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Preoperative MRI measurement of condylar twist angle to optimise femoral component rotation in total knee arthroplasty: A prospective study.Background: Rotational malalignment of the femoral component is a recognized cause of early failure after total knee arthroplasty (TKA). Conventional techniques often rely on fixed external rotation values or bony landmarks, which may be unreliable in arthritic knees. The condylar twist angle (CTA) - the angle between the posterior condylar axis (PCA) and anatomical transepicondylar axis (aTEA) - offers a patient-specific reference. This study evaluated whether preoperative magnetic resonance imaging (MRI) measurement of CTA, reproduced intraoperatively, enhances the accuracy of femoral component rotation. Methods: A prospective study was performed on 23 knees in 12 patients undergoing primary TKA for osteoarthritis between 2014 and 2016. Preoperative MRI was used to calculate the CTA, which was reproduced intraoperatively using a posterior condylar referencing jig. Postoperative computed tomography (CT) was performed to validate femoral component rotation relative to the aTEA. The primary outcome was the difference between planned and achieved CTA. Results: The mean preoperative CTA was 6.47° (range: 3-9°), with higher values in males (7.44°) than females (5.85°). The mean error between planned and postoperative CTA was 0.60°. Parallel alignment to the aTEA was achieved in 8 knees (34.8 %) and a further 14 knees (60.9 %) were 1° or less. All patients demonstrated balanced flexion gaps, stable patellofemoral tracking, and no requirement for lateral release. Conclusions: Preoperative MRI-based CTA measurement provides a highly accurate, patient-specific method for guiding femoral component rotation in TKA, achieving near-parallel alignment with the aTEA. This approach may overcome the limitations of fixed external rotation techniques and reduce the risk of malrotation-related complications. Larger, multicentre studies are warranted to validate these findings and assess long-term outcomes.
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Burning Cities, Burning Brains: Prevalence of Post-Traumatic Stress Disorder in Survivors of Urban Violence in Pakistan – A Neuro PerspectiveUrban violence in Pakistan constitutes a profound assault on both structure and psyche,yet neuro‐specific investigations remain scarce. This experimental study aimed to determine the prevalence of post‐traumatic
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Healthcare professionals' and students' willingness to perform abortion: A systematic review and meta-analysis, 2014-2025Background: Healthcare professionals' and students' willingness to provide abortion influences access to care and workforce readiness. Objective: We conducted a literature synthesis to identify patterns in willingness across various clinical scenarios. Design: Systematic review and meta-analysis. Data sources: We searched five databases (PubMed, Scopus, Web of Science, Medline, and CINAHL) and gray literature for studies (January 2014 to February 2025) without language restrictions. Eligible studies reported cross-sectional data on providers' willingness, while we excluded conditionally framed scenarios. Willingness was defined as the intent, readiness, or affirmative response to provide abortion. Methods: Summary-level data on theme-specific willingness were extracted and re-coded into binary or proportional format (yes/no or n/N). Estimates were pooled using random-effects models. Meta-regression and publication bias assessments were performed. Study quality was assessed using a novel in-house tool tailored for survey-based research. Results: We included 36 studies (n = 18,779), reporting 137 estimates across 24 themes. Willingness to provide was highest for lethal fetal anomalies (88.7%, 95% CI: 76.1%-95.1%) and maternal physical health risks (88.6%, 95% CI: 55.7%-98.0%) but substantially lower for on-request scenarios (33.1%, 95% CI: 14.9%-58.4%), surgical abortion (32.1%, 95% CI: 11.6%-63.0%), and social reasons (range 20.1%-32.0%). Multilevel modeling captured both converging and diverging response patterns across categories. Meta-regression indicated that students had consistently higher willingness than professionals. Dominant religion was also observed to be more strongly associated than legal status and other country-level indices. Evidence of small-study effects was limited apart from in a few themes. Risk of bias was high in 31% of studies, with our tool showing strong structural overlap with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) frameworks. Conclusions: Providers often prioritized abortion in life-threatening contexts but hesitated in non-urgent scenarios. Values-based training and systemic reforms are needed for equitable access to and expansion of abortion care.
