bluuebunny/crossref_metadata_2025 huggingface dataset:
International Relations and the 19th Century Concert System
Authors: Lemke Tobias
Published: August 2023

International relations (IR) scholars have long been fascinated by the politics of the European Concert of Great Powers—the diplomatic institution said to have provided relative peace, calm, and stability across Europe in the wake of the French Revolutionary and Napoleonic Wars. Interest in the Concert is boosted by arguments that the institutional and normative framework of the post-1815 European international order can serve as a useful template for managing great power relations in the increasingly multipolar and multicultural world of the 21st century. From this perspective, the ability of statesmen such as Metternich and Castlereagh to keep the European peace for almost 4 decades and provide pragmatic solutions to the most vexing international problems of revolution, dynastic rivalry, and national competition is meant to inspire contemporary world leaders to provide security and accommodation in the context of declining American hegemony and rising powers.

The persistent centrality of the European Concert as a distinct subject area in IR scholarship raises a number of important questions: What exactly was the Concert and how long did it last? How did the Concert as an institution of great power management change over time? How do different theoretical approaches explain the ability of the Concert to structure interstate dynamics in meaningful ways? Most importantly, is it analytically feasible and normatively desirable to use the 19th century European Concert system as a blueprint for reorganizing international relations today? These questions identify key debates across the existing literature and demonstrate the conceptual, theoretical, methodological, and political diversity of the field. They also reveal that the formation of a disciplinary consensus on the Concert remains an elusive goal. As a result, scholars should remain attuned to ongoing historiographical developments and critically reflect on their own theoretical and political priors regarding the history and future of concert diplomacy.
Los Angeles
Authors: Kim Jessica M.
Published: August 2023

Since the founding of Los Angeles in the 18th century, the region has been a “global city,” defined by links between the region and the broader world. Los Angeles grew into the nation’s second-largest city and one of the world’s “megacities” or “global cities” as a direct result of European imperialism, global capitalism, and national and international patterns of migration. The 1781 founding of the city by Spanish settler colonists and later annexation by the United States were driven by global forces of colonization, conquest, and resource exploitation. Subsequent regional economic development and ties to global markets created economic growth in Los Angeles while drawing global migrations to Southern California from the late 19th century and into the 21st. Global migrations included the movement of millions of people to greater Los Angeles from Asia, Latin America, and around the world. These migrations transformed Los Angeles into one of the most diverse regions of the world by the first decades of the 20th century. The city’s phenomenal economic growth across the 20th century was also extensively tied to global economic links and the expansion of global capitalism. Global patterns of deindustrialization and economic restructuring at the end of the 20th century intersected with a significant rise of post-1965 immigration and settlement in Los Angeles in the final decades of the 20th century. At the start of the 21st century, it is the city’s diverse global communities that are reimagining and remaking the city in the face of deep urban economic and racial inequalities.
Milwaukee
Authors: Seligman Amanda I.
Published: August 2023

Milwaukee means “the good land” in Anishinaabemowin, the language group of the Indigenous people who have lived in the region since the 17th century. Milwaukee is nestled between a subcontinental divide and the western shoreline of Lake Michigan. Some 10,000 years ago, the retreating Wisconsin glacier shaped the region’s topography: at sea level and relatively flat near Lake Michigan and rolling hills in the Kettle Moraine area north and west of the city’s site. The Milwaukee, Kinnickinnic, and Menomonee rivers converge in the city. The water made the land fertile and defined its promise as a transportation hub.

Milwaukee grew from this rich potential into the largest and most diverse city in Wisconsin. During the 19th century, it transformed from a collection of Indigenous villages with a Metis trading post into an industrial powerhouse specialized in heavy manufacturing and brewing. European immigrants (especially from Germany and Poland) and migrants from the eastern United States staffed Milwaukee’s businesses and settled the region with farming hamlets and suburban municipalities. By the early 20th century, Milwaukee consistently ranked among the top twenty US cities by population. But because the city’s area was so compact, it was also one of the most densely populated. For half of the 20th century, Socialists governed Milwaukee. Unusually among Midwestern cities, Milwaukee’s Socialists waged a campaign to annex surrounding areas, leading to a wave of defensive suburban incorporations after World War II.

In the second half of the 20th century, the third wave of the Great Migration brought large numbers of African Americans to Milwaukee’s North Side, and Mexican Americans settled permanently on the South Side. At the same time, the city and its industrial suburbs began to shed manufacturing jobs and decreased the white population. Although the suburbs maintained separate governance, Milwaukee and its surrounding counties (Ozaukee, Washington, and Waukesha) grew into an interconnected metropolitan whole. In the 21st century, the city’s population stabilized at a bit under 600,000 residents, and local government spearheaded downtown revitalization efforts. Approximately one million people lived in the surrounding counties.
Kabbalah in Art and Architecture
Authors: Goldman-Ida Batsheva
Published: August 2023

Kabbalah (literally “the receiving” [of tradition]) is an early form of Jewish mysticism. Key concepts include the ten sefirot (heavenly spheres), the Hebrew alphabet, Shiur Qomah (dimensions of the divine body), the archangel Metatron, and the Shekhinah (the feminine aspect of the Godhead).

