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Background Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) with lumen apposing metal stents has recently emerged as a viable option, as an alternative to surgical gastrojejunostomy and endoscopic enteral stenting, for managing gastric outlet obstruction (GOO). We aim to perform a retrospective analysis of the efficacy, safety and outcomes of EUS-GJ performed at three tertiary institutions in the United Kingdom. Methods Consecutive patients who underwent EUS-GJ between August 2018 and March 2021 were identified from a prospectively maintained database. Data were obtained from interrogation of electronic health records. Results Twenty five patients (15 males) with a median age of 63 years old (range 29–80) were included for analysis. 88% (22/25) of patients had GOO due to underlying malignant disease. All patients were deemed surgically inoperable or at high surgical risk. Both technical and clinical success were achieved in 92% (23/25) of patients. There was an improvement in the mean Gastric Outlet Obstruction Scoring System scores following a technically successful EUS-GJ (2.52 vs 0.68, p Conclusion EUS-GJ in carefully selected patients is an effective and safe procedure when performed by experienced endoscopists.

Recent theological discussion of immigration issues, while acknowledging the scriptural mandate of hospitality to migrants, also recognizes that host governments have a duty to protect their borders against those who might cause harm to their citizens. Looking in particular at the special case of refugees, I argue that government policy in many rich European countries, including the UK, falls well short of the hospitality requirement while greatly exaggerating the possibility of harm. I suggest that social science findings on the impact of immigration on host communities provide helpful background for politically engaged Christians who seek to call their governments to account.

Cine cardiac magnetic resonance (CMR) imaging is considered the gold standard for cardiac function evaluation. However, cine CMR acquisition is inherently slow and in recent decades considerable effort has been put into accelerating scan times without compromising image quality or the accuracy of derived results. In this paper, we present a fully-automated, quality-controlled integrated framework for reconstruction, segmentation and downstream analysis of undersampled cine CMR data. The framework enables active acquisition of radial k-space data, in which acquisition can be stopped as soon as acquired data are sufficient to produce high quality reconstructions and segmentations. This results in reduced scan times and automated analysis, enabling robust and accurate estimation of functional biomarkers. To demonstrate the feasibility of the proposed approach, we perform realistic simulations of radial k-space acquisitions on a dataset of subjects from the UK Biobank and present results on in-vivo cine CMR k-space data collected from healthy subjects. The results demonstrate that our method can produce quality-controlled images in a mean scan time reduced from 12 to 4 seconds per slice, and that image quality is sufficient to allow clinically relevant parameters to be automatically estimated to within 5% mean absolute difference.

Introduction: “Le Coeur en Sabot” (or the boot-shaped heart) is a radiological description of the appearance of the heart on a plain radiograph of a patient with Tetralogy of Fallot. This highlights the importance of the shape of the heart. Maladaptive remodeling is known to occur in patients with repaired Tetralogy of Fallot (rToF) due to residual lesions such as Pulmonary Regurgitant Fraction (PRF) Hypothesis: Shape and function analysis can reveal novel remodeling patterns associated with adverse events in patients with rToF Methods: Biventricular shape and function were studied in 192 patients with rToF (median age 15 years). Linear discriminative analysis (LDA) and principal component analysis (PCA) were used to identify shape differences between patients with and without adverse events (AE). AE included death, arrhythmias, and cardiac arrest (median follow-up 10 years) Results: LDA and PCA showed that shape characteristics pertaining to adverse events included a more circular LV (decreased eccentricity), dilated (increased sphericity) LV base, increased RV apical sphericity, and decreased RV basal sphericity. Multivariate LDA showed that the optimal discriminative model included only RV apical ejection fraction and one PCA mode associated with a more circular and dilated LV base (AUC = 0.78). PRF did not add value, and shape changes associated with increased PRF were not predictive of AE. Conclusions: Remodeling patterns in patients with rToF are associated with AE, independent of PRF. Mechanisms leading to AE include LV basal dilation with a reduced RV apical ejection fraction. That is to say that the old descriptor, “Le Coeur en Sabot'' may also describe that shape that is adverse in rTOF. The toe of this boot would be the dilated and poorly contractile RV apex and the ankle would be the spherical LV base (Figure 1: Top Row Diastole. Middle Systole. Posterior projection (a), anatomical position (b) and superior (c). LV is green)

