Urban street trees (USTs) have a range of values – some of which are easier to quantify than others. Focusing specifically on the UK context and using the Sheffield Tree Protests (2012–) as a case study, whilst confirming existing research as to the variety of values associated with their specifically ‘cultural’ services, the article argues that USTs have an additional potential form – what I call ‘civic-transformative value’. This form of value has at least three key characteristics. Firstly, it is place-based and communal; second, its form is ‘relational’; and finally, as intrinsically contingent, it is pluralistic in the sense that its civic-transformative potential is dependent on successfully integrating a range of other values. The article emphasises both the possibility and necessity of ‘convergence’ – that is, a pluralistic and pragmatic alliance of values which might help protect not only USTs, but other embattled sites of nature.

Introduction Robot-assisted thoracoscopic surgery (RATS) is an alternative to video-assessed thoracoscopic surgery (VATS) for the treatment of lung cancer but concern exists regarding the high associated costs. The COVID-19 pandemic added further financial pressure to healthcare systems. This study investigated the impact of the learning curve on the cost-effectiveness of RATS lung resection and the financial impact of the COVID-19 pandemic on a RATS program. Methods Patients undergoing RATS lung resection between January 2017 and December 2020 were prospectively followed. A matched cohort of VATS cases were analyzed in parallel. The first 100 and most recent 100 RATS cases performed at our institution were compared to assess the learning curve. Cases performed before and after March 2020 were compared to assess the impact of the COVID-19 pandemic. A comprehensive cost analysis of multiple theatre and postoperative data points was performed using Stata statistics package (v14.2). Results 365 RATS cases were included. Median cost per procedure was £7,167 and theatre cost accounted for 70%. Major contributing factors to overall cost were operative time and postoperative length of stay. Cost per case was £640 less after passing the learning curve (p < 0.001) largely due to reduced operative time. Comparison of a post-learning curve RATS subgroup matched to 101 VATS cases revealed no significant difference in theatre costs between the two techniques. Overall cost of RATS lung resections performed before and during the COVID-19 pandemic were not significantly different. However, theatre costs were significantly cheaper (£620/case; p < 0.001) and postoperative costs were significantly more expensive (£1,221/case; p = 0.018) during the pandemic. Discussion Passing the learning curve is associated with a significant reduction in the theatre costs associated with RATS lung resection and is comparable with the cost of VATS. This study may underestimate the true cost benefit of passing the learning curve due to the effect of the COVID-19 pandemic on theatre costs. The COVID-19 pandemic made RATS lung resection more expensive due to prolonged hospital stay and increased readmission rate. The present study offers some evidence that the initial increased costs associated with RATS lung resection may be gradually offset as a program progresses.

Freehand drawings are used frequently for ‘visual’ disciplines and have a range of benefits. Typically, for the social sciences, their utility is framed exclusively for enhancing active learning, but not necessarily as a teaching aid. Emphasising learning and teaching as a dialectical process between student and lecturer, a small-scale qualitative study explored the potential of a freehand drawing to help teach a complex primary text and assist students’ subsequent understanding. Students were taught the text in two ways – (1) verbal explanation accompanied by two static diagrams and (2) verbal explanation accompanied by a freehand drawing. Students discussed their experiences in a focus group. Despite mixed learning preferences, with interesting qualifications, students found the dynamic nature of the freehand drawing essential to understanding. Unintended variation in the delivery of each session produced insightful comment, as did the relationship between the lecturer’s learning preference and their choice of pedagogy.

The literature on policy mixes tends to focus on the instruments that different jurisdictions adopt to tackle public problems, and how policies may complement or conflict with each other. Fewer studies examine the factors that influence instrument choice, particularly within multilevel contexts, despite a recognition that policy mixes to tackle similar issues vary substantially across and within countries. We present a new framework to help understand and predict policy choice in subnational governance, arguing that the level of local support for action influences the type of policy a city adopts, whereas top-down drivers shape the breadth of instruments it deploys. Drawing on in-depth stakeholder interviews and documentary analysis, we apply this framework to explain why two contrasting English cities selected their own distinctive policy mixes to combat air pollution. We suggest that where top-down drivers for action are strong but bottom-up support is muted, as was the case in Nottingham, municipal governments are likely to adopt a broad range of largely (re)distributive, informational and administrative instruments to tackle policy problems. Where local support is strong, as in Westminster, city authorities prefer to introduce regulations, because restrictions entail fewer political costs in these contexts and are more likely to be effective.