The main books of the Kabbalah, written in early antiquity, include Sefer Yetzirah (Book of Creation), an early and major source, thought to be from the 3rd century ce, whose commentaries constitute most subsequent Kabbalistic literature and Sefer ha’Bahir (Book of Enlightenment), first published in the early 12th century. Both works discuss the ten sefirot and the Hebrew letters. Other works are the Hekhalot (Palace) literature, which includes the ritual praxis of “descending to the Chariot” and hymns recited in a celestial Temple, the Apocalypse of Abraham, the book of Enoch, and sections of the Dead Sea scrolls. In the Mishnah Hagigah (220 ce), two variants of Kabbalah are mentioned: the study of Creation and the study of the Heavenly Chariot. These two categories are linked to biblical prooftexts: the study of creation to the first chapter of Genesis, and the study of the Heavenly Chariot to the first chapter of the book of Prophet Ezekiel.

Of the Kabbalistic treatises and texts written in the medieval period, the most important ones are the book of the Zohar (Splendor) by Moses de Leon (c. 1240–1305) and possibly other authors, and the writings of Abraham Abulafia (1240–c. 1291) and that of his student Joseph Gikatilla. The book of the Zohar is distinguished by a reliance on the ten sefirot, although couched in esoteric references, while the many books by Abulafia present linguistic mysticism with permutations of divine names. The former emphasis on the sefirot is also known from the ‘Iyyun (Study) Group in Provence, and Azriel of Gerona (1160–1238), whereas in works by the Hasidei Ashkenaz (German Pietists), led by Judah the Pious (1150–1217) and Eleazar of Worms (c. 1176–1238), numerology and angelology are basic tools.
Luxembourgish
Authors: Gilles Peter
Published: August 2023

This article provides an overview of the structure of the Luxembourgish language, the national language of the Grand Duchy of Luxembourg, which has developed from a Moselle Franconian dialect to an Ausbau language in the course of the 20th century. In the early 21st century, Luxembourgish serves several functions, mainly as a multifunctional spoken variety but also as a written language, which has acquired a medium level of language standardization. Because of the embedding into a complex multilingual situation with German and French, Luxembourgish is characterized by a high degree of language contact. As a Germanic language, Luxembourgish has developed its distinct grammatical features. In this article, the main aspects of phonetics and phonology (vowels, consonants, prosody, word stress), morphology (inflection of nouns, adjectives, articles and pronouns, partitive structures, prepositions, verbal system), and syntactic characteristics (complementizer agreement, word order in verbal clusters) are discussed. The lexicon is influenced to a certain degree by loanwords from French. Regarding language variation and change, recent surveys show that Luxembourgish is undergoing major changes affecting phonetics and phonology (reduction of regional pronunciations), the grammatical system (plural of nouns), and, especially, the lexical level (decrease of loans from French, increase of loans from German).
Establishment of transgenic epithelium-specific Cre-recombinase driving medaka (Oryzias latipes) by homology repair mediated knock-in
Authors: Watanabe Yuko , Katsumura Eri , Domon Tatsuki , Ishikawa Yuta , Oguri Rina , Takashima Minami , Meng Qi , Kinoshita Masato , Hashimoto Hisashi , Hitomi Kiyotaka
Published: August 2023

Deletion of gene expression in the target tissues and cells is an effective strategy for elucidating the physiological functions of the protein of interest. For tissue-specific and/or inducible gene deletion, the Cre-loxP system has been widely used in various model organisms including medaka (Oryzias latipes). The epithelium is the key tissue, locating at the outermost area and playing a role in barrier to external stimuli. Despite a large genetic toolbox developed in medaka, there is no available Cre-driver line that works in an epithelium-specific manner. Here, we established epithelium-specific Cre-driver lines in medaka using a homology-directed repair mediated knock-in approach with CRISPR/Cas9, targeting each of periplakin and keratin genes. We show that Cre-recombinase is expressed exclusively in the epithelium in the knock-in lines and that it efficiently and specifically induces recombination in the tissues. These Cre-driver lines are useful for studying the functions of proteins expressed in the epithelium.
Dominance loss and tenure maintenance in Kalahari meerkats
Authors: Duncan Chris , Thorley Jack , Manser Marta B , Clutton-Brock Tim
Published: August 2023

In many social species, both the acquisition of dominance and the duration that individuals maintain their status are important determinants of breeding tenure and lifetime reproductive success. However, few studies have yet examined the extent and causes of variation in dominance tenure and the duration of breeding lifespans. Here, we investigate the processes that terminate dominance tenures and examine how they differ between the sexes in wild Kalahari meerkats (Suricata suricatta), a cooperative breeder where a dominant breeding pair produces most of the young recruited into each group. Mortality and displacement by resident subordinate competitors were important forms of dominance loss for both sexes. However, dominant males (but rarely females) were also at risk of takeovers by extra-group invading males. Dominant males also differed from dominant females in that they abandoned their group after the death of their breeding partner, when no other breeding opportunities were present, whereas dominant females that lost their partner remained and continued to breed in the same group. We show that a larger number of processes can terminate dominance tenure in males with the result that the average male tenure of breeding positions was shorter than that of females, which contributes to the reduced variance in the lifetime reproductive success in males compared to females. Our analysis suggests that sex differences in emigration and immigration may often have downstream consequences for sex differences in reproductive variance and for the selection pressures operating on females and males.
Optimal selection of suitable templates in protein interface prediction
Authors: Grudman Steven , Fajardo J Eduardo , Fiser Andras
Published: August 2023

