Royal London Research Articles

Safety of inhaled hydrogen gas in healthy mice.

The purpose of this work was to determine the safety of inhaled hydrogen gas in healthy animals. Female mice were exposed to medical air with or without hydrogen gas (concentration 2.4%) for 72 hours (n = 25 mice/group). Mice underwent a standardized and validated neurobehavioral examination, SmithKline Beecham, Harwell, Imperial College, Royal London Hospital, Phenotype Assessment (SHIRPA) protocol, prior to and following the exposure period. Blood was withdrawn for serologic evaluation and all major organ tissues were evaluated histologically. The average hydrogen concentration within the chamber was 2.27%. Following exposure, there was no significant change in body weight in either group. Similarly, there was no significant change in the total SHIRPA score, although hydrogen-treated mice exhibited significantly lower spontaneous locomotor activity (P < 0.0001) in a subset of the test; all other aspects of the mouse neurologic exam were normal in hydrogen-treated animals. Brain histopathology was also normal in all mice, as was the histology of all other major organs. There were no significant differences in complete blood count, serum chemistry, or arterial blood gases between control and hydrogen-treated mice (P > 0.05 for all). Hydrogen gas did not appear to cause significant adverse effects when administered to healthy mice for 72 hours, with the possible exception of decreased spontaneous locomotor activity. The study was approved by the Institutional Animal Care and Use Committee at Boston Children’s Hospital, USA (approved number 18-01-3536) on January 25, 2018.

1922. The Challenges of Caring for People Who Inject Drugs: An Opportunity for an Infectious Diseases Service

BackgroundThe Royal London Hospital is a tertiary public hospital in the eastern region of London, UK—an ethnically diverse area with high levels of poverty and homelessness. Since its inception in 2015 the Infectious Diseases (ID) service has cared for 229 inpatients—10% were people who inject drugs (PWID). Such patients have complex problems including homelessness, domestic violence and psychiatric illness which impact their inpatient stay and discharge from the hospital.MethodsTo retrospectively evaluate the management and treatment of PWID managed by the ID team from April 2015 to June 2017 and identify strategies to improve care.Patients were identified via electronic records. PWID not under the direct care of the ID team were excluded. Reason for admission, microbiological diagnosis, antibiotic choice, blood borne virus status, central venous access and other specialist input were noted.ResultsTwenty-two PWID were identified; 13 (59%) were male, median age was 39.5 years (IQR 32.5–46).Table 1:Infectious Diagnoses of PWIDComplicated MSSA bacteremia12Complicated MRSA bacteremia2Complicated other bacteremia2Non bacteremic presentations6Pulmonary TB3Groin abscess2Vertebral osteomyelitis1Eighteen patients (82%) received antibiotics via a central line. There was one case of line-associated infection (Candida glabrata). Three patients (14%) left hospital against advice, eight attended follow-up after discharge. There were no deaths. The mean length of stay was 39 days. Thirteen patients were identified as homeless and eight of these (62%) were discharged to a home.ConclusionThe majority of PWID managed by the ID team had complicated bacteremia requiring long courses of intravenous antibiotics. Despite concern regarding central access, line associated infection was rare. Significant proportions also had blood borne virus infection (86%) and over 50% had psychiatric illness and/or are homeless. Together these factors represent major obstacles to providing the considered “gold standard” care. These findings highlight the currently unmet need for an integrated multidisciplinary approach to the care of PWID.Disclosures All authors: No reported disclosures.

