A review of minimal access surgery provision and training within the United Kingdom.

When combined with healthcare pressures, the exponential growth of robotic-assisted surgery (RAS) has impacted UK-based training outcomes, including the learning curve to competency. Aim: To ascertain the current provision of RAS and investigate differences in access to minimal access surgical (MAS) facilities and training across the UK. A two-armed electronic survey was conducted. The first arm questioned clinical leads regarding robotic practice and future training provisions. The second investigated trainee and trainers' perceptions of MAS training and facilities. 64% (52/81) of responding trusts utilise a robotic system. The majority (68% [55/81]) have plans to expand or acquire a system within 3 years. 171 responses from 112 UK and Republic of Ireland hospitals were collected for Arm 2. Laparoscopic categories queried whether trainees had access to a formal curriculum, training days and sim-boxes. Most consultants (51.9%) and trainees (51.6%) reported that there was no formal local training curriculum for robotic surgery. Combined responses demonstrated 42.1% (n = 195/463) said "yes", 39.5% (n = 183) "no" and 18.4% (n = 85) "don't know". For combined robotic categories (simulation, training days and operative lists) 28.3% (n = 134/473) responded "yes", 51.6% (n = 244) said "no" and 20.1% (n = 95) said "don't know". This study provides insight into the current provision of robotic-assisted surgery at UK trusts and highlights the need to facilitate regular clinical training and equitable access to MAS simulation within a formal curriculum. This may aid regulation of training in parallel with the expansion of robotic practice and avoid a significant skill acquisition gap and risks to patient safety.

Relapse after cessation of weekly tocilizumab for giant cell arteritis: a multicentre service evaluation in England.

OBJECTIVES: The National Health Service in England funds 12 months of weekly subcutaneous tocilizumab (qwTCZ) for patients with relapsing or refractory giant cell arteritis (GCA). During the COVID-19 pandemic, some patients were allowed longer treatment. We sought to describe what happened to patients after cessation of qwTCZ. METHODS: Multicentre service evaluation of relapse after stopping qwTCZ for GCA. The log-rank test was used to identify significant differences in time to relapse. RESULTS: 336 GCA patients were analysed from 40 centres, treated with qwTCZ for a median (interquartile range, IQR) of 12 (12-17) months. At time of stopping qwTCZ, median (IQR) prednisolone dose was 2 (0-5) mg/day. By 6, 12 and 24 months after stopping qwTCZ, 21.4%, 35.4% and 48.6% respectively had relapsed, requiring an increase in prednisolone dose to a median (IQR) of 20 (10-40) mg/day. 33.6% of relapsers had a major relapse as defined by EULAR. Time to relapse was shorter in those that had previously also relapsed during qwTCZ treatment (P = 0.0017); in those not in remission at qwTCZ cessation (P = 0.0036); and in those with large vessel involvement on imaging (P = 0.0296). Age ≥65, gender, GCA-related sight loss, qwTCZ treatment duration, TCZ taper, prednisolone dosing, and conventional synthetic DMARD use were not associated with time to relapse. CONCLUSION: Up to half our patients with GCA relapsed after stopping qwTCZ, often requiring a substantial increase in prednisolone dose. One third of relapsers had a major relapse. Extended use of TCZ or repeat treatment for relapse should be considered for these patients.

A prospective randomized trial on laparoscopic total vs partial fundoplication in patients with atypical symptoms of gastroesophageal reflux disease.