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Comparing the Molecular Pharmacological Properties of Existing beta-Blockers to Determine the Theoretically Most "Ideal" Anti-Cancer beta-Blocker.There is increasing evidence, from cellular, animal and human epidemiological studies, linking β-blockers with reductions in cancer growth and metastasis. Propranolol is the most investigated β-blocker for cancer; although as many different off-patent β-blockers exist, there is little commercial incentive to drive comparative clinical trials. To minimize any chance of endogenous β-agonist driven cancer growth or metastasis, theoretically, the "ideal" anti-cancer β-blocker would have high affinity, no partial agonism, and long duration of action at β2-adrenoceptors (and for some cancers, additionally at β1 or β3-AR). Using CHO cells stably expressing the wildtype and polymorphic variants of the human β1 and β1-adrenoceptors, this study assessed 35 β-blockers for the affinity and duration of binding (using 3H-CGP12177 whole cell binding) and intrinsic efficacy (CRE-gene transcription). Despite high affinity, some β-blockers had a short binding duration (e.g., alprenolol, bupranolol, levobunolol, nadolol and oxprenolol). Other compounds had substantial partial agonism (e.g., cyanopindolol, bucindolol, pindolol, pronethalol and xamoterol) and other compounds had a biphasic washout (e.g., bucindolol, timolol, carpindolol, and CGP12177) for reasons unknown. Considering all 3 factors, carazolol and ICI118551 may be more "ideal" than propranolol; however, carvedilol, with higher affinity and substantially longer duration of β2 (and β1) receptor binding than propranolol whilst maintaining low partial agonism, may be the most theoretically optimal. Furthermore, it is already widely used in cardiovascular medicine as an off-patent tablet. Thus, carvedilol may have more optimal molecular pharmacological characteristics for an "anti-cancer" β-blocker than propranolol and could enter prospective comparative clinical trials without needing any further clinical workup.
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Artificial intelligence in healthcare: applications, challenges, and future directions. A narrative review informed by international, multidisciplinary expertiseObjectives: This narrative review evaluates the role of artificial intelligence (AI) in healthcare, summarizing its historical evolution, current applications across medical and surgical specialties, and implications for allied health professions and biomedical research. Methods: We conducted a structured literature search in Ovid MEDLINE (2018-2025) using terms related to AI, machine learning, deep learning, large language models, generative AI, and healthcare applications. Priority was given to peer-reviewed articles providing novel insights, multidisciplinary perspectives, and coverage of underrepresented domains. Key findings: AI is increasingly applied to diagnostics, surgical navigation, risk prediction, and personalized medicine. It also holds promise in allied health, drug discovery, genomics, and clinical trial optimization. However, adoption remains limited by challenges including bias, interpretability, legal frameworks, and uneven global access. Contributions: This review highlights underexplored areas such as generative AI and allied health professions, providing an integrated multidisciplinary perspective. Conclusions: With careful regulation, clinician-led design, and global equity considerations, AI can augment healthcare delivery and research. Future work must focus on robust validation, responsible implementation, and expanding education in digital medicine.
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Predicting compounds that interact with the 2 known agonist-induced conformations of the human beta1-adrenoceptorThe β1-adrenoceptor exists in at least 2 agonist-stabilized conformational ensembles: a "catecholamine" ensemble induced via the intrahelical binding site through which catecholamines and most agonists act and a "secondary" ensemble of conformations through which CGP12177 stimulates agonist responses. Several β-ligands stimulate agonist responses through both conformations, resulting in biphasic concentration responses, but little is known about the structure-activity relationship of such ligands. Using a structure-activity hypothesis built on the predicted poses CGP12177 and 3 biphasic agonists (alprenolol, oxprenolol, and bucindolol), predictions based on ligand similarity and structural compatibility reasoning were made about 11 other β1-ligands not yet tested for secondary conformation interaction and examined in radioligand binding and functional assays using human β1- and β2-adrenoceptors. Although the predictions matched with pharmacology in only 6/11 of cases, 3 novel compounds were found to induce an active-state secondary conformation. A CGP12177 derivative (methyl-pyrrole replacing the cyclic urea motif) retained catecholamine site antagonism with secondary site activation. Carteolol (related to CGP12177) and bunitrolol (similar to alprenolol) activated both conformations with biphasic concentration responses. Bunolol (CGP12177 derivative lacking nitrogen in the bicyclic system), as predicted, was a neutral antagonist with no secondary site activation. Moprolol and some bucindolol analogs appeared as conventional agonists, whereas other alprenolol and bucindolol analogs lost all receptor interaction. In a β1-adrenoceptor mutant (β1-V189T-L195Q-W199Y) where secondary site CGP12177 and pindolol interaction is lost, the 3 novel secondary-site compounds were also no longer able to stimulate secondary conformation responses, suggesting that there is a common TM4 secondary conformation-inducing interaction site. SIGNIFICANCE STATEMENT: The β1-adrenoceptor exists in 2 agonist-stabilized, pharmacologically distinguishable conformations. This study pinpointed the interaction site through which the alternative conformation is stabilized and suggested and evaluated additional ligands, thus providing possible molecular determinants.
