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Haemothorax is presence of blood in pleural cavity and is usually caused by chest trauma. Spontaneous rib fractures leading to haemothorax due to excessive coughing has seldom been described in the literature. We report an unusual case with asthma exacerbation who developed intense coughing followed by chest pain, breathlessness, and widespread bruising, without trauma or coagulopathy. Initial chest X-ray (CXR) and CT pulmonary angiogram (CTPA) showed no significant abnormality. CT scan on subsequent presentation showed left sided haemothorax with rib fractures. The patient was managed successfully with chest tube drainage. On follow up imaging, haemothorax resolved but he was found to have malunited rib fractures with chest wall hernia due to wide separation between ribs. He was referred to cardiothoracic surgeons for rib fixation and chest wall repair.

Background Cutaneous abscesses form a significant volume of emergency general surgery operating throughout the UK. They are most commonly managed with an ‘incision and drainage’ (I&D) procedure which tends to be performed with a general anaesthetic (GA). As expected with the unpredictable nature of emergency general surgery, abscesses booked for I&D under GA are often delayed to accommodate a more urgent procedure or unwell patient. Costs and theatre utilisation of abscesses managed under a general anaesthetic were obtained and analysed. A pilot study was then designed to utilise Methoxyflurane (Penthrox/Green Whistle) as an alternative to general anaesthetic for the management of abscesses. Methods Retrospective data of patients requiring I&D of abscesses under GA between January 2020 and January 2021 was collected. Length of stay (LOS), length of surgery (entry into theatre to out of theatre), time spent in theatre (anaesthetic room and operating theatre) and theatre complex (holding bay, anaesthetic room, operating theatre and recovery) were collected. Financial costs were also obtained. Abscesses were organised into different degrees of complexity: complex, medium and simple. ‘Simple’ abscesses were defined as such if the patient met the following criteria: >18 years, ASA 2 or less, non-perianal or ischiorectal and a surgical time of 10 minutes or less. Following the results, a pilot study was designed and proposed. 20 patients were recruited to this pilot study. Recruitment was performed on admission via the emergency portal (surgical assessment unit). To be eligible for this study, patients would need to meet the following criteria: A patient satisfaction survey was conducted via telephone at a later date. Results 381 patients underwent an I&D under GA. Ratio of M:F was 1.12:1. Majority of abscesses drained were perianal (n=120) and pilonidal (n=81). Majority of patients were ASA 1 or 2. 100 ‘simple’ abscesses were identified. The sum of length of stay (LOS) was 949 days. The sum of surgery time (ST) was 4.6 days. The sum of total theatre time (TT) was 14 days. The sum of time in theatre complex (TC) was 48 days. ‘Simple abscesses’ had a total LOS of 144 days, total ST of 12 hours, total TT of 69 hours and total TC of 12 days. Pilot study: 20 patients had cutaneous abscesses drained between July and September 2021 with Penthrox. M:F ratio was 11:9. 19 patients underwent successful drainage of their abscesses whereas 1 procedure had to be abandoned due to pain. Abscess drainage was performed on the 1st day of presentation in 15 patients. There were no 30-day readmissions noted within this pilot group. 83.3% of respondents to the patient satisfaction survey rated their experience as ‘Very Good’. Costing Overall savings of £4,150 were calculated per patient. Conclusions This study aimed to look into the feasibility of a dedicated abscess pathway for patients meeting specific inclusion criteria. Overall, the results have shown that this is feasible and cost-effective. It reduces length of stay, waiting times and costs. Patients are usually discharged home the same day without any complications. Our data has shown that performing an I&D of an abscess under the Green Whistle pathway costs 30-times as less than the same abscess being managed under a GA in the theatre complex. The pilot study has been ratified at management level and we are currently in the process of stocking Green Whistles in our Surgical Ambulatory Unit and we will shortly begin widespread training and use.