Practicalities of a reduced volume formulation of a C1-INH concentrate for the treatment of hereditary angioedema: real-life experience

BackgroundHereditary angioedema (HAE) due to C1 esterase inhibitor (C1-INH) deficiency is characterized by recurrent swelling attacks that can be life-threatening if left untreated. Prompt treatment is vital during acute attacks; plasma-derived C1-INH (Berinert®) is one treatment currently licensed for the intravenous treatment of acute HAE attacks in adults, adolescents and children. A new, volume-reduced formulation, of C1-INH is currently available which aims to reduce the time to treatment, and provide greater convenience to patients and healthcare professionals. Here we compare the clinical experience of the reduced volume 1500 IU vial with multiple 500 IU vials.MethodsHAE patients treated with C1-INH at the Royal London Hospital were selected to take part in this assessment. Included patients were aged 10–65 with moderate to severe HAE requiring high doses of C1-INH. The practicalities of the reduced 1500 IU vial compared with multiple 500 IU vials were assessed, including preparation and administration time, training to self-administer time and several quality of life aspects.ResultsTwenty-three patients participated in this study. Twenty-one patients were previously treated with C1-INH (Berinert®) 500 IU for 1–14 years prior to switching to the 1500 IU vial format, two patients were naïve to C1-INH (Berinert®). Preparation and administration of C1-INH (Berinert®) 1500 IU was faster than an equivalent dose with multiple 500 IU vials (11 and 17 min, respectively) and also required less time to train to self-administer (45 and 55 min, respectively). Overall, patients rated the 1500 IU vial format higher in all assessed aspects than the 500 IU format, including preparation, administration, training, travel and storage. Nonetheless, reconstitution of the 1500 IU vial was noted more difficult, requiring gentle mixing to fully dissolve prior to intravenous injection. Patients remained stable on C1-INH (Berinert®) 1500 IU; two patients switched back to multiple 500 IU vials due to headaches and preference for a larger volume.ConclusionsThe volume-reduced C1-INH concentrate (Berinert®) 1500 IU is a practical and convenient alternative to multiple 500 IU vials for the treatment of HAE, which provides patients with more control and independence over their disease owing to a simpler to administer treatment.

Interviews following physical trauma: A thematic analysis

IntroductionMental health problems are common in trauma survivors. In particular, depression, anxiety, acute stress disorder and post-traumatic stress disorder. Yet little is known about how these can be brought to the early attention of medical professionals through patients’ accounts of trauma within days of being admitted to emergency care. This study aims to understand how physical trauma patients with early signs of psychological distress, stemming from the trauma, might be supported through their communications with healthcare professionals. Methods42 semi-structured interviews with trauma victims attending the Royal London Hospital Trauma Clinic, taken as part of a larger project, were analysed using a qualitative thematic analysis method with a critical realist approach. ResultsFour key themes were highlighted: Pain and Death, Positivity, Powerlessness, and Remembering and Blame, each with relating subthemes such as Facing Death, Heroism, Waiting Time and Self-blame. DiscussionThe themes present within the data suggest that there are cues shared by trauma survivors that medical professionals should attend to with regard to the future mental health of their patients. Results may further equip nurses and clinical staff to spot early signs immediately and shortly after trauma.

Demographic, clinical, and pathological features of early onset pancreatic cancer patients

BackgroundEarly onset pancreatic cancer (EOPC), i.e. pancreatic ductal adenocarcinoma (PDAC) occurring in patients below 50 years of age, is rare and there is limited information regarding risk factors, molecular basis and outcome. This study aimed to determine the demographic and clinicopathological features and survival figures for EOPC.MethodsA retrospective analysis of patients treated at the Royal London Hospital for PDAC between September 2004 and September 2015 was performed. Data on demographics, risk factors, presentation, pathological features, treatment and survival outcome were compared in EOPC and older PDAC patients.ResultsOf 369 PDAC cases identified, 35 (9.5%) were EOPC. Compared to older patients, EOPC patients were more frequently male (71% vs 54%, p = 0.043) and less commonly of British origin (37% vs 70%, p = 0.002). There was no significant difference regarding the prevalence of any of the risk factors known to be associated with older PDAC patients. Fewer EOPC patients presented with resectable disease (23% vs 44%, p = 0.015) and more received adjuvant chemo/radiotherapy (60% vs 46%, p = 0.008). The overall median survival and stage specific survival did not differ significantly between the two groups, although a longer survival for localized disease was seen in EOPC patients (25 months (12.9–37, 95%CI) vs 13 months (10.5–15.5 95%CI) for older PDAC patients).ConclusionsThe EOPC patients had different demographics and were more likely than their older PDAC counterparts to be male. Typically they presented with more advanced disease, received more aggressive treatment, and had on overall similar survival outcome.