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The Impact of Short, Structured ENT Teaching Interventions on Junior Doctors' Confidence and On-Call Preparedness: A Systematic ReviewBackground/objectives: Ear, nose, and throat (ENT) presentations are common across the UK healthcare system and are often managed initially by junior doctors on call. Short, structured teaching interventions (e.g., boot camps and simulation workshops) have been introduced to improve confidence and preparedness. This review evaluated evidence published since 2015 on such ENT teaching interventions for junior doctors, examining effectiveness, study design, and outcome measures. Methods: Five databases were searched (January 2015-July 2025). Eligible studies assessed ENT-specific courses for junior doctors and reported outcomes on confidence, preparedness, knowledge, or performance. Study quality was appraised using the Medical Education Research Study Instrument (MERSQI). Owing to heterogeneity, findings were narratively synthesised in line with Synthesis Without Meta-analysis (SWiM) guidance. Results: Eleven studies (n = 591) met inclusion criteria: nine single-group pre-post studies, one two-group comparative study, and one randomised controlled trial (RCT). Most studies reported increased confidence after the interventions, while three also showed gains in knowledge. A minority reported improvement using blinded performance assessments. Overall methodological quality assessed using MERSQI scores was moderate (mean 10.0/18). Limitations included reliance on self-reported outcomes, limited use of control groups, and generally short follow-up periods. Conclusions: Short, structured ENT courses for junior doctors are associated with immediate improvements in confidence and knowledge, with some evidence of objective performance gains. However, the predominance of single-arm designs and brief follow-up limits causal inference and conclusions regarding retention, workplace behaviour, and patient outcomes. More robust comparative studies with blinded assessment and longitudinal follow-up are needed to determine sustained impact.
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Closing the gap in acute NIV: A scalable nurse-led approach to optimising time-critical care.Introduction The 2023 BTS RSU audit demonstrated a lower all-cause mortality for hospitals with an RSU and enhanced staffing ratios. At Sherwood Forest Hospitals (SHFT), an acute NIV nurse-led outreach and retrieval service, based on an RSU with enhanced staffing and central monitoring of observations, has been in place for over 8 years. However, data demonstrated our median gas and door-to-mask times were 03:29hrs, and 04:15hrs respectively, with delays noted in performing and interpretation of blood gases. Methods We created a digital tracker focusing on gas and door-to-mask times as our improvement measures. Following process mapping and root cause analysis, we redesigned our referrals process and developed an early assessment model for all acute patients. Acute NIV nurses perform an early clinical review at the initial identification of possible NIV patients, optimising patient care, ensuring timely blood gases and earlier ringfencing of RSU beds. Adopting and supplementing the BTS care bundle,2 we added 3 additional locally conceived standards to match our new delivery model and created a checklist to ensure consistency and completeness. We audited the utilisation of our standards before and after the intervention. Results Audit data demonstrated that pre-intervention, only 10% of sampled patients from 2024 received all elements of the care bundle, improving to 74%. Delivery of acute NIV improved with a reduction in both gas and door-to-mask times of 43 minutes and 1 hour 09 minutes, respectively. Conclusion Early results demonstrate an improvement in treatment times. The development of the locally enhanced care bundle enabled the reduction in variation of care and empowered the team to utilise their skills, experience and knowledge. We believe the continuous development of our acute NIV nurse model to now include earlier optimisation and identification of patients is sustainable, cost-effective and applicable to similar services.