Four-dimensional computed tomography (4DCT)-ventilation-based functional avoidance uses 4DCT images to generate plans that avoid functional regions of the lung with the goal of reducing pulmonary toxic effects. A phase 2, multicenter, prospective study was completed to evaluate 4DCT-ventilation functional avoidance radiation therapy. The purpose of this study was to report the results for pretreatment to posttreatment pulmonary function test (PFT) changes for patients treated with functional avoidance radiation therapy.Patients with locally advanced lung cancer receiving chemoradiation were accrued. Functional avoidance plans based on 4DCT-ventilation images were generated. PFTs were obtained at baseline and 3 months after chemoradiation. Differences for PFT metrics are reported, including diffusing capacity for carbon monoxide (DLCO), forced expiratory volume in 1 second (FEVFifty-six patients enrolled on the study had baseline and posttreatment PFTs evaluable for analysis. The mean change in DLCO, FEVThe current work is the first to quantitatively characterize PFT changes for patients with lung cancer treated on a prospective functional avoidance radiation therapy study. In comparison with patients treated with standard thoracic radiation planning, the data qualitatively show that functional avoidance resulted in less of a decline in DLCO and FEV

Aim Malnourished patients make poor surgical candidates, with an increased risk of post-operative complications. We assessed the peri-operative nutritional status of patients undergoing elective and emergency general surgical operations. Methods Data was collected from 1 September 2021 to 1 November 2021. The inclusion criteria included: underwent surgery for gastro-intestinal pathology, length of stay ≥5 days, and high risk of malnutrition as per the Malnutrition Universal Screening Tool (MUST). Results 50 emergency patients were identified. In the pre-operative to post-operative period, these patients had a mean albumin decrease from 30.5 to 23.7, against a decrease in CRP of 146 to 105.5, suggesting worsening nutrition rather than worsening inflammation. 48% of these patients had dietician referrals in-place with 54% of these on oral supplementation. Post-surgical complications increased in these patients without a dietician referral, with wound infection the most common cause (n=4). 50 elective patients were identified. 40% of these patients had dietician referrals in-place with 70% of these on oral supplementation. Post-surgical complications increased in these patients without a dietician referral with the most common complication being acute kidney injury followed by wound infection. Conclusion Optimal nutrition is key to optimal recovery. Most patients with dietician referrals had a plan of oral supplementation. This intervention can be commenced by the immediate surgical team. 56% of patients meeting the MUST tool criteria for high risk of malnutrition had no dietician referral. This can be addressed through early consideration for dietician referral, teaching sessions and educational posters distributed across surgical wards.

Background Revisional surgery is an expanding area in bariatric surgery which reflects a rising need to treat adverse sequelae of primary procedures. Despite the increase, their safety and efficacy remain unclear. We aimed to review revisional bariatric surgery indications and outcomes at our tertiary centre. Methods Data on revisional bariatric surgery was collected prospectively from 2013 and analysed retrospectively, including indications and postoperative outcomes. Results From January 2013 to December 2021, 80 patients (mean age: 51.4 years) undergoing revisional surgery were identified: 38 laparoscopic gastric band (LGB) to Roux-en-Y gastric bypasses (RYGB), 34 sleeve gastrectomies (SG) to RYGB, 6 mini-gastric bypasses (MGB) to RYGB and 2 RYGB revisions. The most common indication for revision was weight regain (56.4%) followed by intolerable reflux (21.3%). Other indications included band complications (15%), obesity-related problems (2.5%), excessive weight loss (2.5%), corkscrewing of sleeve (1.3%), and dumping syndrome (1.3%). There were 11 post-operative complications, with mean length of stay of 2.8 days. In addition to treating primary complications, the mean change in BMI at 12 months for LGB to RYGB revisions and SG to RYGB revisions was -9.5 and -5.3 respectively. Average change in BMI at 24 months for LGB to RYGB revisions and SG to RYGB revisions was -9.4 and -8.6 respectively. Conclusion Revisional bariatric surgery effectively treated the undesirable results from primary surgery. Laparoscopic revisional surgery can be performed after both failed open and laparoscopic procedures with minimal complications. In experienced hands, with careful patient selection & education, satisfactory additional weight loss can be achieved.

