West Hertfordshire Research Articles

Feasibility, clinical outcomes, and learning curves of robotic-assisted colorectal cancer surgery in a high-volume district general hospital: a cohort study

Introduction: Robotic-assisted surgery (RAS) is one of the most influential surgical advances with widespread clinical and health-economic benefits. West Hertfordshire Teaching Hospital NHS Trust was the first in the UK to simultaneously integrate two CMR Surgical Versius robots. This study aims to investigate clinical outcomes of RAS, explore surgeon learning curves and assess the feasibility of implementation within a district general hospital (DGH). Methods: A prospective cohort study of 100 consecutive patient data were collected between July 2022 and August 2023, including demographics, operative and clinical variables, and compared with laparoscopic surgery (LS) data from the National Bowel Cancer Audit. Surgeon learning curves were analysed using sequential surgical and console times. Results: In the RAS cohort, the median age was 70 (IQR 57–78 years) and 60% were male. Retrieval of a minimum of 12 lymph nodes significantly increased in RAS compared to LS (95% vs. 88%, P=0.05). The negative mesorectal margin rate was similar between RAS and LS (97% vs. 91%, P=0.10), as well as length of stay greater than 5 days (42% vs. 39%, P=0.27). For anterior resections performed by the highest volume surgeon (n=16), surgical time was reduced over 1 year by 35% (304.9–196.9 min), whilst console time increased by 111% (63.0–132.8 min). Conclusions: Key quality performance indicators were either unchanged or improved with RAS. There is potential for improved theatre utilisation and cost-savings with increased RAS. This study demonstrates the feasibility and easy integration of robotic platforms into DGHs, offering wider training opportunities for the next generation of surgeons.

619 Training the Trainees in Robotic Surgery – a UK Pilot Scheme

Abstract Aim Training the trainees in robotic surgery is a specialised and crucial process, given the precision and complexity involved in performing operations using robotic systems. Robotic training for trainees is challenging due to limited access to robotic systems and the lack of training opportunities. We describe how we implemented a training programme for trainees at West Hertfordshire Teaching Hospitals (WHTH) NHS Trust within a year of the consultants starting their robotics programme. Method Specialist trainees at WHTH who would have been offered training in laparoscopic surgery in colorectal, upper gastrointestinal and general surgery were selected to train as console surgeons on the CMR Surgical Versius system. All trainees had been on a first assist course and had experience in assisting in robotic surgery. Training included online modules, metrics-based virtual training, and technical skills assessment. Live operating was supervised by consultant trainers who sat beside the trainee. Results Six trainees ranging from ST4 to ST8 level were selected to partake in the training programme over a period of six months. Operations were broken down into modular parts and included segmental colectomies, anterior resections, cholecystectomy, and inguinal hernia repair. The trainees have participated in over thirty operations. Feedback from consultant trainers was given verbally and through work-based assessments. No adverse events were reported in training cases. Conclusions Robotic surgical training for specialist trainees can be implemented safely and in a timely manner. Objective metrics such as docking time, console time and volumetric hand motion may help with trainee assessment in the future.

An evaluation of a service expansion to include patients with heart failure with preserved ejection fraction

Background/Aims The Central London Community Healthcare Trust West Hertfordshire heart failure service expanded in 2020 to include patients with heart failure with preserved ejection fraction, in addition to the patients with heart failure with reduced ejection fraction. The patient population was predicted to double, requiring staff and service adjustments; this warranted an evaluation to determine if care targets were maintained. This study aimed to evaluate the impact of service expansion on service referral rates, length of stay in the service and clinical workload. Methods A retrospective quantitative evaluation of the service data from October 2020 to April 2021 was undertaken to compare referral rates, length of stay in the service and key workload metrics between patients with heart failure with reduced ejection fraction and those with heart failure with preserved ejection fraction. All referrals to the service with a new diagnosis of heart failure (confirmed by echocardiogram or magnetic resonance imaging) were considered for evaluation. Of 250 eligible referrals, 81 were selected for inclusion using a random sampling method. Data were analysed using Chi square test, Fisher’s exact test or the Wilcoxon signed rank test; a P value of <0.05 indicated statistical significance. Results The participants with heart failure with preserved ejection fraction had a median length of stay in the service of 17 weeks. The participants with heart failure with reduced ejection fraction had a significantly longer stay of 35.57 weeks (P<0.001) compared to a pre-expansion length of stay of approximately 17 weeks. Workload was proportional between the two cohorts. Patients with heart failure with preserved ejection fraction were more likely to be reviewed in multidisciplinary teams or by the consultant community clinic. This group was less likely to attend clinic, with 96.4% of face-to-face reviews taking place at home. Telephone reviews occurred at a similar frequency for both cohorts, comprising 50% of follow ups. The heart failure with reduced ejection fraction cohort required more alterations in medication and medication titration, generating additional follow ups. Conclusions The service expansion to include patients with heart failure with preserved ejection fraction has had a significant impact on workload, leading to a reduction in the quality of care for those with heart failure with reduced ejection fraction.