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Establishing real world quality standards for domiciliary non-invasive ventilation.Introduction Chronic Obstructive Pulmonary Disease (COPD) places a significant burden on healthcare. Non-invasive ventilation (NIV) is an established treatment for acute respiratory failure in COPD, with comprehensive guidelines.1 However, evidence for its use in the domiciliary setting is more recent, with no standardised criteria for initiating or monitoring treatment. Trials such as HOT-HMV2 demonstrated clinical benefit but excluded patients with BMI >35 or obstructive sleep apnoea (OSA), highlighting limited real-world applicability. We hypothesised that testing local standards in real-world COPD populations could offer insight into realistic expectations for national domiciliary NIV services. Objectives We developed local criteria for domiciliary NIV initiation and follow-up, assessing their feasibility in routine care to inform service design. We also characterised our COPD population to evaluate how well existing research2 applies to real-world patients. Methods This retrospective observational study used cross-sectional and longitudinal data from 181 COPD patients initiated on domiciliary NIV between 1st July 2021 and 1st July 2024 within an NHS trust. Seven local standards (table 1) were defined using clinical reasoning alongside available guidelines. Demographics were evaluated at initiation. Patients with ≥12 months of follow-up (n=107) were assessed for hospital readmission, comparing admissions in the year before and after NIV initiation. Results Demographics: 62% female, mean BMI 34 (n=138), 48% BMI >35. 35% had OSA, 67% ≥1 additional respiratory diagnoses. Performance against quality standards was variable (see table 1). However, there was a 33% reduction in hospital admissions among patients with ≥12 months follow-up, and 81% attended ≥3 respiratory clinics in the first year on treatment. Conclusions This study trialled proposed quality standards and examined the real-world COPD population. Our findings show that trial populations do not reflect real-world COPD cohorts, limiting research generalisability. Many standards proved overly ambitious, highlighting the need for evidence-based, achievable national guidelines. These findings support the need for a national audit to inform realistic, standardised domiciliary NIV pathways.
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Comparative Analysis of Lung Ultrasound, Computed Tomography, and X-ray in the Diagnosis of Common Pathologies among Critically Ill Mechanically Ventilated Patients-A Prospective Observational StudyBackground and aims: Chest X-ray (CXR) and computed tomography (CT) are established imaging modalities for patients in respiratory distress, and lung ultrasound (LUS) has emerged as an efficient point-of-care alternative. This study aimed to evaluate the diagnostic performance of LUS and CXR in critically ill patients, utilizing CT thorax as the reference standard. Patient and methods: A prospective observational study was conducted in a tertiary care intensive care unit (ICU) involving mechanically ventilated adult patients requiring CT thorax. Before the CT, patients underwent portable CXR and LUS. Diagnostic performance metrics were calculated using sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and AUC-ROC for pneumothorax, pleural effusion, consolidation, collapse, and pulmonary edema for CXR and LUS compared to CT. Inter-rater agreement was assessed using Cohen's κ. Results: A total of 110 patients were included in this study. Overall, the performance of LUS was significantly superior to CXR for diagnosing various pathologies. Lung ultrasound exhibited 100% sensitivity and 97% specificity, outperforming CXR (66.7% sensitivity) for the detection of pneumothorax. For pleural effusion, LUS achieved 100% sensitivity and specificity, reflecting perfect concordance with CT, especially for moderate and severe pleural effusions, while CXR had an accuracy of only 68.18%. Lung consolidation and collapse were identified with 100% sensitivity and PPV by LUS. Furthermore, the accuracy of LUS in diagnosing pulmonary edema was 96.4%, with a specificity of 95.3% and an NPV of 100%. Conclusion: Across five pathologies that were evaluated in this study, LUS consistently outperformed CXR in diagnostic accuracy and concordance with CT thorax.