$^{63}$Cu NMR measurements are reported for the Cu-rich phase of \ch{Cu_{12+x}Sb4S13} ($x \lesssim 2$) and compared to \ch{Cu12Sb4S13}. We identify the NMR signatures of the phase segregation into Cu-poor ($x \approx 0$) and Cu-rich ($x \lesssim 2$) phases, with the metal-insulator transition observed in \ch{Cu12Sb4S13} suppressed in the Cu-rich phase. Based on NMR $T_1$ and $T_2$ measurements, the results demonstrate Cu-ion hopping below room temperature with an activation energy of $\sim$150 meV for the Cu-rich phase, consistent with superionic behavior. The NMR results also demonstrate the effects of Cu-ion mobility in the \ch{Cu12Sb4S13} phase, but with a larger activation barrier. We identify a small difference in NMR Knight shift for the metallic phase of \ch{Cu12Sb4S13}, compared to the Cu-rich phase, and when compared to DFT calculations the results indicate a mix of hyperfine contributions to the metallic shift.

Extracellular matrixes (ECMs), such as the cell walls and biofilms, are important for supporting cell integrity and function and regulating intercellular communication. These biomaterials are also of significant interest to the production of biofuels and the development of antimicrobial treatment. Solid-state nuclear magnetic resonance (ssNMR) and magic-angle spinning-dynamic nuclear polarization (MAS-DNP) are uniquely powerful for understanding the conformational structure, dynamical characteristics, and supramolecular assemblies of carbohydrates and other biomolecules in ECMs. This review highlights the recent high-resolution investigations of intact ECMs and native cells in many organisms spanning across plants, bacteria, fungi, and algae. We spotlight the structural principles identified in ECMs, discuss the current technical limitation and underexplored biochemical topics, and point out the promising opportunities enabled by the recent advances of the rapidly evolving ssNMR technology.

Background During the first wave of the COVID pandemic surgical services we paralysed globally, with cancellation of an estimated 28-million operations during the first 12 weeks. Worryingly, surgical patient with COVID were reported to have unacceptably high peri-operative mortality, approaching 25%. However, there was an urgent clinical need to progress with category 1 and 2 operations, to prevent disease progression and avoidable morbidity and mortality from non-COVID pathologies. During the second and subsequent waves of the pandemic it was vital to protect patients from peri-operative COVID whilst undertaking urgent surgery safely. Methods Our centre developed a ring-fenced 'Green Pathway' for category 1 and 2 patients requiring surgery. Patients were treated in physically separate area of the hospital, with no interaction between COVID and non-COVID patients, healthcare staff or facilities. Patients self-isolated for 14-days prior to admission, and had pre- and peri-operative COVID RT-PCR tests. We assessed outcomes for patients immediately prior to the introduction of the Green Pathway (1/10/2020) and following implementation (31/12/2020) to assess safety. Textbook outcomes for pancreatoduodenectomy were compared to assess safety and quality. Other data suggests that UGI surgery couldn't continue in other hospitals from December 2020. Results There were 47 admissions to surgical HDU following category 1 and 2 upper GI operations during the study; 31 pre-pathway (PP) implementation, and 16 green pathway (GP) patients. Median age 66-years (43-78 range) PP vs 65-years (range 42-74) GP, median ASA 3 vs 2. Median HDU length of stay (LOS) 5-days vs 7-days, and median hospital LOS 11.5-days vs 9-days for PP vs GP respectively. There were 6 cases of peri-operative COVID in PP cohort, and 1 in GP (contract following discharge). There was no mortality within either cohort. For the subgroup of patients undergoing PD: 10 patients PP, 6 patients GP, textbook outcomes were achieved in 90% vs 67% PP vs GP. Conclusions The implementation of the Green Pathway at our institution enabled continuation of surgery for patients with category 1 and 2 operations during the COVID pandemic with a significant reduction in peri-operative COVID infection, no mortality and no increase in length of stay. The TO rate was lower with the GP (not statistically significant), but our 4-year institution TO rate is 70.3%, comparing favourably to other studies. This pathway has enabled safe continuation of urgent surgery during the pandemic and could be a model for adoption in other centres especially if there is resurgence of COVID cases during the coming winter.