OBJECTIVES:To demonstrate the safety and feasibility of advanced nurse practitioner-led (ANP-led) outpatient follow-up after discharge with ambulatory chest drains for prolonged air leak and excessive fluid drainage. METHODS:Patients discharged with ambulatory chest drains between January 2017 and December 2019 were retrospectively reviewed. Discharge criteria included air leak < 200 ml/min or fluid drainage > 100 ml/24 h on a digital drain. Patients were reviewed weekly in the clinic by ANPs, a highly skilled cohort of nurses with physician support available. Outcomes included length of stay, duration of air or fluid leak and complications. RESULTS:Two-hundred patients were included, amounting to 368 clinic episodes. The median age was 68 ± 13 years and 119 (60%) were male. 112 (56%) patients underwent anatomical lung resection (total anatomical lung resections during the study period = 917) equating to a discharge with ambulatory chest drain rate of 12.2% in this group. The median length of stay was 6 ± 3 days and 176 (88%) patients were discharged with air leak versus 24 (12%) with excessive fluid drainage. The median time to drain removal was 12 ± 11 days. Complications occurred in 16 patients (8%) and 12 (6%) required readmission. An estimated 2075 inpatient days were saved over the study period equating to an annual cost saving of £123,167 (US$149,032) per annum. CONCLUSIONS:Patients with air leak or excessive fluid drainage can safely be discharged with ambulatory chest drains, allowing them to return to their familiar home environment safely and quickly. ANP-led clinics are a robust and cost-effective follow-up strategy and are associated with a low complication rate.

Background Many central initiatives to improve digital maturity and interoperability in the NHS started after 2015. There are few prior assessments of digital maturity and interoperability. Methods Freedom of Information Act requests were sent to all English Acute NHS Trusts and Clinical Commissioning Groups (CCGs) to obtain information regarding digital maturity according to the Healthcare Information and Management Systems Society (HIMSS) Electronic Medical Record Adoption Mode (EMRAM) scale, and interoperability. Results One third of Acute NHS Trusts have an EMR that meets requirements for EMRAM stage 6 or above. 17.4% of responding Trusts considered this. 59.1% of responding Trusts stated that their EMR allows for functional interoperability with other (interoperable) EMRs. The majority of responding Trusts had not conferred with other Trusts when making EMR purchasing decisions. Discussion In order to realise the benefits of digitisation and interoperability, we discuss policy recommendations including actions for local health economies.

Objectives: To demonstrate the feasibility and preliminary outcomes of a novel hybrid technique combining percutaneous microwave ablation and wire-assisted wedge resection for patients with multiple pulmonary metastases using intraoperative imaging. Methods: We describe our technique and present a retrospective case series of 4 patients undergoing iCART at our institution between August 2018 and January 2020. Procedures were performed in a hybrid operating suite using the ARTIS Pheno cone beam computerized tomography scanner (Siemens Healthineers, Erlangen, German). Patient information included past history of malignancy as well as lesion size, depth, location, and histology result. Surgical complications and length of stay were also recorded. Results: Five procedures were performed on 4 patients during the study period. One patient underwent bilateral procedures 4 weeks apart. All patients underwent at least 1 ablation and 1 wedge resection during the combined procedure. Patient ages ranged from 40 to 66 years and the majority (75%) were men. All had a past history of cancer. Lesions were treated in every lobe. Size and depth ranged from 6 to 24 mm and 21 to 33 mm, respectively, for ablated nodules and 5 to 27 mm and 0 to 22 mm, respectively, for the wedge resected nodules. Three procedures were completed uniportal and operative time ranged from 51 to 210 minutes. All cases sustained <10 mL blood loss. There were 2 intraoperative pneumothorax, 1 prevented successful completion of the ablation. One patient required a prolonged period of postoperative physiotherapy and was discharged on day 6. The other patients were discharged on postoperative day 2 or 3. All 5 histology specimens confirmed metastatic disease. Conclusions: Our hybrid approach provides a minimally invasive and comprehensive personalized therapy for patients with multiple pulmonary metastases under a single general anesthetic. It provides histology-based diagnosis whilst minimizing lung tissue loss and eliminating the need for transfer from radiology to operating theatre. Emergence of ablation as a treatment for stage 1 non-small cell lung cancer and the expansion of lung cancer screening may widen the application of iCART in the future.