BACKGROUND: Currently very little is known about the impact of anti-reflux surgery on extra-esophageal manifestations of gastroesophageal reflux disease (GERD) when compared with the typical symptoms of reflux. The aim of our study was to evaluate the clinical effect of total (360°) and partial (270°) laparoscopic fundoplication on extraesophageal GERD symptoms. METHODS: One hundred and twenty patients with documented extraesophageal GERD symptoms were randomized to either undergo floppy Nissen (n= 60) or Toupet fundoplication (n= 60). Symptom scores of throat clearing, globus sensation, cough, throat pain, and vocal changes were prospectively evaluated. A reflux symptom index (RSI) questionnaire was used to accurately document the improvement of extraesophageal symptoms. Quality of life was determined according to the laryngopharyngeal reflux-health-related quality of life (LPR-HRQL) questionnaire. RESULTS: No significant differences were identified between the groups regarding demographic data, such as age, gender, or body mass index. The median RSI score before operation and at 24-month follow-up was 22.8 ± 5.3 and 10.4 ± 5.4 respectively in the laparoscopic Nissen fundoplication (LNF) group (p < 0.05) and 21.7 ± 5.0 and 11.6 ± 5 respectively in the laparoscopic Toupet fundoplication (LTF) group (p < 0.05). The median LPR-HRQL score in the LNF group improved from 42.9 ± 13.8 before treatment to 10.7 ± 6.5 at 24 months (p < 0.05). In the LTF group, there was an improvement in the median LPR-HRQL score from 40.4 ± 10.9 prior to treatment to 11.7 ± 5.7 at 24 months (p < 0.05). The median RSI score and LPR-HRQL scores were similar between the groups at follow-up (p > 0.05). CONCLUSIONS: Our report demonstrates that LNF and LTF provide equivalently good results for patients with extraesophageal manifestations of GERD. Quality of life is similar after LNF and LTF.

Effectiveness of three Vitamin D dosing protocols on raising and maintaining blood serum levels of 25-hydroxyvitamin D over a three-month period: a randomized, prospective study.

INTRODUCTION: Vitamin D has gained attention in the medical community due to its critical role in calcium homeostasis and overall bone health. No standard vitamin D dosing protocol in fracture care has been established for patients deficient in 25-hydroxyvitamin D. This prospective and randomized study aimed to find a dosing regimen that would safely achieve and maintain a therapeutic level of 25-hydroxyvitamin D in deficient patients over three months. MATERIALS AND METHODS: Between June 2016 and May 2017, 48 patients with baseline total 25-hydroxyvitamin D less than 30.0 ng/mL were randomly assigned to either group one (one dose of 100,000 international units (IU) of Vitamin D2) or group 2 (100,000 IU of Vitamin D2 once weekly for twelve weeks) or group 3 (50,000 IU of Vitamin D2 daily for ten days followed by 2,000 IU of Vitamin D3 daily for 74 days). Baseline serum levels were drawn followed by interval levels at week 2, 6 and 12. The primary outcome was to determine which protocol could achieve and maintain therapeutic levels of total 25-hydroxyvitamin D over the course of three months. Our secondary outcome was to monitor for negative side effects. RESULTS: Group 1 did not show any statistically significant increase in serum levels and had no reported side effects. There was a statistically significant increase in serum total 25-hydroxyvitamin D in group 2 between all-time points except between weeks 6 and 12. Two (12.5%) participants in group 2 reported side effects. Group 3 had the greatest change in serum levels from weeks 0 to 2 but had a significant decrease between weeks 2 and 6. No change was seen between weeks 6 and 12. Three (17.5%) participants in group 3 reported side effects. CONCLUSIONS: Group 2 sustained and maintained a satisfactory level of total 25-hydroxyvitamin D over three months without any severe side effects.

A "cat"-astrophic case of Bartonella infective endocarditis causing secondary cryoglobulinemia: a case report.