Aims Despite recent improvements, delay to theatre in emergency laparotomy(EL) continues to be associated with increased mortality in the UK. This study aimed to assess if patients requiring urgent surgical intervention for acute abdominal surgical pathology could be identified in the pre-hospital setting. Methods A two-phase, single-centre, cohort study was performed. Phase 1 retrospectively investigated patients who underwent emergency laparotomy between 01/01/2019-31/12/2019 at Leeds Teaching Hospital Trust (LTHT) through the NELA database. Phase 2 prospectively assessed NEWS2 for all patients presenting to LTHT Surgical Admissions Unit with abdominal pain between 01/01/2020-31/01/2020. Results Phase 1: 45 patients were coded through NELA and confirmed through operation note as undergoing EL for gastrointestinal perforation. 66%(n = 30) were assessed by the ambulance service and 80%(n = 24) had a NEWS2 of 3 or greater. Phase 2: 319 patients were assessed in SAU/ED resus of which 69 were initially treated by the ambulance service. 30%(n = 21) of these patients had an initial NEWS2 of 3 or above. The sensitivity of a NEWS2 score of >/3 in predicting the need for immediate surgical intervention including EL was 95%(95%CI, 74-99) and specificity was 95%(95%CI, 83-99) with a PPV of 86%(95%CI 67-95) and NPV of 98%(95%CI, 87-99). Conclusion A NEWS2 score of >/3 predicts the need for emergency surgical intervention including laparotomy for gastroinestinal perforation with reasonable sensitivity in this cohort. A pre-hospital triage tool for patients presenting with abdominal pain could utilise NEWS2 as an adjunct to decision-making in an acute abdominal pathway.

Aims Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The timeline between symptom onset and operation is ill-defined with international variance in assessment and management. This systematic review aims to define where delays to surgery occur and assess the evidence for previous interventions. Methods A systematic review was performed searching MEDLINE and EMBASE databases (January 1st 2005 to May 6th 2020). All studies assessing the impact of time to theatre in patients with acute abdominal pathology requiring emergency laparotomy were considered. Results 17 studies were included in the final analysis. 15 unique timepoints were identified in the patient pathway between symptom onset and operation which could be classified into four distinct phases. Time from admission to theatre (1 to 72 hours), and mortality rate (10.6-74.5%) varied greatly between studies. Mean time to surgery was significantly higher in deceased patients compared to survivors. Delays were related to imaging, diagnosis, decision-making, theatre availability and staffing. Four of five interventional studies showed a reduced mortality following introduction of an acute laparotomy pathway. Conclusions There is wide variation in the definition and measurement of time delays prior to emergency surgery with few studies exploring interventions. Given the heterogenous nature of the patient population and pathologies, an assessment and management framework from onset of symptoms to operation is proposed. This could be incorporated into national mortality prediction and audit tools and assist in the assessment of interventions.

Background Despite the recent improvements in mortality in patients undergoing emergency laparotomy(EL) within the UK, delay to theatre continues to be associated with increased mortality. This study aimed to assess if patients requiring urgent surgical intervention for acute abdominal surgical pathology could be identified in the pre-hospital setting. Method A two-phase, single-centre, cohort study was performed. Phase 1 retrospectively investigated patients who underwent emergency laparotomy between 01/01/2019-31/12/2019 at Leeds Teaching Hospital Trust (LTHT) through the NELA database. Phase 2 prospectively assessed NEWS2 for all patients presenting to LTHT Surgical Admissions Unit with abdominal pain between 01/01/2020-31/01/2020. Results Phase 1: 45 patients were coded through NELA and confirmed through operation note review as undergoing EL for gastrointestinal perforation. 66%(n = 30) were assessed by the ambulance service and 80% (n = 24) had a NEWS2 of 3 or greater. Phase 2: 319 patients were assessed in SAU/ED, of which 69 initially treated by the ambulance service. 30% (n = 21) of these patients had an initial NEWS2 of 3 or above. Sensitivity of a NEWS2 score of >/3 in predicting the need for immediate surgical intervention including EL was 95%(95%CI, 74-99) and specificity was 95% (95%CI, 83-99) with a PPV of 86%(95%CI 67-95) and NPV of 98% (95%CI, 87-99). Conclusions A NEWS2 score of >/3 predicts the need for emergency surgical intervention including laparotomy for gastrointestinal perforation with reasonable sensitivity in this cohort. A pre-hospital triage tool for patients presenting with abdominal pain could utilise NEWS2 as an adjunct to decision-making in an acute abdominal pathway.