A Romano-British puddingstone quarry in the Hertfordshire Chilterns

A 10.5 Ha site within three lobes of ancient woodland on the Gaddesden Estate, West Hertfordshire, was investigated using geological and archaeological techniques. 2–3 m of Paleogene silt-sand and gravel drapes the Chalk. Discontinuous lenses of pebbly conglomerate have been silicified to create concretions of Hertfordshire Puddingstone [HPS hereafter], one of which was in situ, a very rare find. The HPS is associated with a pure white sand and a previously un-reported lithology, a soft white pebbly Sarsen. During the Quaternary the feather edge of the Cenozoic cover was punctured following underlying dissolution features in the chalk to create 93 dolines, the largest concentration in the Chilterns AONB. As they grew the dolines were filled with Pleistocene loessic brickearth during the Wolstonian stage (MIS7) and captured blocks of HPS. These were exploited by the Romans as valuable raw material for quern-making. Shortly after the Roman Conquest in AD43 the site was cleared by felling and burning the tree cover. The cortex and poor-quality core stone were cut away from concretions with picks, manageable slices were detached using steel wedges and initial shaping was undertaken to produce blanks of querns to be finished elsewhere. Quarrying continued for, at most, fifty years. The excavated doline fills or upcast formed rims around the pits, which taken together protect the second largest remaining area of Roman ground surface in Hertfordshire. The site was abandoned and has been largely undisturbed apart from some quarrying of chalk and brickearth and offers further opportunities for research.

Incidence and Clinical Features of Pneumomediastinum and Pneumothorax in COVID-19 Pneumonia.

BackgroundPneumothorax (PTX) and pneumomediastinum (PM), collectively termed here “air leak”, are now well described complications of severe COVID-19 pneumonia across several case series. The incidence is thought to be approximately 1% but is not definitively known.ObjectivesTo report the incidence and describe the demographic features, risk factors and outcomes of patients with air leak as a complication of COVID-19.MethodsA retrospective observational study on all adult patients with COVID-19 admitted to Watford General Hospital, West Hertfordshire NHS Trust between March 1st 2020 and Feb 28th 2021. Patients with air leak were identified after reviewing both chest radiographs (CXRs) and axial imaging (CT Thorax) with confirmatory radiology reports inclusive of the terms PTX and/or PM.ResultsAir leak occurred with an incidence of 0.56%. Patients with air leak were younger and had evidence of more severe disease at presentation, including a higher median CRP and number of abnormal zones affected on chest radiograph. Asthma was a significant risk factor in the development of air leak (OR 13.4 [4.7-36.4]), both spontaneously and following positive pressure ventilation. CPAP and IMV were also associated with a greater than six fold increase in the risk of air leak (OR 6.4 [2.5-16.6] and 9.8 [3.7-27.8] respectively). PTX, with or without PM, in the context of COVID-19 pneumonia was almost universally fatal whereas those with alone PM had a lower risk of death.ConclusionDespite the global vaccination programme, patients continue to develop severe COVID-19 disease and may require respiratory support. This study demonstrates the importance of identifying that deterioration in such patients may be resultant from PTX or PM, particularly in asthmatics and those managed with positive pressure ventilation.

Does quality matter to you? Ward accreditation and improving patient care.