BACKGROUND: Culture-negative infective endocarditis (IE) constitutes approximately 10% of all cases of IE. Bartonella endocarditis is a common cause of culture-negative endocarditis and is associated with a high mortality rate. To date, no cases of Bartonella IE has been reported in association with cryoglobulinemia in the UK. We present a unique case of Bartonella IE causing secondary cryoglobulinemia in a young female. CASE PRESENTATION: A 17-year-old female with a background of pulmonary atresia and ventricular septal defect repaired with a cardiac conduit at the age of 4, presented with a one-year history of weight loss (from 53 to 39 kg) and poor appetite. She subsequently developed a vasculitic rash and haematoproteinuria with decline in renal function, requiring urgent hospital admission. Initial blood tests showed a near normal creatinine, but a raised cystatin C. Renal biopsy showed focal necrotizing glomerulonephritis with no acute tubular necrosis or chronic change. Subsequent blood tests supported a diagnosis of cryoglobulinaemic vasculitis (high rheumatoid factor, low complement, polyclonal gammopathy, Type 3 cryoglobulin). A weak positive PR3 meant there was some uncertainty about whether this could be a primary ANCA-associated vasculitis (AAV). Initial workup for an infectious cause, including multiple blood cultures, were negative. However, an echocardiogram showed definite vegetations on her surgical conduit. The patient did not respond to empirical antimicrobials and so was referred for surgical revision of her conduit. Tissue samples obtained intra-operatively demonstrated Bartonella species. With targeted antimicrobials post-operatively, she improved with resolution of immunologic abnormalities and at last review had a normal renal profile. On reviewing her social history, she had adopted several stray cats in the preceding year; and thus, the cause of the Bartonella infection was identified. CONCLUSION: This is the first reported case of Bartonella endocarditis causing secondary cryoglobulinemia reported in the UK. The key learning points from this case include that Bartonella endocarditis can present as a cryoglobulinaemic vasculitis and should be considered in any differential when the cause of cryoglobulinaemia is not clear and to enquire about relevant exposures especially when culture-negative endocarditis is suspected.

Chemotherapy-induced nausea and vomiting from oral chemotherapy for childhood acute lymphoblastic leukaemia: feasibility study.

OBJECTIVE: To evaluate the feasibility of a large prospective trial aimed at improving chemotherapy-induced nausea and vomiting (CINV) control in paediatric patients undergoing oral chemotherapy during acute lymphoblastic leukaemia (ALL) maintenance therapy. METHODS: English-speaking children, 4.0-17.99 years old and undergoing ALL maintenance treatment with an English-speaking guardian, were eligible to participate in this observational, serial, cross-sectional feasibility study. Data were collected from participants over one to three 7-day periods during months 2-3, 5-6 and 11-12 of ALL maintenance treatment. A future trial was considered feasible if the mean time to enrol 10 patients in each of three data collection periods was ≤1 year with ≥80% of patients returning evaluable data. CINV control was described as a secondary endpoint. RESULTS: Twenty-nine of 31 consenting patients (median age: 6.5 years, IQR: 5.1-9.2) completed the study: 10 in months 2-3, 10 in months 5-6 and 9 in months 11-12. The total time to recruit 29 patients was 1.2 years. In each of the three data collections periods, 72% of the patients provided evaluable data. Complete CINV control was reported in 6/21 (29%) evaluable study periods. CONCLUSIONS: A future trial to evaluate interventions to improve CINV control in patients with ALL undergoing oral maintenance chemotherapy as designed in this study is not feasible. An electronic data capture method and deferring patient recruitment until the mid-maintenance to late-maintenance phase should be considered in the design of a future trial.

Perceptions of parents of pediatric patients with acute lymphoblastic leukemia on oral chemotherapy administration: A qualitative analysis.

OBJECTIVE: To describe the experiences and perspectives of parents of pediatric patients with acute lymphoblastic leukemia (ALL) regarding oral chemotherapy administration during maintenance therapy. METHODS: English-speaking parents of patients 4 to <18 years who were receiving ALL maintenance oral chemotherapy were eligible to participate in this mixed methods study. Using semi-structured interviews, we asked participants how difficult they found oral chemotherapy administration. We also probed regarding barriers and facilitators of oral chemotherapy administration and strategies used to overcome challenges. Lastly, we asked participants for their advice to future parents giving oral chemotherapy to their children. RESULTS: Twenty-three participants were interviewed. One-fifth of participants stated that oral chemotherapy administration at home was hard or very hard. Common factors influencing oral chemotherapy administration were product-related (e.g., formulation) and treatment-related adverse effects (e.g., nausea), lifestyle adjustment (e.g., fitting in with family schedule), and attitudes (e.g., onus of medication administration). Strategies to address oral chemotherapy administration included several administration techniques, scheduling of medication administration, and normalization of medication taking. CONCLUSIONS: Oral chemotherapy administration during ALL maintenance therapy was hard for some parents. Identification of these parents and discussion of strategies to facilitate adherence to oral chemotherapy regimens may optimize patient outcomes.