Motivation

Molecular-level classification of protein–protein interfaces can greatly assist in functional characterization and rational drug design. The most accurate protein interface predictions rely on finding homologous proteins with known interfaces since most interfaces are conserved within the same protein family. The accuracy of these template-based prediction approaches depends on the correct choice of suitable templates. Choosing the right templates in the immunoglobulin superfamily (IgSF) is challenging because its members share low sequence identity and display a wide range of alternative binding sites despite structural homology.

Results

We present a new approach to predict protein interfaces. First, template-specific, informative evolutionary profiles are established using a mutual information-based approach. Next, based on the similarity of residue level conservation scores derived from the evolutionary profiles, a query protein is hierarchically clustered with all available template proteins in its superfamily with known interface definitions. Once clustered, a subset of the most closely related templates is selected, and an interface prediction is made. These initial interface predictions are subsequently refined by extensive docking. This method was benchmarked on 51 IgSF proteins and can predict nontrivial interfaces of IgSF proteins with an average and median F-score of 0.64 and 0.78, respectively. We also provide a way to assess the confidence of the results. The average and median F-scores increase to 0.8 and 0.81, respectively, if 27% of low confidence cases and 17% of medium confidence cases are removed. Lastly, we provide residue level interface predictions, protein complexes, and confidence measurements for singletons in the IgSF.

Availability and implementation

Source code is freely available at: https://gitlab.com/fiserlab.org/interdct_with_refinement.
crosshap: R package for local haplotype visualization for trait association analysis
Authors: Marsh Jacob I , Petereit Jakob , Johnston Brady A , Bayer Philipp E , Tay Fernandez Cassandria G , Al-Mamun Hawlader A , Batley Jacqueline , Edwards David
Published: August 2023

Genome-wide association studies (GWAS) excels at harnessing dense genomic variant datasets to identify candidate regions responsible for producing a given phenotype. However, GWAS and traditional fine-mapping methods do not provide insight into the complex local landscape of linkage that contains and has been shaped by the causal variant(s). Here, we present crosshap, an R package that performs robust density-based clustering of variants based on their linkage profiles to capture haplotype structures in a local genomic region of interest. Following this, crosshap is equipped with visualization tools for choosing optimal clustering parameters (ɛ) before producing an intuitive figure that provides an overview of the complex relationships between linked variants, haplotype combinations, phenotype, and metadata traits.

Availability and implementation

The crosshap package is freely available under the MIT license and can be downloaded directly from CRAN with R >4.0.0. The development version is available on GitHub alongside issue support (https://github.com/jacobimarsh/crosshap). Tutorial vignettes and documentation are available (https://jacobimarsh.github.io/crosshap/).
BJS 3 On the use of Cytosponge as a tool to manage the burden of Barrett’s surveillance
Authors: Singh Gautam , Asarbakhsh Mariam , Verma Harsh , Olejnik Hannah , McDonald Claire , Saha Arin
Published: August 2023

Introduction

After the Covid pandemic, a backlog of over a million endoscopies built up in the UK. Many patients with Barrett’s oesophagus did not receive surveillance within recommended time frames as Barrett’s surveillance endoscopies take more time. This study aimed to assess the role of the Cytosponge test in Barrett’s surveillance and whether it could help reduce endoscopy backlogs.

Methods

251 patients waiting for Barrett’s surveillance prior to or in 2022 were triaged. Patients suitable for Cytosponge were approached and offered this procedure in lieu of endoscopy. Outcomes, complications and reduction in endoscopy usage were measured.

Results

193 patients (77%) had a Cytosponge procedure as their primary Barrett’s surveillance. Of the remaining 58 patients, 26 were unsuitable and 29 patients could not be contacted to discuss the test. 3 patients declined a Cytosponge. 121 patients (62%) had waited longer than their recommended interval for Barrett’s surveillance.

There were no significant complications. Urgent endoscopy was required in 18 patients (9%) after Cytosponge; 15 patients had abnormal findings and 3 patients had an inadequate sample. 175 patients (91%) did not require endoscopic assessment after Cytosponge and have been booked for routine surveillance.

Conclusions

Over 90% of patients who had a Cytosponge for Barrett’s surveillance did not require endoscopy. This ‘saved’ almost 440 points of endoscopy time (or 44 endoscopy lists). Given that around 1% of adults develop Barrett’s oesophagus, these data suggest substantial opportunities to reduce burden of surveillance endoscopies if Cytosponge was used as a primary test for Barrett’s oesophagus.
SP1.4 Evaluating the impact of increased sub-specialist cover on NELA outcomes: A retrospective single centre study
Authors: Vaughan-Burleigh Sebastian , Hollyman Marianne
Published: August 2023

Aims

Emergency general surgery is managed by upper gastrointestinal (UGI) and colorectal surgeons. Outcomes are improved when emergency procedures are within the specialty of the surgeon. This study evaluates the impact of surgeon specialisation and increased consultant cross-cover on patient outcomes.