British Journal of NursingVol. 31, No. 3 CommentDoes quality matter to you? Ward accreditation and improving patient careMichelle HopeMichelle Hope(E-mail Address: [email protected])Associate Chief Nurse, West Hertfordshire Hospitals NHS TrustSearch for more papers by this authorMichelle HopePublished Online:12 Feb 2022https://doi.org/10.12968/bjon.2022.31.3.176AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Allen T, Walshe K, Proudlove N, Sutton M. Using quality indicators to predict inspection ratings: cross-sectional study of general practices in England. Br J Gen Pract. 2019;70(690):e55-e63. https://doi.org/10.3399/bjgp19X707141 Crossref, Medline, Google ScholarCare Quality Commission. A new strategy for the changing world of health and social care—CQC's new strategy, 2021. 2021. https://tinyurl.com/4masr2us (accessed 1 February 2022) Google ScholarDarzi AW, Department of Health. Quality at the heart of everything we do. In: High quality care for all. NHS next stage review final report. 2008: 47. https://tinyurl.com/2p82ah3t (accessed 1 February 2022) Google ScholarGottwald M, Lansdown G. Clinical governance: improving the quality of healthcare for patients and service users. Maidenhead: Open University Press/McGraw Hill; 2014. Google ScholarHanefeld J, Powell-Jackson T, Balabanova D. Understanding and measuring quality of care: dealing with complexity. Bull World Health Organ. 2017;95(5):368-374. https://doi.org/10.2471/BLT.16.179309 Crossref, Medline, Google ScholarIngelsby-Burke E. Example 2: Salford Royal NHS Foundation Trust. In: May RNHS Improvement. Guide to developing and implementing ward and unit accreditation programmes. March 2019: 20-22. https://tinyurl.com/mrymj79r (accessed 1 February 2022) Google ScholarLee, F. If Disney ran your hospital. Boseman (MT): Second River Healthcare Press; 2004. Google ScholarMay R; NHS Improvement. Guide to developing and implementing ward and unit accreditation programmes. March 2019. https://tinyurl.com/mrymj79r (accessed 1 February 2022) Google ScholarPeters, T. The problem is never the problem. The response to the problem is almost always the real problem. 7 April 2012. YouTube video. https://tinyurl.com/3j7a5yx3 (accessed 1 February 2022) Google ScholarUnited Kingdom Accreditation Service, British Standards Institution Health Quality Improvement Partnership. UKAS, BSI and HQIP: joint statement of intent regarding clinical service accreditation and health Executive summary Executive summary. 2019. https://tinyurl.com/4ezdh7ze (accessed 1 February 2022) Google ScholarWhat matters to you? A global movement to improve outcomes. 2020. https://wmty.world/ (accessed 1 February 2022) Google Scholar FiguresReferencesRelatedDetails 10 February 2022Volume 31Issue 3ISSN (print): 0966-0461ISSN (online): 2052-2819 Metrics History Published online 12 February 2022 Published in print 10 February 2022 Information© MA Healthcare LimitedAcknowledgement:I would like to thank Polly Pascoe, my supervisor during my recent MBA dissertation ‘The impact of ward accreditation on the quality of patient care. A realist literature review.’, on which this article is basedPDF download

Three-month cardiac outcomes of survivors of COVID-19 presenting to a district general hospital in West Hertfordshire, UK

Abstract Background COVID-19 is novel entity associated with significant morbidity and mortality. Most patients recover completely, however, a proportion describe persistent symptoms consistent with cardiopulmonary disturbance. The long-term cardiac and respiratory outcomes of COVID-19 are not known. Purpose The aim of this study was to undertake a comprehensive cardiopulmonary assessment of survivors of COVID-19 with post recovery symptoms. The cardiac findings are presented here. Methods Survivors of COVID-19 presenting to a general hospital in West Hertfordshire between 18 March 2020 and 15 May 2020, were reviewed at 3 months using a structured prespecified protocol. Patients with persistent symptoms and those admitted to the intensive care unit (ICU) were invited to attend a clinical assessment comprising an electrocardiogram (ECG), echocardiography, chest x-ray (CXR) and pulmonary function tests. At follow up, patients were categorised according to disease course: 1) monitored via a community based virtual hospital, 2) admitted for supplemental oxygen, 3) requiring non-invasive ventilation and 4) ICU admission. Results 448 eligible patients were evaluated by telephone. 11 patients admitted to ICU and 147 patients with persistent symptoms were invited for further assessment. At presentation, hospitalised patients were older, had higher levels of obesity and increased rates of hypertension than those managed virtually (p<0.05). Among hospitalised patients, the degree of pulmonary infiltration on CXR was higher, ROX index for intubation lower, eGFR lower, C-reactive protein levels higher and lymphocyte counts lower, compared to those managed virtually (p<0.05). The prevalence of known respiratory conditions was higher among patients admitted to hospital, with a trend towards statistical significance (p=0.051). There were no differences in the prevalence of known cardiac disorders and other co-morbidities amongst both patient groups (table 1). At follow up, CXR appearances were improved and similar among patients monitored virtually, those admitted for supplemental oxygen, those requiring non-invasive ventilation and those treated on ICU. There were no differences in heart rhythm and ECG parameters in the four patient groups. Left ventricular systolic and diastolic dimensions, Simpson's biplane ejection fraction, left atrial volume and left ventricular filling pressures were similar in all four patient groups. There were no differences in right ventricular dimensions, right ventricular fractional area change, tricuspid annular plane systolic excursion and pulmonary artery systolic pressures among patients irrespective of disease severity (table 2). Conclusions At 3 months, we identified no differences in ECG indices and echocardiographic parameters of left and right ventricular function among survivors of COVID-19, independent of disease course. The findings of this study argue against significant cardiac sequalae following COVID-19 infection. Funding Acknowledgement Type of funding sources: None.