Repair of Large Hiatal Hernias With the Use of Mesh and Autologous Platelet-Rich Plasma.

BACKGROUND: According to recent studies, large hiatal hernias (HH) can be associated with a lower content of type-I and type-III collagen in the phrenoesophageal ligament (POL). We therefore hypothesize that the use of a mesh implant with autologous platelet-rich plasma (PRP) for repair of large HH would have a positive effect on long-term outcome.The purpose of our study was to determine the level of type-I and type-III collagens in the POL of patients with large HH with the aim of improving the technique of HH repair. MATERIALS AND METHODS: During the first phase of the study, the collagen content within the POL was assessed in 18 patients with HH and 14 cadaveric specimens without HH. During the second phase, 54 patients with large HH (defined as 10 to 20 cm2), that required surgery were recruited. Laparoscopic repair involved use of a nonabsorbable self-fixating ProGrip mesh infiltrated with 2 to 4 mL of autologous PRP was used for reinforcement of crural repair. Results were assessed using endoscopy, barium swallow, 24-hour impedance-pH monitoring and a quality of life gastroesophageal reflux disease-health related quality of life questionnaire. RESULTS: The content of collagen within POL in patients with HH was significantly lower than in the cadaveric specimens without HH. Of the 54 patients undergoing HH repair, all procedures were performed laparoscopically and there were no mortalities in this group. At 48 months, only 2 HH recurrences (3.7%) were detected. During this period, the mean gastroesophageal reflux disease-health related quality of life score decreased from 15.7±5.5 to 5.9±0.6 (P<0.05). CONCLUSION: Our study has shown that the collagen content is reduced in patients with large HH; thus, it is advisable to use mesh for HH repair in such patients. Use of mesh infiltrated in PRP is safe and can have positive impact on results of HH repair.

Influence of Wrap Fixation Technique on the Results of Fundoplication.

BACKGROUND: Different techniques of wrap fixation in laparoscopic Nissen fundoplication (LNF) have been proposed with of the aim to reduce the complications, but the optimal technique is yet to be determined. The aim of our prospective study was to evaluate several techniques of wrap fixation and determine whether the application of a combined approach to perform wrap fixation reduces the failure rate in short-term and long-term follow-up. MATERIALS AND METHODS: One hundred two patients with sliding or paraesophageal hiatal hernia (type I or type II), who underwent antireflux surgery were randomized into 2 groups. In group I, LNF was supplemented with suturing the wrap to the diaphragmatic crura (35 patients) or to the body of stomach (16 patients). This was dependent on the strength of the crura (defined as weak or strong). The control group (51 patients) underwent LNF without wrap fixation. All patients were assessed using a validated symptom and quality of life (gastroesophageal reflux disease-Health Related Quality of Life) questionnaire, 24-hour impedance-pH monitoring, and barium swallow. RESULTS: At the 48-month follow-up, the overall rate of complications was not significantly different between the 2 groups; however, there was a tendency toward a lower frequency of reoperations in the first group (P=0.059). Fixation of the fundoplication of wrap was noted to lead to significantly lower rates of postoperative dysphagia (P<0.05). These patients (group I) were also found to have significant improvement in gastroesophageal reflux disease-Health Related Quality of Life score (from 19.3±13.2 to 4.3±3.9 vs. from 18.7±11.9 to 9.3±7.7). CONCLUSION: Fixation of the Nissen fundoplication wrap has been shown to have a positive impact on the reduction of postoperative dysphagia and leads to an improvement in disease-specific quality of life.