Methods

The local NELA database was analysed between November 2013 and May 2022. Procedures were classified into UGI, colorectal, or general. Comparison was made between procedures performed within or outside of surgeon sub-specialty and before and after a modified consultant rota was introduced. Primary outcome was 30-day mortality.

Results

A total of 1,313 NELA procedures were performed (90 UGI, 606 colorectal, 617 general); 167 (13%) procedures were performed outside the surgeon sub-speciality. Mortality was lower following procedures within sub-specialty (7.6% vs 12.6%, p=.029). Mortality was lower following colorectal operations performed by colorectal surgeons (colorectal 6.8% vs UGI; 14.0%, p=.01). Multivariate analysis demonstrated that procedures within a surgeon sub-specialty were still associated with lower mortality (OR 0.76, p<0.01) when urgency of operation was accounted for.

In 2019, following addition of cross-cover in the consultant rota, the number of operations performed outside of sub-specialty was reduced (2013-2019; 15.4% vs 2019-2022; 9.8%, p=.05). Across the data collection period mortality decreased overall (2013-2019; 10.0% vs 2019-2022; 6.5%, p<0.01). There was a trend towards decreased mortality following operations outside the surgeon sub-specialty (2013-2019, 14.4%, 2019-2022, 8.9%, p=0.32).

Conclusion

Mortality following laparotomy is reduced when the procedures are within the sub-specialty of the operating surgeon. Rota changes to allow sub-speciality cover can improve peri-operative mortality.
SP1.7 DILEMMAs in emergency laparotomy care: preliminary results of an international quality enhancement initiative focused on decision making
Authors: Perin Giordano , Bellio Gabriele , Ghirardo Sergio , Favero Alberto , Hormis Anil , Cresswell Andrew
Published: August 2023

Aim

The aim of our study is to assess how professionals take decisions when evaluating suitability of patients for emergency laparotomy or palliation.

Methods

We created and validated a dataset of 90 case vignettes based on real patients admitted with surgical pathology correctable only via an emergency laparotomy. We removed information concerning real life outcomes. We submitted the vignettes to consultants and trainees in surgery, anaesthesia and intensive care, asking them if they would offer an emergency laparotomy. Concordance between assessors and real life decisions, accuracy scores (the lower the value the higher the likelihood of operating on patients that survived) and inconsistency scores were calculated. Judgement Analysis methodology (binomial logistic regression) was used to identify variables relevant to the decision making process for each participant.

Results

This report includes results for the first 100 participants. Twelve centres provided data (4 from Italy, 7 from the UK, 1 from Greece). 47 consultants, 9 SAS doctors, 28 higher trainees, 13 core trainees or equivalent took part in the study. 59 were surgeons, 25 anaesthetists and 9 intensivists. Average concordance between decision makers and real life was 78.9%. Median accuracy was 16.5 (IQR 11-30.5). Median inconsistency was 13% (IQR 7%-20%). Accuracy and consistency were better for consultants and worse for trainees. Judgment Analysis demonstrated differences between grades, specialities and institutions.

Conclusions

Different clinicians, when faced with the same information, make different decisions. Our data supports the adoption of multidisciplinary decision making protocols as well as senior involvement.
SP7.1 Effect of gastrojejunal anastomosis diameter in laparoscopic one-anastomosis gastric bypass for the treatment of morbid obesity and related disorders: a comparative study
Authors: Elabbassy Islam , Elgohary Hatem , Abdulrahman Mohammed Gamal , Boshnak Noha
Published: August 2023

Background

One-anastomosis gastric bypass (OAGB) is a safe and effective bariatric procedure that employs a long gastric pouch with antecolic loop gastrojejunal (GJ) anastomosis. The optimum anastomosis diameter is still unclear, as there are many differences in the literature.

Aim

This study aims to evaluate the short-term effect of different GJ anastomosis diameters in patients offered laparoscopic OAGB regarding weight loss, bile reflux, and nutritional and metabolic effect. Patients and methods A total of 59 patients were included in this study, and they were divided into two groups: group A included patients with GJ anastomosis made by a 45-mm stapler reload, and group B included patients with GJ anastomosis made by 20 mm of the stapler reload.

Results

There was no statistically significant difference between groups regarding postoperative mean BMI at 3, 6, 9 months, and 1 year; excess weight loss (EWL%); remission of comorbidities; and bile reflux (P>0.05). Hypoalbuminemia was significantly more evident in group B at 3, 9 months, and 1 year, with P values of less than 0.001, 0.035, and 0.031, respectively. Moreover, group B patients had more iron-deficiency anemia, which was statistically significant at 3, 6, and 9 months (P<0.05), whereas there was no significant difference at 1 year (P=0.128).