SARS-CoV-2 infection, antibody positivity and seroconversion rates in staff and students following full reopening of secondary schools in England: A prospective cohort study, September-December 2020.

BackgroundOlder children have higher SARS-CoV-2 infection rates than younger children. We investigated SARS-CoV-2 infection, seroprevalence and seroconversion rates in staff and students following the full reopening of all secondary schools in England.MethodsPublic Health England (PHE) invited secondary schools in six regions (East and West London, Hertfordshire, Derbyshire, Manchester and Birmingham) to participate in SARS-CoV-2 surveillance during the 2020/21 academic year. Participants had nasal swabs for RT-PCR and blood samples for SARS-CoV-2 antibodies at the beginning (September 2020) and end (December 2020) of the autumn term. Multivariable logistic regression was used to assess independent risk factors for seropositivity and seroconversion.FindingsEighteen schools in six regions enrolled 2,209 participants, including 1,189 (53.8%) students and 1,020 (46.2%) staff. SARS-CoV-2 infection rates were not significantly different between students and staff in round one (5/948; [0.53%] vs. 2/876 [0.23%]; p = 0.46) or round two (10/948 [1.05%] vs. 7/886 [0.79%]; p = 0.63), and similar to national prevalence. None of four and 7/15 (47%) sequenced strains in rounds 1 and 2 were the highly transmissible SARS-CoV-2 B.1.1.7 variant. In round 1, antibody seropositivity was higher in students than staff (114/893 [12.8%] vs. 79/861 [9.2%]; p = 0.016), but similar in round 2 (117/893 [13.1%] vs.117/872 [13.3%]; p = 0.85), comparable to local community seroprevalence. Between the two rounds, 8.7% (57/652) staff and 6.6% (36/549) students seroconverted (p = 0.16).InterpretationIn secondary schools, SARS-CoV-2 infection, seropositivity and seroconversion rates were similar in staff and students, and comparable to local community rates. Ongoing surveillance will be important for monitoring the impact of new variants in educational settings.

Predictors of clinical deterioration in patients with suspected COVID-19 managed in a ‘virtual hospital’ setting: a cohort study

ObjectiveIdentify predictors of clinical deterioration in a virtual hospital (VH) setting for COVID-19.DesignReal-world prospective observational study.SettingVH remote assessment service in West Hertfordshire NHS Trust, UK.ParticipantsPatients with suspected COVID-19 illness enrolled...