A cohort study analysing outcomes following transanal haemorrhoidal dearterialisation (THD).

BACKGROUND: Although conventional open haemorrhoidectomy and stapled haemorrhoidectomy are effective procedures, they can lead to significant post-operative pain with risks to continence. Current evidence favours transanal haemorrhoidal dearterialisation (THD) and targeted mucopexy to be an efficacious alternative to conventional modalities. Our aim was to assess the midterm outcomes following THD. METHODS: Prospective data was collected for patients undergoing day case THD under a single consultant over a 9-year period (March 2009 to February 2018). Data collected included: intra-operative findings, post-operative pain (defined as requirement of analgesia in recovery), post-operative complications and requirement of further procedures. RESULTS: Over this time period, 271 patients underwent THD, with 203 (74.9%) patients also undergoing targeted mucopexy for 2nd to 4th degree haemorrhoids. Only 4 (1.5%) patients suffered from post-operative complications, including significant bleeding (n = 1), urinary retention (n = 1) and constipation (n = 2). Post-operative pain was identified in only 10 (3.7%) patients; eight of which had simultaneously undergone an additional procedure (e.g. excision of anal polyps and skin tags). Only 5 (1.8%) patients were identified that required further haemorrhoidal invasive intervention subsequently. CONCLUSIONS: These results are comparable with national data and demonstrate that THD is a safe procedure for symptomatic haemorrhoids with minimal morbidity.

A phase 0 analysis of ixazomib in patients with glioblastoma.

Improving overall survival in recurrent glioblastoma remains a challenge, and drugs acting by unique mechanisms are urgently required. Ixazomib is an orally-administered proteasome inhibitor used in combination with lenalidomide and dexamethasone to treat patients with multiple myeloma who have received at least one prior therapy. However, ixazomib's ability to reach brain tumors has not been studied during its development. The aim of the present study (ClinicalTrials.gov, NCT02630030) was to establish and quantify ixazomib's presence in glioblastoma. The present study investigated 3 patients with recurrent glioblastoma after administration of oral ixazomib citrate (MLN 9708) at a fixed 4.0 mg dose within a 3-hpreoperative window. A total of 2 blood samples were taken from each patient at the time of incision, tumor sampling and closure. Brain tumor samples were collected during tumor resection. These samples were then used to measure the plasma and brain tumor tissue concentration of the biologically-active form of ixazomib (MLN 2238). Patient 1 had plasma concentrations of ixazomib averaging 26.2, 21.8 and 15.3 ng/ml at incision, tumor sampling and closure, respectively. The brain tumor tissue concentration was 7.88 ng/g. Patient 2 had the same interval and brain tumor tissue measurements of 19.0, 18.0 and 8.93 ng/ml, and 2.03 ng/g. Patient 3 had plasma concentration interval measurements of 25.6, 36.2 and 28.7 ng/ml. Multiple brain tumor tissue samples were taken in patient 3, with an average tissue ixazomib concentration of 3.37 ng/g. Ixazomib was found at plasma concentrations commensurate with its previously established pharmacokinetic profile without clinically relevant drug-related adverse events. Ixazomib reaches glioblastoma tissues at measurable concentrations at the time of tumor resection, confirming target tissue delivery. This justifies the phase I study of ixazomib in recurrent glioblastoma currently in development.

Symptomatic patients with P369S-R408Q mutations: familial Mediterranean fever or mixed auto-inflammatory syndrome?