A 42-year-old man with multiple sclerosis presented with recurrent vomiting, in the context of recent weight loss. Computed tomography scan of the abdomen and pelvis revealed duodenal compression by the superior mesenteric artery (SMA), consistent with intermittent SMA syndrome. Subsequent gastroscopy and barium meal follow-through showed resolution of the obstruction. SMA syndrome is rare and has not previously been reported in a patient with multiple sclerosis. We hypothesize that loss of the aortomesenteric fat pad on the background of contorted body habitus from multiple sclerosis placed the patient at risk for intermittent positional compression of his duodenum. Keywords: Superior mesenteric artery, Multiple sclerosis

The semiconductor technology developed, with the printing of integrated circuits and eventually microprocessors on a single chip, this sector continued to expand in Scotland, again through foreign direct investment. To other commentators, however, attempts to develop or restructure economies using foreign investment involve more of a Faustian bargain. For much of the twentieth century, the Scottish economy has suffered from the decline of industries which had earlier been the source of its pre-eminence: shipbuilding, coal-mining, iron and steel manufacture. To those who see globalization as a major force for encouraging a more effective use of the world's resources, the dominance of foreign firms in the Scottish electronics sector presents no problem. The defence sector continued to be a major market for UK electronics companies based in Scotland: not only for Ferranti, but also for Barr and Stroud, Marconi Instruments and Racal.

Wound healing is a complex biological process which results in the restoration of tissue integrity. Physiologically, it can be broken down into four distinct phases of haemostasis, inflammation, proliferation and tissue remodelling. This article describes the cellular basis of wound healing and the extracellular signalling processes which control them. The function of platelets, neutrophils, macrophages and fibroblasts are considered in detail. The concept of healing by primary and secondary intention is discussed. Many factors are known to adversely affect healing including malnutrition, hypoxia, immunosuppression, chronic disease and surgery. It is essential that surgeons understand the key physiological processes involved in healing in order to minimize patient morbidity from delayed healing.

Grafts from donation after cardiac death (DCD) donors are used to increase the number of organs available for liver transplantation. There is concern that warm ischemia may impair graft function. We compared our DCD recipients with a case-matched group of donation after brain death (DBD) recipients. Between January 2002 and April 2008, 39 DCD grafts were transplanted. These were matched with 39 DBD recipients on the basis of identified variables that had a significant impact on mortality. These were used to individually match DCD and DBD patients with similar predictive mortality. We compared patient/graft survival, primary non-function (PNF), and rates of complications. Of all liver transplants, 6.1% were DCD grafts. PNF occurred twice in the DCD group. The incidence of nonanastomotic biliary strictures (NABS; 20.5% versus 0%, P = 0.005) and hepatic artery stenosis (HAS; 12.8% versus 0%, P = 0.027) in the DCD group was higher. One-year (79.5% versus 97.4%, P = 0.029) and 3-year (63.6% versus 97.4%, P = 0.001) graft survival was lower in the DCD group. Three-year patient survival was also lower (68.2% versus 100%, P < 0.0001). Our study is the first to use case-matched patients and compare groups with similar predictive mortality. There was a higher incidence of NABS and HAS in the DCD group. NABS were likely a result of warm ischemia. HAS may have been due to ischemia or arterial injury during retrieval. The DCD group had significantly poorer outcomes, but DCD grafts remain a valuable resource. With careful donor/recipient selection, minimization of ischemia, and good postoperative care, acceptable results can be achieved.

PurposePublic private partnership (PPP), which has been operating in China for over 20 years. In addition, an increased focus on value for money in the public sector has led to a need to improve the efficiency of the management, delivery and effectiveness of public services, especially at the local level. This paper aims to examines the PPP system and the problems yet to be overcome at a time when China is seeking to widen the use of PPP in sectors as yet not open to it.Design/methodology/approachThe paper examines the current PPP system in China and identifies the constraints facing it in the context of several models of bureaucracy arguing that these are as valid in China as they have been in the West.FindingsThe paper argues that there are five key constraints present in the Chinese PPP system and that these are fundamentally associated with risks of various types.Practical implicationsExtending PPP in China will require significant reform of public sector administration, closer supervision, transparent regulatory systems and easier access to capital for local private sector firms.Originality/valueThis paper should be of interest to both academics and practitioners in the field of PPP in terms of theoretical debate, key issues and the specific prospects for PPP in China.