Conclusion

OAGB is an effective bariatric procedure, but the use of a 45-mm stapler reload for GJ anastomosis may be associated with less nutritional deficiencies than using 20 mm of the reload. Further studies are needed on a larger number of patients with long-term follow-up.
SP7.2 Marginal ulcers following one-anastomosis gastric bypass: a systematic review
Authors: Lee Shiela , Supparamaniam Shreyas , Varghese Chris , Mahawar Kamal
Published: August 2023

Aims

This systematic review aims to understand the incidence rates, associated factors, and management of MU following OAGB.

Methods

Four databases (PubMed, Cochrane CENTRAL, Embase) were used to systematically identify all studies on OAGB where authors had reported on MU. Data were collected on basic demographics, incidence rates, risk factors, and management of this condition.

Results

Thirty-two studies involving 8868 patients were analysed. The mean age and preoperative BMI were 40.9+/-4.5 years and 47.6+/-5.6 kg/m2 respectively. Approximately 72.0% (6388/8868) of patients were females. 20.6% (1825/8868) had preoperative gastroesophageal reflux disease. The mean operative time was 90.6+/-33.5 minutes. Only 14.1% (1252/8868) of patients were described to have been prescribed proton-pump inhibitors after surgery. The overall incidence of marginal ulcers was 2.59% (95% CI 1.89-3.52). Approximately 23.2% (53/228) of these presented within 12 months. 17.5% (40/228) were diagnosed with marginal ulcers after having endoscopy due to symptoms. Patients with a 45 mm sized gastrojejunal anastomosis (OR: 0.997, 95% CI 0.995-0.997, p=0.004) with double layer closure of stapler site (OR: 0.996, 95% CI: 0.994-0.998, p<0.001) were significantly less likely to develop a MU. Approximately, 88.1% (141/160) of patients were treated conservatively with proton-pump inhibitors (PPIs). The 30-day morbidity rate was 4.6% (411/8868). The 30-day morbidity rate including Clavien Dindo classification ≥ 3 was 1.3% (119/8868). Mortality rate was 0.1% (11/8868).

Conclusion

Marginal ulcer is an uncommon complication following one anastomosis gastric bypass. Majority of patients are treated conservatively with PPIs. This is the first systematic review in literature characterising MU after OAGB.
SP7.4 Autologous blood transfusion reduces the requirement for peri-operative allogenic blood transfusion in patients undergoing major hepatobiliary surgery
Authors: Lakha Adil Siraj , Chadha Radhika , Maher Keith , Barbosa Antonio , Reddy Srikanth , Gordon-Weeks Alex
Published: August 2023

Aims

Major HPB surgery is associated with a high risk of major blood loss. We aimed to assess whether autologous transfusion of blood salvaged intra-operatively reduces the requirement for post-operative allogenic transfusion. This is clinically important because blood is a scarce resource and allogenic transfusion is associated with the potential for morbidity.

Methods

We analysed data from a prospective database of 501 patients undergoing major HPB resection (2015–2022). Patients who received cell salvage (n=264) were compared with those who did not (n=237). Non-autologous transfusion was assessed from the time of surgery to 5 days post-surgery, and blood loss tolerance was calculated using the Lemmens-Bernstein-Brodosky formula. Multivariate analysis was used to identify factors associated with the need for allogenic blood transfusion.

Results

32% of lost blood volume was replaced through autologous transfusion in patients receiving cell salvage. Although cell salvage patients experienced significantly higher intra-operative blood loss compared with the non-cell salvage group (1360ml vs 971ml, p=0.0005), they received significantly less allogenic red blood cell units (1.5 vs 0.92 units/patient, p=0.03). In addition, more of the non-cell salvage patients required low-level transfusion (≤3 units). Use of cell salvage and correction of blood loss tolerance are both independently associated with avoidance of transfusion. There was no difference in major morbidity, 30 or 90-day mortality between the groups.

Conclusions

Use of cell salvage was associated with a reduction in allogenic blood transfusion. Further work is needed to understand whether this is a cost-effective means of reducing allogenic transfusion to support the routine use of intraoperative cell salvage in major HPB surgery.
SP7.10 Laparoscopic Cholecystectomy Operation Notes (LaCON) Quality Improvement Project
Authors: Kapsampelis Panagiotis , Price Daniela , Saunders Jada , Bezzaa Sabrina , Gerogiannis Ioannis
Published: August 2023

Aims

Accurate and comprehensive operation notes are essential for patient care, quality assurance and medico-legal purposes. Laparoscopic cholecystectomy is a common procedure where the quality of operative documentation can impact future patient care. The LaCON project aims to evaluate and improve the quality of LC operation notes with a view to implementing a novel software for standardised operation note creation.

Method

We retrospectively reviewed operation notes of LCs performed at our institution between August and November 2022. Electronic notes were assessed against the Royal College of Surgeons' Good Surgical Practice standard, consisting of 18 items.

Results

We assessed a total of 80 operation notes. There was 100% compliance in surgeon's name, operation name, incision, port placement, and closure technique. High-scoring items included indication (98%), operative findings (98%), operation date (91%) and assistant's name (90%). Among the lowest-scoring items were detailed postoperative instructions (46%), designation as elective or emergency (38%), intraoperative complications-problems (36%), additional procedures performed (23%), operative diagnosis (16%) and estimated blood loss (8%).