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Critical evidence synthesis on rehabilitation following arthroscopic shoulder stabilisation surgery for traumatic anterior instability: consensus recommendations for clinical practice and research - commissioned by the British Elbow & Shoulder Society.Arthroscopic shoulder stabilisation surgery (ASSS) is a common procedure for treating anterior shoulder instability. Postoperative rehabilitation remains a crucial, but under-researched, aspect of patient recovery. Despite its importance, no comprehensive rehabilitation guideline based on robust clinical trials has emerged, leaving a gap in evidence-based practice. To address this, the British Elbow & Shoulder Society appointed the Allied Health Professional Clinical Guideline Group to review current practices and establish clinical guidance on rehabilitation. This evidence synthesis aims to provide a critical synthesis and discussion on rehabilitation following ASSS. The intended outcome is to highlight areas of uncertainty and make recommendations for clinical practice and further research. The development of this evidence synthesis followed a rigorous five-stage process: (1) systematic literature review, (2) UK national practice survey, (3) expert consensus (Delphi) study, (4) updated literature search and review and (5) synthesis of the previous four stages. Stages 1–3 have been published previously. This evidence synthesis comprised stages 4 and 5. 10 key domains for postoperative rehabilitation from immediate postsurgery to return to normal function, including sports, were identified. This paper synthesises current knowledge and provides a platform for recommendations in clinical practice and future research. In particular, early shoulder movement was recommended during the ‘immobilisation period’, but confined to shoulder elevation up to 90°, anterior to the scapular plane, with neutral external rotation. Further high-quality primary research is needed to address uncertainties and expand the evidence base, thereby informing and challenging clinical practice.
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Asking pre-operative patients to opt out of referral to Stop Smoking Services via Short Message Service: A controlled interrupted time series analysis.Background and aims: Smoking tobacco increases the risk of intra- and post-operative complications. Abstinence before surgery reduces these risks and costs to healthcare services. This study measured smoking abstinence among elective pre-operative patients who smoked following a modified clinical pathway. Design: An observational, follow-up study of patients who received the changed pre-operative pathway, supplemented by a controlled interrupted time series analysis (ITSA) of hospital patients referred to the community Stop Smoking Service (SSS) between April 2020 and August 2024. Patients referred to the SSS by primary care clinicians acted as a negative control to assess whether any observed changes reflected general time trends rather than the intervention effect. Setting: A district general hospital in Nottinghamshire, United Kingdom, during January 2024. Participants: 476 pre-operative patients recorded as smokers in primary care electronic health records (52% female; mean age 52 years) awaiting elective procedures taking place in more than 6 weeks were included. Intervention: Patients who had completed the routine pre-operative care pathway were invited via Short Message Service message (SMS) to opt out of SSS referral. Those who did not respond within 14 days were referred. The SSS provided usual care consisting of face-to-face or virtual counselling and an offer of nicotine replacement therapy. The intervention was low-cost and used existing pre-operative services. Measurements: The primary outcome was patient-reported smoking abstinence 28 days after an agreed quit date. This is a routinely collected SSS outcome. Controlled ITSA compared weekly counts of first SSS appointments between secondary care and primary care referrals among patients who subsequently achieved abstinence, before and after the intervention was implemented. Findings: 10.5% (50/476) of patients reported 28-day abstinence. 25.4% (121/476) booked an SSS appointment and 16% (77/476) opted out of SSS referral. 63.9% (304/476) were contactable by the SSS and 54.2% (258/476) confirmed smoking. 19.4% (50/258) of patients who were contactable and confirmed smoking stopped. ITSA indicated an immediate increase in weekly hospital patients referred who reported abstinence was not due to any general time trends (5.83, 95% confidence interval = 2.50-9.16, P < 0.001), consistent with a pulsed intervention of limited duration. Conclusions: Inviting elective surgical patients to opt out of Stop Smoking Service referral via Short Message Service message appears to increase 28-day smoking abstinence.