Characteristics of patients admitted to Intensive care units with severe Influenza and management outcome at a large district general hospital in East of England, UK

Background: Influenza pneumonia can be challenging to treat particularly in critically ill patients. The aim of this study is to review the risk factors for severe influenza infection, the course of the disease, the choice of antivirals and the management outcome in patients admitted with complicated influenza illness to ICU Method Sixteen patients who were admitted to ICU at West Hertfordshire hospitals NHS Trust with severe influenza illness were reviewed between 20th December 2018 and 14th February 2019. Data on Demographics, vaccination status, viral strain and clinical outcome were collected and analysed. Results High proportion of patients were below the age of 65 (n=9).The predominant strain was A(H1N1) pdm09 (n=10), followed by A(H3N2) (n=5) and 1 patient had no strain reported. All patients were initiated on Oseltamivir. Six patients developed multi-organ failure and were switched to IV Zanamivir. None of the latter were severely immunosuppressed. 56.25% (n=9) were not vaccinated and third with unknown status (n=5). 66% of the patients below the age of 65 were not vaccinated and had to switch to Zanamavir. Fourteen patients made good recovery and 2 died while on Zanamavir Conclusion: Our result suggest that the majority of patients admitted to ICU did not carry risk factor for complications and were below the age of 65, but were unvaccinated and infected with A(H1N1)pdm09 strain. Larger study is required to fully understand the risk factors for ICU admission including vaccination status in this group of patients and the optimum antiviral choice.

Appropriateness of meropenem prescriptions at a large district general hospital, East of England, UK

Introduction Meropenem is a broad spectrum antibiotic used to treat a variety of bacterial infections. There are no clear standards nationally for the use of meropenem. The purpose of this study is to audit the appropriateness of Meropenem prescription at West Hertfordshire NHS trust METHODOLOGY Patients started on meropenem were identified via the hospital pharmacy in the period from 1st January 2019 to 31st March 2019. Patients’ clinical notes, drug charts and blood tests were reviewed. Appropriateness of meropenem prescription was judged based on the following: indication, penicillin allergy and its nature, pathogen antibiogram, microbiologists approval, indications for escalation and duration of treatment RESULTS forty-eight patients were identified during the study period. The main indications were hospital-acquired/community-acquired pneumonia and UTI. Penicillin allergy was documented in 31%, the nature of allergy was intolerance in 13% and not known in 20%. Of note, in 42% of these, treatment was not pathogen guided. In 45.5% of non-penicillin allergic patients, escalation to meropenem were neither supported by antibiogram nor by microbiologists. The main driver was raised inflammatory markers (62.5%). Of the 37 patients who completed their treatment during the study period, 21.6% had > 7 days with only 50% recommended by Microbiologists. CONCLUSION: In third of the patients, meropenem use was driven by penicillin allergy, however the nature of allergy did not justify its use in many of these cases. Lack of microbiology approval, failure to de-escalate and long courses of meropenem were additional areas identified to target in our antimicrobial stewardship programme

Interval Breast Cancer Epidemiology, Radiology and Biological Characteristics

When mammography screening programs are fully implemented, interval cancers comprise a substantial proportion of incident breast cancers. Interval cancers may have been overlooked at the last mammography examination or become apparent because they grew so rapidly that the detectable preclinical phase (sojourn time) was shorter than the screening interval. This overview describes the epidemiology, radiological and biological characteristics and time of diagnosis of interval breast cancers in population of mammography screening. Our team retrospectively collected data of symptomatic patients who presented to the West Hertfordshire Trust Breast Unit during the period from 1st of October 2016 until the 30th of September 2017 and identified any interval cancers (screening imaging 40 months prior). Imaging included two-view digital mammogram as well as ultrasound. The total number of cancers diagnosed during this period was 335 patients of which a total of 49 patients (14.6%) were interval cancers, with an average age of 62.42 years; 48 patients (97.9%) had new cancers while one patient (2.1%) had recurrent disease, and 2 patients (4%) had metastatic disease. Average tumour size was 26.79 mm (range 81 mm); 37 patients (75. 5%) had IDC with or without other pathology while average tumour grade was grade 2. Our review demonstrated that interval cancers are more common with invasive high-grade disease; multicentre further studies including larger numbers will be very informative.

The Watford low anterior resection syndrome pathway for pre- and post-stoma reversal patients

There is increasing awareness of the high incidence of bowel dysfunction experienced by patients after sphincter-preserving rectal resection, termed low anterior resection syndrome (LARS); there remains no agreement on effective methods of treatment or effective management strategies. In West Hertfordshire Hospitals NHS Trust, there were no set protocols in place prior to the development of a nurse-led LARS clinic, which has ensured that all patients undergoing anterior resection surgery are monitored, encouraged and empowered to take an active role in their own care. While being the first point of contact for these patients, the nurse works as part of a wider multidisciplinary team (MDT) and the surgical consultants continue to have overall responsibility for patient care. The Watford LARS pathway is a guide with a method of how best to approach management of patients prior to stoma reversal and in preventing symptoms of LARS. In spite of only being set up in 2018, the pathway and clinics are already showing great success.