‘I think I was more pleased to see her than any one ‘Cos she’s so fine’: nurses’ friendships, trauma, and resiliency during the first world war

This article considers how two professional nurses described in their diaries their relationships with other women during their service on the Western Front, and how those relationships provided the solace and support necessary to cope with the traumatic sights and experiences they encountered. It also considers how women worked together to create spaces of peace, comfort, and solidarity in the midst of the masculine environments of war. In so doing, this article expands the study of women’s wartime emotional experiences to incorporate women’s traumatic experiences and the relationships that they developed in order to survive the hell of war. Specifically, it focuses on the diary of Nurse Hilda Wells, held at the Royal London Hospital Archive, and Eva Smith, whose diary is held by the Imperial War Museum. Both women’s diaries provide excellent examples of how nurses developed friendships, created spaces of solitude and support, and crafted entertainments for each other to make their war experiences endurable. These individual examples prove how women’s friendships were often key resources that women utilised to survive the war.

Outcomes following trauma laparotomy for hypotensive trauma patients: A UK military and civilian perspective

The management of trauma patients has changed radically in the last decade, and studies have shown overall improvements in survival. However, reduction in mortality for the many may obscure a lack of progress in some high-risk patients. We sought to examine the outcomes for hypotensive patients requiring laparotomy in UK military and civilian cohorts. We undertook a review of two prospectively maintained trauma databases: the UK Joint Theatre Trauma Registry for the military cohort (February 4, 2003, to September 21, 2014) and the trauma registry of the Royal London Hospital major trauma center (January 1, 2012, to January 1, 2017) for civilian patients. Adults undergoing trauma laparotomy within 90 minutes of arrival at the emergency department (ED) were included. Hypotension was present on arrival at the ED in 155 (20.4%) of 761 military patients. Mortality was higher in hypotensive casualties (25.8% vs. 9.7% in normotensive casualties; p < 0.001). Hypotension was present on arrival at the ED in 63 (35.7%) of 176 civilian patients. Mortality was higher in hypotensive patients (47.6% vs. 12.4% in normotensive patients; p < 0.001). In both cohorts of hypotensive patients, neither the average injury severity, the prehospital time, the ED arrival systolic blood pressure, nor mortality rate changed significantly during the study period. Despite improvements in survival after trauma for patients overall, the mortality for patients undergoing laparotomy who arrive at the ED with hypotension has not changed and appears stubbornly resistant to all efforts. Specific enquiry and research should continue to be directed at this high-risk group of patients. Prognostic/Epidemiologic, level IV.

Clinical perspectives into the use of thalidomide for central nervous system tuberculosis.

Central nervous system (CNS) tuberculosis (TB) accounts for over 4% of all TB notifications in the UK and causes death or significant disability in over half of those affected. Tumour necrosis factor alpha is a critical cytokine involved in the neuropathogenesis of CNS TB. Thalidomide has been trialled in CNS TB due to its immunomodulatory and immune reconstitution effects through the inhibition of tumour necrosis factor alpha. Despite animal models demonstrating dramatic improvement in survival, studies in paediatric patients have been associated with higher levels of mortality. The effects of thalidomide have not yet been studied in adults with CNS TB. This narrative case series guides clinicians through a range of CNS TB clinical cases seen in a large London teaching hospital, serving a region with a high incidence of TB (32 per 100 000) with 55% of TB cases manifesting as extrapulmonary disease. We aimed to illustrate our experiences of using thalidomide to treat a range of severe CNS TB complications. Five inpatients at The Royal London Hospital, London, UK treated with thalidomide in addition to standard TB treatment are described in detail. The rationale for treatment initiation with thalidomide is explained. The case examples are used to guide our reflections and lessons learnt regarding the use of thalidomide. Responses to treatment and functional outcomes suggest that thalidomide may be a useful adjunct to standard TB therapy in selected adult cases. The experience gained from using thalidomide in this small case series may provide evidence leading to more research into using thalidomide to treat severe CNS TB.