Background The COVID-19 pandemic has significantly impacted healthcare delivery globally with consequent restructuring of surgical services during the peak period and prioritisation of emergency and cancer surgery over elective operations. We present outcomes for laparoscopic cholecystectomy during the peak period for COVID-19 in the UK and compare this with data for the same period in 2019 Methodology This is a prospectively study. Analysis of collected data on patients who underwent laparoscopic cholecystectomy during the peak period for COVID-19 from 1st March 2020 – 30th June 2020 (study cohort) at the Royal Stoke University Hospital. Data from the same period in 2019 (control cohort) was compared and analysed. Results 104 patients underwent a laparoscopic cholecystectomy during the peak period compared to 217 during the same period in 2019. Median age in the study cohort was 51.5 years (15-84 years) and 52 years (19-91 years) in the control cohort (p = 0.49). Male to Female ratio was 1:2 in the study cohort and 1:2.2 in the control cohort (p = 0.67) Emergency admissions constituted the majority of cases and there was no statistically significant difference between both groups (61.5% vs 61.8%, p = 0.49). Most cholecystectomies were for biliary colic (41.3% vs 35.5%) and cholecystitis (37.5% vs 43.8%), and there was no statistically significant difference between both groups (p = 0.31 and p = 0.29 respectively). Conclusion This study demonstrates that laparoscopic cholecystectomy was feasible and safe in patients with symptomatic gall bladder disease during the peak period for COVID-19 when compared to a historic cohort in 2019.

The field of robotic surgery is an exciting and growing field that has bolstered its way to become a mainstream application in a number of surgical disciplines. The application of robotic surgery in cleft surgery is novel and has captivated many with the benefit it provides: the slender and small arms with wrist articulation at the instrument tip; motion scaling; tremor elimination; and high fidelity, three-dimensional visualization make the robot a very attractive platform for use in confined spaces with small surgical targets. The story of the origin of robotic surgery in cleft surgery is an interesting one, and one that has arisen from other allied surgical specialities to render robotic cleft surgery as its own specialised field. A field that has coined its own terms and has demonstrated a number of applications for its use. This review details the origins of robotic cleft surgery, its evolution and its current status and elaborates on future directions to enhance its application.

We apply $^{125}\mathrm{Te}$ nuclear magnetic resonance (NMR) spectroscopy to investigate the Dirac semimetal ${\mathrm{ZrTe}}_{5}$. With the NMR magnetic field parallel to the $b$ axis, we observe significant quantum magnetic effects. These include an abrupt drop at 150 K in spin-lattice relaxation rate. This corresponds to a gap-opening transition in the Dirac carriers, likely indicating the onset of excitonic pairing. Below 50 K, we see a more negative shift for the ${\mathrm{Te}}_{z}$ bridging site, indicating the repopulation of Dirac levels with spin polarized carriers at these temperatures. This is the previously reported 3D quantum Hall regime; however, we see no sign of a charge density wave as has been proposed.

We report $^{59}$Co, $^{93}$Nb, and $^{121}$Sb nuclear magnetic resonance (NMR) measurements combined with density functional theory (DFT) calculations on a series of half-Heusler semiconductors, including NbCoSn, ZrCoSb, TaFeSb and NbFeSb, to better understand their electronic properties and general composition-dependent trends. These materials are of interest as potentially high efficiency thermoelectric materials. Compared to the other materials, we find that ZrCoSb tends to have a relatively large amount of local disorder, apparently antisite defects. This contributes to a small excitation gap corresponding to an impurity band near the band edge. In NbCoSn and TaFeSb, Curie-Weiss-type behavior is revealed, which indicates a small density of interacting paramagnetic defects. Very large paramagnetic chemical shifts are observed associated with a Van Vleck mechanism due to closely spaced $d$ bands splitting between the conduction and valence bands. Meanwhile, DFT methods were generally successful in reproducing the chemical shift trend for these half-Heusler materials, and we identify an enhancement of the larger-magnitude shifts, which we connect to electron interaction effects. The general trend is connected to changes in $d$-electron hybridization across the series., Comment: 22 pages, 6 figures