Conclusions

We identified several areas for improvement in LC operation notes. The next step of the LaCON project is to standardise operation notes by implementing an evidence-based standardised proforma for LC. This will be accessible through an online app that integrates with our hospital's electronic record system. It will also allow the extraction of operative data for research and audit purposes. This integrated online system has the potential for wider distribution across other procedures, specialities and centres to ensure high standards of safety and care and enhance collaborative multi-centre research.
SP8.9 Pre-operative blood tests in abscess patients: Audit and cost analysis
Authors: Tattsbridge Jasmine , Hang Shaun , Aukland Adam , Abdelrahman Shadi
Published: August 2023

Introduction

Abscess is one of the most common presentations in the emergency surgical setting. It is common practice in our unit to perform blood tests as part of the initial triage process by our nurses. However, NICE guidance (NG45) recommends that bloods should not be taken routinely for patients undergoing minor surgery (including abscess) who are ASA 1 or 2.

Aims

To determine the department’s compliance with NICE guidance, identify ways to improve compliance if required, Identify methods to improve patient experience e.g. waiting times and perform a cost analysis of unnecessary blood tests.

Methods

Retrospective analysis of 100 consecutive patients from June to September 2022, who had incision and drainage of abscess. The patients were selected from Surgical Emergency Unit admission book. Patient data including demographics, immunological compromise status, Morbidities such as diabetes, abscess site, anaesthetic type, blood tests performed and results, and admission and discharge times.

Results

56 females, 44 males. Majority fall in age group 25-59. 7 patients were ASA 3 or higher. 10 patients were diabetic.

93 patients had blood tests performed preoperatively. 16 patients had CRP >50, and 9 patients had WCC >15. Only 6 patients spent more than 1 day inpatient.

Cost of unnecessary blood tests in this group is 4,092£, cost over a year period is 24,552£.

Conclusion

There was poor compliance with NICE guidance costing the trust 24,552£ yearly. Blood tests did not change management plans or patients’ course. Better compliance can improve patient experience and save significant cost.
SP9.10 Identifying Malnutrition in Emergency General Surgery (EGS): A Systematic Review
Authors: Ashmore Daniel , Rashid Adil , Wilson Timothy , Halliday Vanessa , Lee Matthew
Published: August 2023

Aims

Emergency general surgery (EGS) practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. Aims of this study were to examine the current methods of defining and determining malnutrition in EGS. This included examining the use of nutrition screening and assessment tools, and other measures of malnutrition.

Methods

Medline, Embase, CINAHL, trial registries and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any EGS diagnosis, managed operatively or conservatively with an assessment of nutritional status. Mixed populations were included if more than 50% of patients were EGS or EGS results could be separately extracted. Studies whereby patients had received nutritional support were excluded.

Results

From 6,700 studies screened, 324 full texts were retrieved, and 31 were included in the analysis. A definition of malnutrition was provided in 75% (n = 23) of studies, with nutritional status being determined by a variety of methods. Seven nutrition screening tools and nine ‘assessment’ tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was body mass index followed by albumin level.

Conclusions

Wide variation exists in approaches to identify malnutrition risk in EGS patients, using a range of tools and nutrition markers. Future studies should seek to standardise nutrition screening and assessment in the EGS setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.
SP9.11 Comparison of non-mesh Desarda technique versus Lichtenstein technique for inguinal hernia repair: A systematic review and meta-analysis of 14 comparative studies
Authors: Mohamedahmed Ali Yasen , Wuheb Ali Ahmed , Albendary Mohamed , Sillah Abdul Karim
Published: August 2023

Background

The aims of this systematic review and meta-analysis were to compare non-mesh Desarda technique (DT) with the standard mesh-based Lichtenstein technique (LT) for inguinal hernia repair.

Methods

A systematic literature search for comparative studies comparing between DT and LT was conducted using electronic databases and Google scholar service. Studies were evaluated for hernia recurrence, post-operative complications, and time to return to work. We pooled the data using fixed effects model and random effects model after assessing the heterogeneity among the included studies.

Results

A total number of 14 studies were included in this meta-analysis with a total number of 3673 patients divided between Desarda group (n=1794) and Lichtenstein group (n= 1879). There was no difference in terms of recurrence between the Desarda repair and Lichtenstein repair group [P = 0.47]. There was a significant lower rate of overall post-operative complications [P=0.0001], seroma [P=0.0002] and (SSI [P = 0.03] in the Desarda group. The two groups showed comparable results for haematoma [P=0.12], scrotal oedema [P=0.25], and testicular atrophy [P=0.15]. Moreover, Desarda group was associated with shorter operative time and return to work when compared to Lichtenstein group, [P=0.01] and [P=0.008], respectively.

