to that of antibiotic treated controls. Conclusion We demonstrate for the first time that MUC5AC/Muc5ac induction in acute colitis controls injury by reducing bacterial breach of the MGL. Therefore, developing strategies to induce MUC5AC expression may protect the intestinal barrier in UC.

This chapter reviews the effects of low-level lead exposure framed by the case of a 6-year-old with lead exposure via drinking water in the context of multiple neurodevelopmental and psychosocial considerations. Despite primary prevention efforts, lead exposure remains an important pediatric environmental health problem. Lead effects brain development and function through multiple mechanisms, primarily involving displacement of calcium and zinc in several cellular processes involved in neuronal growth, differentiation, development, and communication. Outcomes at low levels are idiosyncratic and span a variety of neurocognitive domains. Consequently, a tailored approach to evaluation and intervention are essential to maximizing outcomes for affected youth. Ongoing efforts to improve secondary and tertiary prevention while working toward primary prevention of newly recognized lead sources such as water are also imperative. This case highlights the capacity for lead exposure to complicate potentially underlying neurodevelopmental disabilities, cloud diagnostic clarity, and contribute to exacerbation of neuropsychiatric symptoms in addition to causing new-onset symptomatology.

We describe a usability evaluation of a teleconsultation model for primary care physicians (PCPs) with patients with autism spectrum disorders and a developmental-behavioral pediatrician (DBP) with relevant expertise. Six PCPs participated in a total of 12 consultations with a DBP. Detailed observations and user ratings and comments were collected. Standard usability metrics were used, and the communication quality and interactions of the two participating parties (PCP and DBP) were examined. High post-task and post-study ratings (including System Usability Scale, Communication Quality, and attitudes toward teleconsultation process scores), as well as the positive comments from participants, indicated that the teleconsultations were successful, and demonstrated the effectiveness of this type of communication, particularly for validating PCPs’ ideas and strengthening their confidence in talking with families, providing new ideas and redirected their thinking, and connecting PCPs with location-sensitive resources. PCPs found value in the opportunity to connect with an ASD specialist in a timely and efficient manner. Most indicated that the video element of the consultation enhanced clarity and understanding, attention, engagement, and collegiality, while acknowledging drawbacks such as reduced ability to multitask compared to consultations by phone. Recommendations for enhancements of the teleconsultation process focus on supporting PCPs in getting started with Zoom; providing ground rules and establishing procedures; creating information sharing/summary templates for the teleconsultation process; and fostering communication quality in a mediated environment.