Mind the gap: 11 years of train-related injuries at the Royal London Hospital Major Trauma Centre.

Introduction This study presents an extensive retrospective database of patients with polytrauma following train-related injuries and highlights the key lessons learnt in this rare clinical presentation. Materials and methods We retrospectively collected data from 127 patients who presented to Royal London Hospital after sustaining train related trauma. We analysed demographics, accident report data, aetiologies and clinical management interventions. All data were screened and injuries were mapped to various anatomical regions. The revised trauma score, injury severity score and new injury severity scores were used to quantify injury extent. Results Mean patient age was 41 years (range 16-81 years) with a 73% to 27% male to female ratio. Deliberate injuries occurred in 71% of patients, with accidental injury accounting for 29%. The mean new injury severity score was 26.48 (range 1-75), with the most common injuries sustained to the chest and the extremities. Pneumothorax, haemothorax or tension pneumothorax occurred in 44% of patients, with 11% suffering a flail chest injury. Traumatic amputations occurred in 33% of patients and 56% of patients required admission to intensive care. Total mortality rates were 19%, with 12% of patients dying at day 0 and 18% at day 7, respectively. Conclusions This study demonstrated the significant impact of train-related polytrauma and provided a comprehensive injury patterns. It was observed that deliberate polytrauma is related to psychiatric deliberate harm but there is no significant difference in the patterns of injuries between accidental and deliberately caused injuries. Overall injuries to the thorax and extremities were the most severe, demonstrating the highest mean injury scores.

Five Steps to Internal Mammary Vessel Preparation in Less than 15 Minutes

Sir: We commend the authors on describing steps to improve efficiency in rib harvest for deep inferior epigastric perforator breast reconstruction.1 Their video demonstrates rapid dissection of the internal mammary vessels with a rib removal technique. The case appears to be a nonirradiated chest with virgin tissues. We would like to highlight some points of the technique described that may save time and avoid serious complications. This is particularly the case in an irradiated or previously infected wound bed. We start by splitting the pectoralis major in line with its fibers; however, we raise the muscle both inferiorly and superiorly in a subpectoral plane, taking care to preserve internal mammary artery perforators. In some cases, if a sizable internal mammary artery perforator is present, there is no need to perform a rib removal, and this should save precious surgical time. Another approach that we have used—particularly if there is a large rib space—is the rib-preserving approach (Fig. 1); careful lateral-to-medial dissection with bipolar cautery can be used to identify the vessels. This technique has a learning curve but has potential advantages, such as reduced pain, lower chance of chest wall contour deformity, and faster dissection.2Fig. 1.: Rib-preserving approach.Once the third rib is exposed, the pectoralis major muscle is dissected superiorly and inferiorly. Good exposure is achieved with a deep retractor, stay sutures,3 or fish hook retractors. Like the authors, we split the perichondrium and start dissection with an Obwegeser elevator; if the plane is not clear because of irradiation or previous infection, we use a finer instrument such as a Mitchell trimmer to develop a clear plane and release the adherent posterior perichondrium. This helps develop a natural plane behind the rib, avoiding bleeding and subsequent loss of time (Fig. 2).Fig. 2.: Careful dissection of irradiated scarred tissues of posterior perichondrium with a Mitchell trimmer.Right- and left-handed cardiac Doyen rib elevators are also useful in speeding up rib removal, but care must be taken to first remove all of the posterior perichondrium. Once the rib is dissected free, it is cut on the lateral side with protection from the Doyen rib elevator. If this has been performed carefully, one can disarticulate rib from the sternal joint in one go. We would caution (particularly the less experienced) against use of rongeurs to remove the rib piecemeal in the irradiated chest. The pulling motion to remove the rib can cause avulsion of underlying adherent scarred tissues, which may in turn lead to a hole in the recipient vessels. We use rongeurs only if the disarticulation is incomplete medially. Finally, we must highlight that care must be taken around the dissection of the vein, as it can easily become attenuated, with damage to the vessel wall. We would advise the use of bipolar cautery rather than monopolar that was demonstrated in the video when close to the vessels. In the many units where we have trained, two microsurgical reconstructions are still possible using the additional techniques described. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Mohammed Farid, M.R.C.S., M.Sc.Onur Gilleard, F.R.C.S.(Plast.)Dariush Nikkhah, M.Sc., F.R.C.S.(Plast.)Barts Health NHS TrustThe Royal London HospitalWhitechapel, London, United Kingdom