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Reconstruction of large glenoid bone defects with graft and extended caged base plate yields positive mid-term results.Background This retrospective study assessed postoperative functional outcomes and radiographic graft integration following reverse total shoulder arthroplasty (rTSA) and glenoid reconstruction using computed navigation. Methods A case series of 14 patients underwent rTSA with an augmented glenoid baseplate using autograft or allograft. All patients had preoperative computed tomography scanning to assess glenoid defects and repeat scans at a minimum of 12 months to assess graft integration. Outcome measures were collected, consisting of the Oxford Shoulder Score (OSS), visual analogue pain scale (VAS), and range of motion figures at a minimum 12-month follow-up. Results This study included 14 patients (13 females, 1 male) with a median age of 74 (range: 58-86) years, a median body mass index of 29 (range: 18-35), and a median American Society of Anesthesiologists physical status classification system of 2 (range: 1-3). Ten were primary replacements, and 4 were revisions. Humeral head autograft was used for 6 patients, and femoral head allograft in 8 patients. All patients demonstrated graft integration on computed tomography at a median of 15 months (range: 11-42 months). The outcome measures (OSS, VAS, and range of motion) revealed overall improvement in functional outcomes. Median OSS improved from 21 (range: 7-34) preoperatively to 45 (range: 12-49), median VAS improved from 8 (range: 5-10) to 0 (range: 0-8), median lateral abduction improved from 60 to 90°, and median forward flexion 80 to 140°. These improvements were significant. Glenoid version correction, although not significant, improved from a median of 24° retroversion to 9° retroversion. Navigation was performed in all patients except 2, one by choice in a primary rTSA and the other due to intraoperative coracoid fracture during a revision case. Conclusion This study demonstrated an effective solution for managing complex glenoid defects in rTSA with excellent radiographic and functional outcomes.
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Pulse transit time respiratory swing as a diagnostic test for obstructive sleep apnoea in children-An observational study.Background Pulse transit time (PTT) has been identified as a potentially useful tool for diagnosing obstructive sleep apnoea (OSA) due to its high sensitivity in detecting cortical arousals. However, its use in clinical practise has been disappointing as it appears to lack the ability to distinguish between individuals with or without OSA. The majority of studies evaluating PTT for sleep-disordered breathing (SDB) have assessed the pulse transit time arousal index (PTT-AI), and there are limited published data on PTT respiratory swing (PTTrs). We previously conducted an observational study of PTT in 368 children with SDB. Our findings indicated that depending on the cut-off used, PTTrs identified OSA with low-to-moderate sensitivity and moderate-to-high specificity, using limited multi-channel sleep studies (MCSS) as the comparator. Methods We conducted this cross-sectional observational study in another cohort of 1,031 children with SDB who attended a secondary care centre consecutively for MCSS between July 2022 and November 2024. Polysomnography (PSG) is not available in UK secondary care centres, and our use of MCSS in this setting is novel. We analysed the data of 629 children using multinomial regression and machine learning. Results We found a stepwise increase in PTTrs with increasing severity of SDB. Children with mild OSA had a mean PTTrs of 20.7 ms. Machine learning analysis indicated that the oxygen desaturation index (ODI3) and PTTrs were the most important predictors of SDB amongst the 15 variables studied. Conclusion Our findings suggest that PTTrs could complement oximetry to improve the detection of OSA in children. A validation study comparing PTTrs with PSG is needed.
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Variation in missed opportunities for secondary fracture prevention.Introduction Despite clear national guidelines and government support for Fracture Liaison Services, the osteoporosis treatment gap remains significant. The Fracture Liaison Service Database (FLS-DB), a national audit run by the Royal College of Physicians (RCP), has recently expanded its reporting to highlight this issue. Method Previously the FLS-DB benchmarked data from those trusts submitting data to the audit. From January 2025, an extra column has been added to show ‘Missed Opportunities’ that includes data from sites not participating in the FLS-DB. Using local hip fracture data for 2022 from the National Hip Fracture Database (NHFD) figures, the predicted local FLS caseload was determined by multiplying the number of hip fractures by 5. Expecting 80% of the predicted caseload to be identified, at least 50% of those to be recommended treatment (accounting for mortality, severe comorbidities etc.) and 80% of those initiating and staying on treatment up to 12 months gives the expected on treatment population. This was compared with the data from the FLS-DB and NHFD KPI set to generate the number with a missed opportunity. Results 77 FLS are participating with the FLS-DB with 82 NHFD sites not covered by an FLS. While 80,767 records were submitted in 2022, the missed opportunity count was estimated to be 56,550 patients (48,214 in England and 6180 in Wales) per annum. When the missed opportunity estimate was analysed in 36 ICSs, there was an over 100-fold difference in the estimate. Conclusions Despite clear guidelines and prioritisation of FLSs, over 50,000 patients are not on osteoporosis treatment when they should be. By making this data visible at the local hospital and ICS/Health board level, care providers can better judge the level of resources required for FLS locally, and the data provides support for ICSs in FLS implementation.