In this work, we report nuclear magnetic resonance (NMR) combined with density functional theory (DFT) studies of the transition metal dichalcogenide ZrTe$_2$. The measured NMR shift anisotropy reveals a quasi-2D behavior connected to a topological nodal line close to the Fermi level. With the magnetic field perpendicular to the ZrTe$_2$ layers, the measured shift can be well-fitted by a combination of enhanced diamagnetism and spin shift due to high mobility Dirac electrons. The spin-lattice relaxation rates with external field both parallel and perpendicular to the layers at low temperatures match the expected behavior associated with extended orbital hyperfine interaction due to quasi-2D Dirac carriers. In addition, calculated band structures also show clear evidence for the existence of nodal line in ZrTe$_2$ between $\Gamma$ and A. For intermediate temperatures, there is a sharp reduction in spin-lattice relaxation rate which can be explained as due to a reduced lifetime for these carriers, which matches the reported large change in mobility in the same temperature range. Above 200 K, the local orbital contribution starts to dominate in an orbital relaxation mechanism revealing the mixture of atomic functions., Comment: 9 pages, 5 figures

We present a 63Cu and 65Cu NMR study of Cu12Sb4S13, the basis for tetrahedrite thermoelectric materials. In addition to electronic changes observed at the Tc = 88 K metal–insulator transition, we find that locally there are significant structural changes occurring as the temperature extends above Tc, which we associate with Cu atom displacements away from symmetry positions. Spin-lattice relaxation rates (1/T1) are dominated by a quadrupolar process indicating anharmonic vibrational dynamics both above and below Tc. We used a quasiharmonic approximation for localized anharmonic oscillators to analyze the impact of Cu rattling. The results demonstrate that Cu-atom rattling dynamics extends unimpeded in the distorted structural configuration below Tc and provide a direct measure of the anharmonic potential well.

Background Augmented reality (AR) uses a set of technologies that overlays digital information into the real world, giving the user access to both digital and real-world environments in congruity. AR may be specifically fruitful in reconstructive microsurgery due to the dynamic nature of surgeries performed and the small structures encountered in these operations. The aim of this study was to conduct a high-quality preferred reporting items for systematic reviews and meta-analyses (PRISMA) and assessment of multiple systematic reviews 2 (AMSTAR 2) compliant systematic review evaluating the use of AR in reconstructive microsurgery. Methods A systematic literature search of Medline, EMBASE, and Web of Science databases was performed using appropriate search terms to identify all applications of AR in reconstructive microsurgery from inception to December 2018. Articles that did not meet the objectives of the study were excluded. A qualitative synthesis was performed of those articles that met the inclusion criteria. Results A total of 686 articles were identified from title and abstract review. Five studies met the inclusion criteria. Three of the studies used head-mounted displays, one study used a display monitor, and one study demonstrated AR using spatial navigation technology. The augmented reality microsurgery score was developed and applied to each of the AR technologies and scores ranged from 8 to 12. Conclusion Although higher quality studies reviewing the use of AR in reconstructive microsurgery is needed, the feasibility of AR in reconstructive microsurgery has been demonstrated across different subspecialties of plastic surgery. AR applications, that are reproducible, user-friendly, and have clear benefit to the surgeon and patient, have the greatest potential utility. Further research is required to validate its use and overcome the barriers to its implementation.