Cultivating Spaces to Take Risks: An Interview with the Royal Academy of Arts' Kate Goodwin

A 250‐year history does not stop London's Royal Academy of Arts from constantly exploring new ground. Its expanding architecture programme, led by Head of Architecture and Drue Heinz Curator Kate Goodwin, is no exception. Here she talks to Guest‐Editor Owen Hopkins about the purposes and methods of cultural commissioning, and the curator's responsibilities to artists/architects and public. Key to her approach are establishing mutual trust, resisting the temptation to play it safe, and knowing when to take a step back.

Treatment of supragastric belching with cognitive behavioral therapy improves quality of life and reduces acid gastroesophageal reflux.

Excessive supragastric belching (SGB) manifests as troublesome belching, and can be associated with reflux and significant impact on quality of life (QOL). In some GERD patients, SGB-associated reflux contributes to up to 1/3 of the total esophageal acid exposure. We hypothesized that a cognitive-behavioral intervention (CBT) might reduce SGB, improve QOL, and reduce acid gastroesophageal reflux (GOR). We aimed to assess the effectiveness of CBT in patients with pathological SGB. Patients with SGB were recruited at the Royal London Hospital. Patients attended CBT sessions focused on recognition of warning signals and preventative exercises. Objective outcomes were the number of SGBs, esophageal acid exposure time (AET), and proportion of AET related to SGBs. Subjective evaluation was by patient-reported questionnaires. Of 51 patients who started treatment, 39 completed the protocol, of whom 31 had a follow-up MII-pH study. The mean number of SGBs decreased significantly after CBT (before: 116 (47-323) vs. after 45 (22-139), P<0.0003). Sixteen of 31 patients were shown to have a reduction in SGB by >50%. In patients with increased AET at baseline, AET after CBT was decreased: 9.0-6.1% (P=0.005). Mean visual analog scale severity scores decreased after CBT (before: 260 (210-320) mm vs. after: 140 (80-210) mm, P<0.0001). Cognitive behavioral therapy reduced the number of SGB and improved social and daily activities. Careful analysis of MII-pH allows identification of a subgroup of GERD patients with acid reflux predominantly driven by SGB. In these patients, CBT can reduce esophageal acid exposure.

Strategy to reduce E. coli bacteraemia based on cohort data from a London teaching hospital

Background and aimIn 2017, National Health Service Improvement set a 10% reduction target for Escherichia coli bacteraemia by 2018, followed by a 50% reduction in healthcare-associated Gram-negative bacteraemias by 2022....