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Surgical training for simple and complex hernia repair in the UK: results of a nationwide training survey.Introduction: Abdominal wall reconstruction (AWR) is increasingly recognised as a subspecialty in general surgery, owing to the growing complexity and advancement of hernia repair techniques. Concerns have been raised among UK hernia specialists about current surgical training adequately preparing trainees for both simple and complex hernia procedures. Methods: A CHERRIES-compliant survey was developed by a panel of hernia experts to evaluate UK training in hernia surgery. The 41-item questionnaire assessed perceived competence and confidence in performing eight types of hernia repair, categorised as simple (primary inguinal, umbilical, laparoscopic inguinal and Rives-Stoppa) or complex (recurrent inguinal, component separation and parastomal hernia repair), along with broader AWR-related topics (open abdomen management, participation in multidisciplinary meetings). The survey was disseminated via social media, targeted chat groups and surgical conferences. Results: The survey was conducted from 21 January to 27 September 2024. Of approximately 500 possible respondents, 116 completed the survey (47 surgical trainees (ST) 7-8s, 30 clinical fellows and 34 consultants), yielding an estimated 22.2% response rate. Curriculum requirements were met only for open inguinal and umbilical hernia repair. Although there are no formal curriculum requirements for complex repairs, trainee exposure remains limited; two-thirds had performed fewer than ten recurrent inguinal or component separation procedures. For parastomal hernias, confidence was highest with suture repair despite these being associated with poor outcomes. Overall, median confidence scores were highest for simple repairs and lowest for complex ones. Conclusions: Current UK surgical training provides inadequate exposure to complex AWR, highlighting the need for targeted curriculum improvement.
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Semaglutide-associated drug-induced liver injury: a case report and review of the literatureSemaglutide is a glucagon-like peptide-1 receptor agonist (GLP-1RA) used to manage type 2 diabetes and, since 2021, for weight loss in individuals with obesity or weight-related comorbidities. It works by enhancing insulin secretion, delaying gastric emptying and reducing appetite. Common side effects include hypoglycaemia, gastrointestinal disturbances, nausea, weight loss and cholelithiasis. While some studies have noted an association with acute kidney injury, reports of liver injury are rare. We present a rare case of drug-induced liver injury in a middle-aged female, associated with transient liver failure after semaglutide use. She presented one month after starting the medication with rapidly worsening liver function tests. Investigations, including a non-invasive liver screen, viral studies, ultrasound and CT imaging, revealed no clear cause. A liver biopsy supported the diagnosis of drug-induced liver injury. The patient improved with supportive treatment and withdrawal of semaglutide. This case underscores the importance of clinician awareness given its increasing, and often unregulated, use for weight loss.
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A Comparison of the Molecular Pharmacological Properties of Current Short, Long, and Ultra‐Long‐Acting β2‐Agonists Used for Asthma and COPDβ-agonists have been used in asthma for 120 years. There are two recent changes: ultra-long-acting agonists for COPD and new asthma guidelines recommending formoterol/ICS inhalers phasing out short-acting salbutamol inhalers. Few studies directly compare the molecular pharmacological properties of short (salbutamol, terbutaline, fenoterol), long (formoterol, salmeterol), and ultra-long-acting (indacaterol, olodaterol, vilanterol) β2-agonists. Here, the in vitro molecular pharmacological properties of affinity, selectivity, intrinsic efficacy, and duration of β2-agonists at human β2 and β1-adrenoceptors and the 4 β2-polymorphisms stably expressed in CHO cells were directly compared using radioligand binding and functional studies. Whilst short-acting drugs were similar, there was huge variation and complete overlap in the molecular pharmacological properties of drugs labeled as long and ultra-long-acting β2-agonists. Salmeterol and vilanterol were highly β2-selective (> 1000-fold) whereas indacaterol was similar to salbutamol (40-fold). Formoterol and indacaterol were the most efficacious, whereas salmeterol had the longest duration of binding. Salmeterol and vilanterol utilize a β2-specific exosite (β2-H296-K305) for high affinity and selectivity (that does not affect intrinsic efficacy or duration) whilst the β2-selectivity of formoterol and olodaterol resides elsewhere. Duration of binding closely correlated with lipophilicity. β2-polymorphisms had no substantial effect on β2-agonist properties. Comparison with other β-ligands suggests that affinity and duration could both be improved further. However, given the very wide range of molecular pharmacological properties of β-agonists that are clinically effective and widely used, non-pharmacological properties (physiochemical, patient factors, devices and combination inhaler availability) may be as important in final clinical patient outcomes as the molecular pharmacological properties of the individual β2-agonists themselves.