The field of robotic surgery is an exciting and growing field that has bolstered its way to become a mainstream application in a number of surgical disciplines. The application of robotic surgery in cleft surgery is novel and has captivated many with the benefit it provides: the slender and small arms with wrist articulation at the instrument tip; motion scaling; tremor elimination; and high fidelity, three-dimensional visualization make the robot a very attractive platform for use in confined spaces with small surgical targets. The story of the origin of robotic surgery in cleft surgery is an interesting one, and one that has arisen from other allied surgical specialities to render robotic cleft surgery as its own specialised field. A field that has coined its own terms and has demonstrated a number of applications for its use. This review details the origins of robotic cleft surgery, its evolution and its current status and elaborates on future directions to enhance its application.

We report $^{125}$Te NMR measurements of the topological quantum material ZrTe$_5$. Spin-lattice relaxation results, well-explained by a theoretical model of Dirac electron systems, reveal that the topological characteristic of ZrTe$_5$ is $T$-dependent, changing from weak topological insulator to strong topological insulator as temperature increases. Electronic structure calculations confirm this ordering, the reverse of what has been proposed. NMR results demonstrate a gapless Dirac semimetal state occurring at a Lifshitz transition temperature, $T_c=85$ K in our crystals. We demonstrate that the changes in NMR shift at $T_c$ also provide direct evidence of band inversion when the topological phase transition occurs., Comment: 5 pages, 4 figures

We report $^{59}$Co NMR and transport measurements on $n$-type filled skutterudites Ba$_x$Yb$_y$Co$_4$Sb$_{12}$ and $A$$_x$Co$_4$Sb$_{12}$ ($A$= Ba, Sr), promising thermoelectric materials. The results demonstrate consistently that a shallow defect level near the conduction band minimum dominates the electronic behavior, in contrast to the behavior of unfilled CoSb$_3$. To analyze the results, we modeled the defect as having a single peak in the density of states, occupied at low temperatures due to donated charges from filler atoms. We fitted the NMR shifts and spin-lattice relaxation rates allowing for arbitrary carrier densities and degeneracies. The results provide a consistent picture for the Hall data, explaining the temperature dependence of the carrier concentration. Furthermore, without adjusting model parameters, we calculated Seebeck coefficient curves, which also provide good consistency. In agreement with recently reported computational results, it appears that composite native defects induced by the presence of filler atoms can explain this behavior. These results provide a better understanding of the balance of charge carriers, of crucial importance for designing improved thermoelectric materials., Comment: 9 pages, 8 figures

We present a

To investigate the electronic behavior and magnetic properties of NbFeSb, we have performed 93Nb NMR, specific heat and magnetic measurements on NbFeSb samples heat treated at high temperatures. Magnetic measurements combined with an observed Schottky anomaly and changes in the NMR line width indicate the presence of a 0.2% concentrated native magnetic defect in stoichiometric NbFeSb samples. The origin of these native defects is believed to be due to Fe antisites on Nb sites. In addition, NMR shift and spin-lattice relaxation results below 200 K reveal a Korringa-like response indicating heavily-doped p-type behavior due to native defects. Above 280 K, this converts to an activated behavior, indicating the presence of an impurity band, empty at low temperatures, which is located around 0.03 eV above the valence band maximum.

The Kondo-necklace model can describe magnetic low-energy limit of strongly correlated heavy fermion materials. There exist multiple energy scales in this model corresponding to each phase of the system. Here, we study quantum phase transition between the Kondo-singlet phase and the antiferromagnetic long-range ordered phase, and show the effect of anisotropies in terms of quantum information properties and vanishing energy gap. We employ the "perturbative continuous unitary transformations" approach to calculate the energy gap and spin-spin correlations for the model in the thermodynamic limit of one, two, and three spatial dimensions as well as for spin ladders. In particular, we show that the method, although being perturbative, can predict the expected quantum critical point, where the gap of low-energy spectrum vanishes, which is in good agreement with results of other numerical and Green's function analyses. In addition, we employ concurrence, a bipartite entanglement measure, to study the criticality of the model. Absence of singularities in the derivative of concurrence in two and three dimensions in the Kondo-necklace model shows that this model features multipartite entanglement. We also discuss crossover from the one-dimensional to the two-dimensional model via the ladder structure., Comment: 12 pages, 6 figures