P689 UK Asians are prescribed vedolizumab earlier in disease history than Caucasians, but respond equally well to therapy

The phenotype and natural history of IBD in British Asians differs from Caucasians. As such response to treatment may also differ. UK Asians with CD at Royal London Hospital are more likely to stop anti TNFs due to treatment failure.1 This study investigates whether British and Caucasian patients also have a difference in response to Vedolizumab. A single-centre retrospective cohort study of patients prescribed Vedolizumab was undertaken. Cases were identified from attendance records of infusion clinics 2015–2017. Data collected included: ethnicity, Montreal Classification, disease duration until therapy, persistence on therapy and indication for cessation. Patients with ethnicity other than Asian and Caucasian were excluded. After screening 82 patients were identified, 47.6% (n = 39)CD, 50% (n = 41) UC and 2.4% (n = 2) IBD-U. Ethnicity was as follows: Asian (40.2%, n = 33) and Caucasian (59.8%, n = 49). Asian patients were younger at first infusion of Vedolizumab; median (IQR)age was 30 years (24–37.5) for Asians and 34 years (25.75–55.5)for Caucasians (p = 0.0272). The duration to follow-up did not vary with ethnicity for CD or UC: CD Asian 375 days (294.3–675.3), CD Caucasian 389 days (183–564) (p = 0.6874), UC Asian 428.5 days (233.8–609.8), Caucasian 494.5 days (141–745.5 days) (p = 0.8227). Montreal classification including perianal involvement did not vary with ethnicity. 76.8% (n = 63) of patients prescribed Vedolizumab had previously been prescribed a TNF antagonist. Prior anti TNF use also did not vary with ethnicity (p = 0.434). Asians with CD are prescribed Vedolizumab over 5 years earlier in disease course, as measured as duration of disease until first infusion; Asian 8.31 years (6.5–12.5) vs Caucasian 14.0 years (8.3–21.4) (p = 0.016). However disease duration at first prescription did not vary with UC; Asian 9.5 years (4.7–14.1) vs. Caucasian 9.6 years (3.6–14.8) (p = 0.789). Disease duration until Vedolizumab 46.3% patients prescribed Vedolizmab stopped therapy due to intolerance or suboptimal response. Rates of therapy failure did not differ with ethnicity (Asian 51.52% vs. Caucasian 40.82% p = 0.3727). Median persistence on Vedolizumab did not vary with ethnicity (CD Asian 152 days vs. Caucasian 183 days, p = 0.6947, UC Asian 218 days vs. Caucasian 162 days, p = 0.2791). Vedolizumab is prescribed earlier in disease course in British Asians with CD in comparison with Caucasians. However, persistence on Vedolizumab until treatment failure and rates of treatment failure did not differ between groups. 1. Gadhok et al. ECCO 2017: anti-TNFs more frequently stopped due to loss of response in British Asians with Crohn’s disease: a single-centre retrospective analysis. 2017.

Solid pseudopapillary tumour of the pancreas: clinicopathological analysis.

We report on our experience of the surgical management and outcomes of 11 patients with solid pseudopapillary tumour of the pancreas (SPT). We sought to correlate the immunohistochemical staining of these tumours with that previously reported in the literature. A retrospective analysis of the clinical presentation, radiological findings, surgical treatment, histopathological characteristics and outcomes for patients surgically managed with SPT at The Royal London Hospital. A literature search was performed to analyse the immunohistochemical stains commonly used to diagnose SPT. Between August 2006 and April 2016, 10 females and one male patient underwent surgery for SPT. The localization of the tumour was in the pancreatic head in two patients, one in the neck, three in the body and five in the tail. All 11 patients had localised disease. Six patients suffered post-surgical complications. Histopathology shows immunoreactivity for: β-catenin, vimentin, CD-10, CD-56, α1-antitrypsin and negative staining for synaptophysin and chromogranin. At a median of 24 months of follow-up, the disease-free survival rate was 100% and no recurrence was noted. A literature review generated 38 suitable articles with 116 individual cases of SPT, with high expression of vimentin and neuron specific enolase throughout, and low rates of chromogranin and synatophysin positivity. SPT is rare and affects mostly young women. An accurate diagnosis is important as the relative indolent behaviour can be managed with surgical resection even when large in size, bringing excellent long-term outcomes.