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Environmental sustainability in pediatric otolaryngology: An international survey of operating room practice patterns.Objectives: The primary objective of this study was to evaluate international practice patterns related to environmental sustainability in pediatric otolaryngology ORs, with a focus on the use of single-use versus reusable supplies. Methods: An electronic survey was distributed using REDCap to members of an international pediatric otolaryngology WhatsApp group (n = 324). The survey included multiple-choice, Likert-scale, and open-ended questions regarding drape, gown, and glove usage for adenotonsillectomy, ear tube insertion, and laryngoscopy/bronchoscopy procedures, and broader sustainability practices including barriers and enablers. Results: Response rate was 16.0 % (n = 52/324). Respondents were from North America (30.8 %), Europe (25.0 %), Australia/New Zealand (23.1 %), Asia (15.4 %), South America (3.8 %), and Africa (1.9 %). For adenotonsillectomy 61.5 % reported using single-use patient drapes, 61.5 % use single-use table drapes, and 44.2 % use single-use gowns. For ear tube insertions, single-use table drapes (53.8 %) were most frequently reported; single-use patient drapes (38.4 %) and gowns (21.2 %) were less common. For laryngoscopy/bronchoscopy, the majority did not use patient drapes (31.4 %) or gowns (32.7 %), while 62.8 % use single-use table drapes. Top barriers to improving sustainability in the OR were cost (51.9 %) and infection prevention and control (IPAC) practices (44.2 %). Enablers included sufficient technological (46.2 %) and financial (36.6 %) resources, dedicated policies (30.8 %), and supportive leadership (34.6 %). Conclusion: There remains a strong reliance on single-use materials in pediatric otolaryngology ORs globally. Cost, IPAC, education, and leadership are important considerations in sustainability efforts. These findings identify actionable targets for waste reduction and support the need for specialty-specific sustainability interventions.
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989 Obturator Hernia: A Rare Surgical EmergencyAim Obturator hernias are a rare pelvic hernia with an incidence of approximately 1%. These are more common in emaciated, elderly women and typically present with acute obstruction. Diagnosis can be challenging as clinical signs are non-specific and CT scan is the optimal imaging modality. Treatment is surgical and both open and laparoscopic methods have been demonstrated. We present a safe and effective approach to repair an acutely obstructed left sided obturator hernia using a laparoscopic Transabdominal preperitoneal (TAPP) technique. We aim to demonstrate the anatomical landmarks neighbouring an obturator hernia that require consideration for a safe repair. Method An 86-year-female presented with acute abdominal pain, vomiting and constipation. A CT scan confirmed an acutely obstructed left sided obturator hernia. Laparoscopy demonstrated small bowel herniating through the obturator canal in keeping with the transition point of obstruction. The hernia was reduced and small bowel viable. A pre-peritoneal flap was created and Prolene mesh placed to cover the defect. The pre-peritoneal flap was closed over the mesh and fixed in place using an absorbable strap fixation device. Care was taken to avoid injury to the obturator nerve and artery. Results The patient made an excellent recovery and was discharged at day five. They were followed up three months later and reported their long-term intermittent symptoms of obstruction were cured after surgery. Conclusions Obturator hernias are a rare presentation to the emergency general surgical take. They can cause diagnostic uncertainty and an operative challenge. Laparoscopic TAPP repair is a safe and effective approach for obturator hernias.