A 51-year-old South African female of Ashkenazi Jewish descent was admitted with acute pleuritic chest pain, shortness of breath, fatigue and fever. She experienced vague abdominal and calf pains for 30 years. Her monozygotic twin was investigated independently for recurrent abdominal pain. Despite initially responding to antibiotics, treating suspected pneumonia, she developed recurrent fevers and pleuritic chest pain. After thorough investigation without significant findings, she re-attended days after discharge with similar symptoms. Familial Mediterranean fever (FMF) was suggested as she met diagnostic criteria and responded to colchicine, though FMF normally presents before 20 years old. Genetic testing showed no pathogenic mutations but heterozygous P369S and R408Q mutations. The significance of these mutations remains unclear, as they are found in asymptomatic patients, suggesting incomplete penetrance. She remains well, with full symptom resolution, but mixed auto-inflammatory syndrome may be a more appropriate diagnosis in symptomatic patients with both P369S and R408Q mutations.

Schwannoma in the ascending colon, a rare finding on surveillance colonoscopy.

Schwannomas are peripheral nerve sheath tumours that can present as a rare tumour of GI tract, and even more uncommonly within the colon. We present a case of colonic schwannoma in an asymptomatic patient identified on surveillance colonoscopy. The tumour is of mesenchymal origin and is often challenging to diagnose prior to surgical resection. Endoscopy usually fails to provide adequate sample and diagnosis is usually confirmed on immunohistochemistry.

Frequent discussion of insomnia and weight gain with glucocorticoid therapy: An analysis of Twitter posts.

In recent years, social media websites have been suggested as a novel, vast source of data which may be useful for deriving drug safety information. Despite this, there are few published reports of drug safety profiles derived in this way. The aims of this study were to detect and quantify glucocorticoid-related adverse events using a computerised system for automated detection of suspected adverse drug reactions (ADR) from narrative text in Twitter, and to compare the frequency of specific ADR mentions within Twitter to the frequency and patterns of spontaneous ADR reporting to a national drug regulatory body. Of 159,297 tweets mentioning either prednisolone or prednisone between 1st October 2012 and 30th June 2015, 20,206 tweets were deemed to contain information resembling an ADR. The top AE MedDRA® Preferred Terms were 'insomnia' and 'weight increased', both recognised non-serious but common side effects. These were proportionally over-reported in Twitter when compared to spontaneous reports in the UK regulator's ADR reporting scheme. Serious glucocorticoid related AEs were reported less frequently. Pharmacovigilance using Twitter data has the potential to be a valuable, supplementary source of drug safety information. In particular, it can illustrate which drug side effects patients discuss most commonly, potentially because of important impacts on quality of life. This information could help clinicians to inform patients about frequent and relevant non-serious side effects as well as more serious side effects.

Erratum: Author Correction: Frequent discussion of insomnia and weight gain with glucocorticoid therapy: an analysis of Twitter posts.

[This corrects the article DOI: 10.1038/s41746-017-0007-z.].

Enhanced sensing and conversion of ultrasonic Rayleigh waves by elastic metasurfaces.

Recent years have heralded the introduction of metasurfaces that advantageously combine the vision of sub-wavelength wave manipulation, with the design, fabrication and size advantages associated with surface excitation. An important topic within metasurfaces is the tailored rainbow trapping and selective spatial frequency separation of electromagnetic and acoustic waves using graded metasurfaces. This frequency dependent trapping and spatial frequency segregation has implications for energy concentrators and associated energy harvesting, sensing and wave filtering techniques. Different demonstrations of acoustic and electromagnetic rainbow devices have been performed, however not for deep elastic substrates that support both shear and compressional waves, together with surface Rayleigh waves; these allow not only for Rayleigh wave rainbow effects to exist but also for mode conversion from surface into shear waves. Here we demonstrate experimentally not only elastic Rayleigh wave rainbow trapping, by taking advantage of a stop-band for surface waves, but also selective mode conversion of surface Rayleigh waves to shear waves. These experiments performed at ultrasonic frequencies, in the range of 400-600 kHz, are complemented by time domain numerical simulations. The metasurfaces we design are not limited to guided ultrasonic waves and are a general phenomenon in elastic waves that can be translated across scales.