Benjamin Franklin in Passy, 1784

Benjamin Franklin in Passy, 1784 Carla J. Mulford (bio) Ellen R. Cohn, et al., eds. The Papers of Benjamin Franklin, Volume 42, March 1 through August 15, 1784. New Haven and London: Yale University Press, 2017. lvii + 571 pp. Illustrations, short title bibliography, chronology, texts, notes, and index. $125.00. The cold and difficult winter of 1783 to 1784 kept Benjamin Franklin indoors, aching from serious bouts of his old complaints (gout and bladder stones) and from the long delay in the arrival of the signed treaty ratification papers from Congress. In North America, ice floes blocked the waterways, and roadways were treacherous. The weather's harshness made it impossible for members of Congress to convene for the ratification of the Treaty of Paris. On Franklin's side of the Atlantic, ice and snow made travel difficult, and it grew so cold that the French government ordered a rationing of firewood. Franklin, in poor health, was essentially stuck at his residence at Jacques Donatien Leray's Hôtel de Valentinois, at Chaumont. Although he had numerous visitors, Franklin worried about his health and the delay of the singularly important papers from Congress. But Franklin was also aching to be back in Philadelphia. In early March, 1784, he wrote to Henry Laurens (awaiting his departure for America) that he wished his own departure "was as near." He was troubled that his repeated pleas for recall to America, now that the peace was concluded, had gone unanswered. With an openness characteristic of these years, Franklin remarked, "I wish rather to die in my own Country than here." He continued with a striking architectural and engineering metaphor that he would repeat in a slightly different version to others, that "tho' the upper Part of the Building appears yet tolerably firm, yet being undermin'd by the Stone and Gout united, its Fall cannot be far distant." The next day, he picked up his pen again, this time to explain he was "too modest" to claim "Infallibility," but he nonetheless desired Laurens would continue to refute the aspersions cast by his enemies in America. He had "liv'd beyond all other Ambition than that of dying with the fair Character he has long endeavour'd to deserve," he wrote (p. 49). Volume 42 of the exemplary edition of The Papers of Benjamin Franklin provides insight on a significant period in Franklin's career as an international [End Page 573] diplomat, economist, scientist, and philosopher. The volume begins at March 1, 1784, when Franklin was worrying about the delays in the arrival of the peace treaty papers, and it concludes just after the time when Franklin learned from Joseph Banks that he was being honored by London's Royal Society for his part, during the war, in keeping American ships from "molesting" the ships of James Cook, "that great Circumnavigator" of the seas (p. 497). There is much to commend in this forty-second volume of a long and prestigious series. This review will trace some of Franklin's key concerns, many of which might be incomprehensible without the editorial apparatus provided, and then remark about the editorial accomplishment of the volume. The Treaty of Paris marked Franklin's major diplomatic success, so of course he was worried about its ratification within the timeframe allotted for the process. The treaty papers finally arrived in France in very late March. They were signed by King George III on April 9, 1784. David Hartley brought the papers to Paris, where he arrived on April 27. Franklin's hope of returning home to Philadelphia were dashed when the commissioners received correspondence from Congress (in documents dating from May 7 to June 3) that Franklin, John Adams, and Thomas Jefferson were appointed to negotiate treaties of amity and commerce with twenty European nations and North African powers. Franklin knew such efforts would be nearly impossible, and he was bemused by the decision made in Congress to reduce the salaries of the commissioners. To John Adams, still in The Hague, he wrote acerbically, "You will see that a good deal of Business is cut out for us, Treaties to be made with I think twenty Powers, in two Years, so...