Conclusion

DT and LT were found to have comparable results in terms of hernia recurrence rate, haematoma formation, and testicular atrophy. However, DT is superior to LT in terms of reducing postoperative mesh-attributed complications, such as SSI and Seroma formation besides shorter operative time and return to work. We recommend performing a well-designed, large cohort RCT to evaluate the cost-effectivity and impact in less economically developed countries.
SP10.2 Systematic review and meta-analysis of self-expanding metal stents in the management of benign large bowel obstruction
Authors: Fardanesh Armin , George Jayan , Hughes Daniel , Stavropoulou-Tatla Stavroula , Mathur Pawan
Published: August 2023

Aims

Methods

This systematic review protocol was registered on Prospero (ID: CRD42021239363). Seven online databases were searched for relevant papers, with subsequent abstract and full-text screening by two reviewers. The primary outcome was the technical success of stenting. Pooled rates of successful stenting and related complications were calculated through meta-analysis of proportions performed using random effects.

Results

266 papers were collected with 15 studies included for analysis. 290 patients were included with an average age of 68, and a male predominance of 57%. The pooled rate of clinical success was 94.4% (95%CI 90.3 – 96.8%). The pooled rate of technical success was 76.0% (95%CI: 64.9-84.5%). Adverse effects were low; perforation 9% (19.9 – 38.6%), recurrence 28% (19.9 – 38.6%) and stent migration (14.6 – 36.0%). The reporting on long-term outcomes of stenting as a bridge to surgery was vastly variable.

Conclusions

This study demonstrates SEMS could be clinically effective and safe in benign LBO. We propose the introduction of a widescale database to assess current practice and its clinical application.
SP10.16 Impact of joint surgical and medical management on outcomes in inflammatory bowel disease. A retrospective review of medical management and surgical outcomes in a District General
Authors: Shaukat Mubasher , Zaman Iqbal , Ditta Allah , Junejo Muneer
Published: August 2023

Aim

A combined medical and surgical team approach for management of inflammatory bowel disease (IBD) facilitates optimized medical and surgical management through dedicated MDTs and clinics. These benefits were delivered during the COVID-19 pandemic impacting planned medical care.

Method

Data was collected for all IBD patients undergoing resection surgery over 16 years of age covering a 2-year period before and a 2-year period after the impact of COVID-19 pandemic and start of a combined IBD practice. It included demographics, immune-suppression and planned and unplanned surgery between January 2018 to September 2021.

Results

62 patients underwent major resection surgery. Six were excluded for non-IBD related indication (malignancy, infective colitis and volvulus). Of the remaining 56 patients, 20 (35.7%) had Crohn’s Disease, 35 (62.5%) had Ulcerative colitis and one (1.8%) with indeterminate colitis on histopathology. The median age was 43.6 years (16 to 80) with 64.3% females.

In the first 2-year period, 73.7% (14) underwent surgery with high perioperative immunosuppression. This reduced to 26.3% (5) in the combined IBD period. Proportion of patients undergoing emergency surgery declined from 59% to 12.5%. Use of biologics increased from 29% to 50% of patients with the average of 0.71 vs 2.13 failed biologics use before surgical intervention.

Conclusion

Combined medical and surgical IBD practice offers optimised care through timely escalation of medical treatment and reduces risks associated with major emergency surgery. Despite the restrictions to planned surgical treatment during the COVID-19 pandemic, improved outcomes were achieved with combined practice for IBD patients.
SP11.3 Utilising an Accelerated Delphi Process to Develop Consensus on The Requirement and Components of a Pre-procedural Core Robotic Surgery Curriculum
Authors: Burke Joshua , Fleming Christina , King Martin , El-Sayed Charlotte , Bach Simon P , Collins Justin
Published: August 2023

Aim

Robot-assisted Surgery (RAS) continues to grow globally. Despite this, in the UK and Ireland, it is estimated that over 70% of surgical trainees across all specialities have no access to robot-assisted surgical training (RAST). This study aimed to provide educational bodies guidance on a pre-procedural core robotic surgery curriculum (PPCRC) from the perspective of the end user; the surgical trainee.

Methods

The study was conducted in four Phases: P1: A steering group was formed and a systematic review conducted P2: Pan-Specialty Trainee Panel Virtual Classroom Discussion, P3: Accelerated Delphi Process and P4: Formulation of Recommendations. Forty-three surgeons in training representing all surgical specialties and training levels contributed to a three-round Delphi process. Additions to the second- and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥80% agreement.

Results

There was 100% response from all three rounds. The formulated guidance showed good internal consistency (Cronbach alpha >0.8). There was 97.7% agreement that a standardised PPCRC would be advantageous to training and that, independent of speciality, there should be a common approach (95.5% agreement). Consensus was reached in multiple areas: 1. Experience and Exposure, 2. Access and context, 3. Curriculum Components, 4 Target Groups and Delivery, 5. Objective Metrics, Benchmarking and Assessment.

Conclusions

Using the Delphi methodology, multispecialty consensus among trainees to develop and reach content validation for the requirements and components of a PPCRC in the UK and Ireland was achieved. This guidance will benefit from further validation following implementation.
SP11.6 UK Medical National Teaching Initiative (UKMNTI): A novel digital platform for the delivery of surgical education
Authors: Gobriel Morcos , Ahmed Nauman , Chan Anthony
Published: August 2023

Introduction

Online teaching delivery has seen a recent rise in popularity, but evidence suggests significant barriers such as inadequate digital infrastructures and limited technical abilities of educators and learners. We have developed a digital platform, UKMNTI.com, as proof of concept for cost-effective and reliable delivery of surgical education.