Abstract Background Paraspinal tumors are rare neoplasms arising from neurogenic elements of the posterior mediastinum and surgical resection can be challenging. Here, we demonstrate feasibility and outcomes from the first European case series of combined laminectomy and video‐assisted thoracoscopic surgery (VATS) resection of thoracic neurogenic dumbbell tumors. Methods A retrospective review of all combined thoracic dumbbell tumor resections performed at our institution between March 2015 to February 2019 was undertaken. Outcomes included operative time, blood loss, length of stay and recurrence rate. Statistical analysis was performed with SPSS statistics (v26). Values are given as mean ± standard deviation and median ± interquartile range. Results Seven patients were included in the case series and there were no major complications or mortality. Mean tumor size and operative time were 66 (± 35) mm and 171 (± 63) min, respectively. Median blood loss and length of stay were 40 (± 70) ml and four (± 3) days, respectively. One patient required conversion to thoracotomy to remove a tumor of 135 mm in maximal dimension. Histology in all seven cases confirmed schwannoma. There was no disease recurrence at a maximum follow‐up of 54 months. Conclusions Our experience demonstrates favorable operative times, minimal blood loss and short length of stay when dealing with relatively large tumors compared to previous reports. Thoracotomy may be required for tumors exceeding 90 mm and chest drain removal on the operative day can facilitate early mobility and discharge. We advocate a combined, minimally invasive laminectomy and VATS resection as the gold‐standard approach for thoracic neurogenic dumbbell tumors.

Joe Zhang , Harpreet Sood, Oliver Thomas Harrison, Ben Horner, Nikhil Sharma and Sanjay Budhdeo Intensive Care Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, St. Thomas’ Hospital, London SE1 7EH, UK University College London Hospital NHS Foundation Trust, London NW1 2BU, UK Telefonica Alpha Health, Torre Telefonica, Barcelona 08019, Spain Guy’s and St. Thomas’ NHS Foundation Trust, St. Thomas’ Hospital, London SE1 7EH, UK Healthcare, Boston Consulting Group, London W1U 3PZ, UK National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK Department for Neuromuscular Diseases, Queen Square Institute of Neurology, University College London, London WC1E 6BT, UK Corresponding author: Joe Zhang. Email: jzhang@nhs.net

Sternal osteomyelitis is a morbid and challenging condition, which can rarely occur after trauma, with no established consensus over best therapeutic options. In this case, a 47-year-old man with history of intravenous drug use presented 11 weeks after a minor blunt chest trauma with a severe necrotizing osteomyelitis involving sternum, muscles, fascia and subcutaneous tissue and positive blood cultures for Methicillin Sensitive Staphylococcus aureus. Alongside tailored antibiotic therapy, extensive surgical debridement was performed, leaving a full thickness 3 × 4 cm sternal defect and a large skin defect. After 4 weeks of antibiotics and Vacuum-Assisted-Closure pump, a novel reconstruction technique was utilized, with full collaborations of thoracic surgeons, orthopaedic surgeons and plastic surgeons. An autologous tricortical iliac crest bone graft was harvested and shaped to fit the full-thickness sternal defect, while two titanium sigmoid-shaped clavicle plates were used for internal fixation of the autograft. The large skin defect was covered with a pedicled myocutaneous latissimus dorsi flap. Integrity and stability of the chest wall was fully restored, and infection was completely eradicated. No complications occurred and the patient was well at the 18 months follow-up. To the best of our knowledge, this is the first report on autologous iliac crest bone graft in the treatment of sternal osteomyelitis. In this case, it proved to be a viable therapeutic option, providing good long-term clinical and cosmetic results.

Benign tracheal tumours have an incidence of 1 in 1,000,000, of which leiomyomas represent only 1%. We report a case of tracheal leiomyoma masquerading as asthma for over 20 years. A 48-year-old man presented aged 26 years with asthma symptoms unresponsive to treatments and an obstructive spirometry pattern. Symptoms were not particularly troubling but suddenly exacerbated 22 years later. Flow-volume studies were consistent with upper airway obstruction. Computed tomography chest revealed a 2.3 cm mass arising from the posterior aspect of the trachea 2 cm above the carina. Bronchoscopic resection was performed using a Nd:YAG laser. Histology confirmed leiomyoma. Follow-up after 6 weeks revealed complete resolution of symptoms with normal spirometry. Tracheal masses should be considered in any patient with atypical asthma. A flow-volume loop may provide a clue to diagnosis and bronchoscopic laser resection is a minimally invasive treatment option.