Patient perceptions of glucocorticoid side effects: a cross-sectional survey of users in an online health community.

OBJECTIVES: To identify the side effects most important to glucocorticoid (GC) users through a survey of a UK online health community (Healthunlocked.com). DESIGN: Online cross-sectional survey. SETTING: Participants were recruited through Healthunlocked.com, an online social network for health. PARTICIPANTS: Adults who were currently taking GCs, or had taken GCs in the past month. METHOD: Responders scored the importance of listed side effects from 1 to 10, with 10 being of high importance to them. For each side effect, histograms were plotted, and the median rating and IQR were determined. Side effects were ranked by median ranking (largest to smallest) and then IQR (smallest to largest). The scores were categorised as low (scores 1-3), medium (scores 4-7) and high (scores 8-10) importance. RESULTS: 604 responders completed the survey. Histograms of side effect scores showed a skew towards high importance for weight gain, a U-shaped distribution for cardiovascular disease (CVD), diabetes, eye disease and infections, and a skew towards low importance for acne. When ranked, the side effect of most importance to responders was weight gain (median score=9, IQR 6-10) followed by insomnia and moon face with equal median score (8) and IQR (5-10). Three serious side effects, CVD, diabetes and infections, were ranked of lower importance overall but had wide ranging scores (median score=8, IQR 1-10). CONCLUSIONS: The three most highly rated side effects were not clinically serious but remained important to patients, perhaps reflecting their impact on quality of life and high prevalence. This should be taken into consideration when discussing treatment options and planning future GC safety studies.

A UK perspective on smartphone use amongst doctors within the surgical profession.

INTRODUCTION: Hospitals are increasingly looking for mobile solutions to meet their information technology needs. Medical professionals are using personal mobile devices to support their work, because of limitations in both time and space. Our aims were to assess smartphone use amongst UK surgical doctors, the prevalence of medical app use and online activity. METHODS: A thirteen-item questionnaire was derived to identify the proportion of surgical doctors of all grades using smartphones within the workplace. The following factors were evaluated: use of medical apps; use of online medical resources and if users were willing to use their own smartphone for clinical use. RESULTS: A total of 341 participants were surveyed with a complete response rate: 93.5% of which owned a smartphone, with 54.2% of those owning medical apps and 86.2% using their device to access online medical resources. Junior doctors were more likely to use medical apps over their senior colleagues (p = 0.001) as well as access the Internet on their smartphone for medical information (p < 0.001). Overall, 79.3% stated that they would be willing to use their smartphone for clinical use, which was found not to be dependent on seniority (p = 0.922). CONCLUSION: Online resources contribute significantly to clinical activities with the majority of smartphone users willing to use their own device. The information gathered from this study can aid developers to create software dedicated to the smartphone operating systems in greatest use and to potentially increase the use of a bring your own device (BYOD) scheme.

Stroma: fertile soil for inflammation.

Biological therapies for the management of immune mediated inflammatory diseases such as rheumatoid arthritis have proven to be extremely successful in recent years. Despite these successes, even the most effective of therapies do not lead to cure. Why chronic inflammation persists indefinitely within the rheumatoid synovium despite an absence of continuous stimulation, and why some patients with early synovitis progress to persistent disease whilst others do not, has remained unexplained. In contrast to the paradigm that stromal cells are biochemically active but immunologically passive, there is now growing evidence that stromal components from the rheumatoid synovium play a crucial part in the immunopathology of rheumatoid arthritis. Stromal cells play a central role in the transformation of an acute, resolving to a chronic inflammatory process, and to the persistence of synovial inflammation and joint destruction through a variety of immune mechanisms. Therapeutic manipulation of the stroma is a largely unexplored, yet potentially vital area of research. Targeting pathogenic stromal cells has the potential to provide a cure for chronic inflammatory disorders such as rheumatoid arthritis.