Methods

The platform was developed using an open-source Moodle content management system with video conferencing and real-time interactive capabilities. An initial session (‘acute abdomen’) was written and delivered using a constructivist pedagogy. A Likert Scale of Confidence was used to objectively assess feedback from learners as well as free-text comments.

Results

A total of 56 participants attended the session and 28 of them participated in the feedback ranging from medical students (n=13) to Foundation doctors (4), Core Trainees and Specialty Registrars (3) and Allied Health Professionals (8) from 8 countries. Access and delivery were conducted without technical issues and rated good overall (4/5). Knowledge of ‘the acute abdomen’ increased from average (2.5/5) to good (4/5), and learners were engaged (4/5) and found the content helpful (4/5).

Discussion

Digital platforms are effective adjuncts to the delivery of medical education and help address socio-economic factors such as the cost of living and contribute to the sustainability agenda.

With the above in mind, we created UKMNTI.com. UKMNTI.com is a new free clinical-oriented medical teaching website that was created to help medical trainees and students to keep their medical knowledge up to date. The website offers a regular teaching schedule along with a wealth of teaching tools, such as interactive modules, quizzes, and case studies.
SP11.11 Getting It Right First Time (GIRFT): An Audit of General Surgical Documentation in a District General Hospital
Authors: Rashid Samin , Tournas Ioannis , Parmar Chetan , Mukhtar Hasan
Published: August 2023

Aim

Getting It Right the First Time (GIRFT) has released national guidance regarding operation documentation for common general surgical procedures, namely laparoscopic appendicectomy, laparotomy & laparoscopic bowel resection surgery, laparoscopic cholecystectomy and inguinal hernia repair. This audit sought to assess compliance in a single District General Hospital Surgical Department.

Method

Retrospective analysis of operation notes was undertaken for consecutive cases. The audit included 25 laparoscopic appendicectomy, 25 laparoscopic cholecystectomy, 10 laparoscopic inguinal hernia, 20 open inguinal hernia and 10 laparotomy/laparoscopy with bowel resection procedures. Cases were included from a range of Consultants (range: 4 for laparoscopic inguinal hernia to 9 for laparoscopic appendicectomy). Operation notes were compared to the GIRFT guidelines.

Results

Overall compliance was 36% for open inguinal hernia, 44% for laparoscopic cholecystectomy, 45% for laparoscopic inguinal hernia, 54% for laparoscopy/laparotomy with bowel resection and 56% for laparoscopic appendicectomy.

Notable areas of poor compliance included documentation of achievement of the critical view of safety in laparoscopic cholecystectomy (28%), if the appendiceal base was healthy in appendicectomy (60%), if the ilioinguinal nerve was protected or divided (35%) or if the vas deferens/testicular vessels were protected (50%) in open inguinal hernia repair and post operative oral intake status after bowel resection (80%).

Conclusions

Overall there was poor compliance between the operation notes and the GIRFT guidelines. These can potentially jeopardise the position of the surgeon and Trust during medicolegal claims. Use of standardised pre-populated electronic operation notes will be introduced Department-wide and compliance re-audited.
SP11.14 Evaluating the Efficacy and Cognitive Load of a Real-Time Intelligent Coaching System versus Human Expert Instruction in Surgical Technical Skills Training: A Randomized Controlled Study
Authors: Tee Trisha , Yilmaz Recai , Fazlollahi Ali , Bakhdair Mohamad , Alsayegh Ahmad , Del Maestro Rolando
Published: August 2023

Aims

An artificial intelligence-driven tutoring system provides risk-free training on realistic simulated procedures and objective assessment to improve surgical technical skills. This study compared its teaching efficacy to human instructor training.

Methods

Ninety-eight medical students completed 5 simulated brain tumor resections, scored by the intelligent system. Participants were randomly sorted into 3 feedback groups: (1) no real-time feedback, (2) real-time intelligent instruction, (3) real-time human instruction. Each participant completed a base-line repetition without feedback. Group 1 received visual feedback based on expert benchmarks following each repetition. Group 2 was tutored by the intelligent system in real-time. After each repetition, the system provided the student’s error clips and correlating expert-level demonstrations. Group 3 was tutored by human instructors in real-time. After each repetition, instructors provided critiques and demonstrated correction techniques. Following the final repetition, each participant completed a questionnaire of Leppink’s Cognitive Load Index on a 5-point Likert scale. Performance scores were compared from the first to the last repetition of the task within and between-groups to assess learning.

Results

Compared with baseline, groups 2 and 3 significantly improved in performance by the third and second repetition, respectively (p<0.01 and p=0.01). Between-groups comparison revealed significantly higher scores and extrinsic load for group 2 than group 3 in the fifth repetition, respectively (p<0.01 and p<0.01). No between-group differences existed for intrinsic and germane load.

Conclusion

The intelligent system provided more efficient learning than human instruction. Such systems may enhance trainees’ learning and facilitate the shift towards standardized, competency-based surgical training.