Editorial introductions

Current Opinion in Obstetrics and Gynecology was launched in 1989. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of obstetrics and gynecology is divided into nine sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Joseph AquilinaJoseph AquilinaJoseph Aquilina, FRCOG, MFFP is a consultant obstetrician and gynaecologist at Barts Health NHS Trust based St. Bartholomew's and the Royal London Hospitals and Honorary Senior Lecturer in Obstetrics & Gynaecology at Queen Mary University of London, UK. He is the Lead Clinician for Fetal Medicine Clinical Academic Group and runs a one-stop Menstrual Disorders clinic at St Bartholomew's Hospital, London, UK. Mr Aquilina obtained his primary medical degree in Malta and then moved to the UK for his basic postgraduate training in Bristol, and in London at King's College and Greenwich Hospitals. He subsequently undertook research and subspecialty training in feto-maternal medicine/gynaecological ultrasound as a lecturer at St.Bartholomew's and Royal London Medical School, Queen Mary Westfield College, based at Homerton Hospital, UK. He is recognised as a preceptor for training in gynaecological scanning by the Royal College of Obstetricians and Gynaecologists. His special interests include polycystic ovarian syndrome, prediction of pre-eclampsia and the application of ultrasound in the diagnosis and management of benign gynaecological conditions. Paul D. BlumenthalPaul D. BlumenthalPaul D. Blumenthal, MD, MPH is Professor of obstetrics and gynecology at Stanford University School of Medicine. He directs the Stanford Gynecology Service and the Division of Family Planning Services and Research at Stanford. He also directs SPIRES, the Stanford Program for International Reproductive Education and Services, an initiative providing technical assistance and training to family planning programs in a wide variety of countries across Africa, Asia, and Central America. For over 25 years, Dr Blumenthal has been an advisor to multiple international agencies such as Gynuity Health Projects, Ipas, Pathfinder, Family Health International, Path, JHPIEGO Corporation, and the World Health Organization and served as the Special Advisor to Minister of Health and Family Planning of the Republic of Madagascar. He currently serves as the Global Medical Director for Population Services International. Dr Blumenthal is committed to the development and implementation of innovative approaches to reproductive health issues in both the domestic and international arenas.

Orbital Compartment Syndrome: An Audit on the Performance and Documentation of Eye Observations on Post-Operative Cranio-Maxillofacial Trauma Patients at the Royal London Hospital

Orbital Compartment Syndrome: An Audit on the Performance and Documentation of Eye Observations on Post-Operative Cranio-Maxillofacial Trauma Patients at the Royal London Hospital

The treatment of perilunate ligament injuries in multiply injured patients.

Perilunate injuries are rare, severe injuries of the carpus. They can present as isolated injuries or in the poly-traumatised patient. This is the first documented series of these injuries treated in a Major Trauma Centre. The aims were to assess the management, treatment algorithm and outcomes, of perilunate injuries in our department, review whether concomitant polytrauma affected those outcomes and identify if delay to definitive treatment had a significant effect on overall outcome. Perilunate injuries admitted to the Royal London Hospital between Oct 2011 and March 2016 were identified. All definitive surgical procedures were performed by the senior author; hand therapists supervised patient rehabilitation. Outcomes were assessed by Mayo Wrist and QuickDASH scores. We identified 23 perilunate injuries (22 patients). There was an associated nerve injury in 10 cases with other system injuries present in 12 cases. At final review, the mean carpal height ratio was 0.56, Mayo Wrist score was 81 and QuickDASH score was 16.4. There were no differences when comparing the outcomes of patients who had early against those with more delayed definite treatment or when comparing patients with isolated wrist injuries against polytrauma patients. Satisfactory outcomes can be achieved, even in the presence of other injuries, if initial treatment is prompt and follows a clear management protocol. Prompt early reduction and neurological decompression followed by subsequent accurate definitive fixation leads to good outcomes. A delay of definitive fixation of up to 18days does not appear to have a deleterious effect on outcome.

Automated peritoneal dialysis: case study at the Royal London Hospital

Despite guidance from the National Institute for Health and Care Excellence encouraging its use, peritoneal dialysis (PD) remains underutilised as a dialysis modality, both at home and in-centre. In this article, Sally Punzalan describes the experience of the Royal London Hospital in using a new automated PD system, when compared with conventional PD.