The effect of integrated care on self-management and emergency department attendance.

Aims and methodThe Frequent Attenders Programme is a joint initiative between Hertfordshire Rapid Assessment, Interface and Discharge service and the Emergency Department of the West Hertfordshire NHS Trust, which aims to divert frequent attenders from the emergency department by addressing their unmet needs. This paper describes the range of interventions put in place from the time that the service was set up in 2014 until the introduction of the new national Commissioning for Quality and Innovation 2017-2019, which tasked National Health Service trusts to improve services for people with mental health needs who present to Accident and Emergency. The terms emergency department and Accident and Emergency are used interchangeably, reflecting the practice in policy documents. A subsequent article will report on the impact of the Commissioning for Quality and Innovation in Hertfordshire. RESULTS: Analysis of the interventions indicated a highly significant (P < 0.0001) mean reduction in attendances. Lower gains were made in patients whose primary presentations were alcohol-related. A failure to effect change in two patients led to a significant revision of their respective care plans, resulting in a subsequent reduction in their attendances.Clinical implicationsAn integrated approach to patients with complex presentations was associated with high levels of both patient and referrer satisfaction. It is hypothesised that dismantling the barriers between physical and mental health may lead to similar successes in frequent attenders in other in-patient and community medical and psychiatric services.Declaration of interestNone.

An insight into living with diabetes.

Laura Lennard, Children's Diabetes Nurse, West Hertfordshire Hospitals NHS Trust, reflects on the challenges of encouraging behaviour change and the importance of understanding patients' real-life experiences.

Finding the jewels in adversity: reflections on a secondment.

Laura Lennard, on secondment as Children's Diabetes Nurse, Hemel Hempstead Hospital, West Hertfordshire Hospitals NHS Trust, shares what she has learned from the sometimes painful experience of stepping out of her comfort zone and learning the ropes in a new role.

HomeFirst – an integrated, community-based admission avoidance project: data from 1,370 patients referred to the service

HomeFirst (a multidisciplinary team integrating health and social care) was established in Hertsmere, West Hertfordshire in January 2013 with the aim of reducing hospital admissions by providing rapid response (RR) and virtual ward (VW) services in patients’ homes. Patients’ clinical data were collated and compiled into an electronic database. Details concerning referrals made between January 2013 and June 2014, including patient demographics, diagnosis and outcome, were extracted. …

Audit of thyroid surgery outcomes for benign thyroid disease at west Hertfordshire hospitals NHS trust 2010-2012

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

The impact of maternal age over forty years on the caesarean section rate: Six year experience at a busy District General Hospital

A retrospective study over a 6-year period was undertaken to determine the trend in age at booking for antenatal care at West Hertfordshire Hospitals NHS Trust and to investigate the relationship between maternal age at booking for antenatal care and mode of delivery. Between 2006 and 2011, there was an 80% increase in the number of women over the age of 40 years booking for antenatal care. The overall caesarean section rate in this cohort of women increased from 34.6% in 2006 to 53.7% in 2011, comprising of an increase in both elective and emergency caesarean sections. It appears that increasing maternal age may explain a significant proportion of the rising caesarean section rate in our unit.

Three care plans from one West London multidisciplinary group workshop.

This section of LJPC provides multidisciplinary insights into ways in which to explore the problems of patients, particularly those with long-term conditions. Each case presented must have had multidisciplinary discussions to arrive at a management plan. To retain patient anonymity the specific location of the case study must not be mentioned and details that might identify specific individuals should be altered. When submitting papers to this section your covering letter should explain which bits have been altered. Each case should be structured as follows: The Problem(s) as perceived by the clinician presenting the case;The Story-a brief summary of the history and context;Suggestions made by team members about ways to think about the problem(s);Action Points, including data to be gathered by the clinician to explore the approach to the problem; andA Review (where done)-of what happened. Authors are encouraged to complete this section at a later date including what they learned. The Editor for this section of LJPC is Dr Senan Devendra, Consultant Physician in Acute Medicine & Endocrinology, West Hertfordshire Hospitals NHS Trust. Email: ddevendra@nhs.net.