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac abnormality affecting 1–2% of the population and is associated with a significantly increased risk of ascending aortic aneurysm. However, predicting which patients will develop aneurysms remains a challenge. This pilot study aimed to identify candidate plasma biomarkers for monitoring ascending aortic diameter and predicting risk of future aneurysm in BAV patients.

This article rethinks John Holloway's emancipatory theory by "opening" his key concept of "dignity." It argues that, while Holloway's use of this concept works well for emphasising the uniqueness of human beings' ability to both resist and challenge capitalist social relations, due to its underlying Kantian heritage, it is both excessively restrictive and limits the extent to which he can unlock the full potential of his theory, particularly when considering the development of new ecological sensibilities. To this end, the article explores the possibility of supplanting the concept of dignity with that of "Self-realisation." While not entirely unproblematic, this concept not only reinforces the uniqueness Holloway associates with human agency but also helps unravel a more substantive virtue-orientated approach consistent with his thought.

This article provides a critical examination of Michael Hardt and Antonio Negri's and John Holloway's theory of revolutionary subjectivity, and does so by applying their theories to the Occupy movement of 2011. Its central argument is that one should avoid collapsing 'autonomist' and 'open' Marxism, for whilst both approaches share Tronti's insistence on the constituent role of class struggle, and also share an emphasis on a prefigurative politics that engages a non-hierarchical and highly participatory politics, there nevertheless remain some significant differences between their approaches. Ultimately, when applied to the Occupy movement, whilst their theory isn't entirely unproblematic, I will argue that Hardt and Negri's 'autonomist' approach offers the stronger interpretation, due mainly to their revised historical materialism.

Background: The global burden of disease is increasingly dominated by non-communicable diseases.These diseases are less amenable to curative and preventative interventions than communicable disease. This presents a challenge to medical practice and medical research, both of which are experiencing diminishing returns from increasing investment. Objective: Our aim was to (1) review how medical knowledge is generated, and its limitations, (2) assess the potential for emerging technologies and ideas to improve medical research, and (3) suggest solutions and recommendations to increase medical research efficiency on non-communicable diseases. Methods: We undertook an unsystematic review of peer-reviewed literature and technology websites. Results: Our review generated the following conclusions and recommendations. (1) Medical knowledge continues to be generated in a reductionist paradigm. This oversimplifies our models of disease, rendering them ineffective to sufficiently understand the complex nature of non-communicable diseases. (2) Some of these failings may be overcome by adopting a "Systems Medicine" paradigm, where the human body is modeled as a complex adaptive system. That is, a system with multiple components and levels interacting in complex ways, wherein disease emerges from slow changes to the system set-up. Pursuing systems medicine research will require larger datasets. (3) Increased data sharing between researchers, patients, and clinicians could provide this unmet need for data. The recent emergence of electronic health care records (EHR) could potentially facilitate this in real-time and at a global level. (4) Efforts should continue to aggregate anonymous EHR data into large interoperable data silos and release this to researchers. However, international collaboration, data linkage, and obtaining additional information from patients will remain challenging. (5) Efforts should also continue towards "Medicine 2.0". Patients should be given access to their personal EHR data. Subsequently, online communities can give researchers the opportunity to ask patients for direct access to the patient's EHR data and request additional study-specific information. However, selection bias towards patients who use Web 2.0 technology may be difficult to overcome. Conclusions: Systems medicine, when combined with large-scale data sharing, has the potential to raise our understanding of non-communicable diseases, foster personalized medicine, and make substantial progress towards halting, curing, and preventing non-communicable diseases. Large-scale data amalgamation remains a core challenge and needs to be supported. A synthesis of "Medicine 2.0" and "Systems Science" concepts into "Systems Medicine 2.0" could take decades to materialize but holds much promise.

Measuring appropriate outcomes is at the core of patient-centred medicine. With an ever-increasing number of clinical trials being published, the heterogeneity of outcome measures used in different trials makes direct comparisons difficult. Despite this, clinical effectiveness research is increasingly influential in making decisions about which treatments are best for patients. A recent judgment has strengthened the importance of commissioners in the UK National Health Service (NHS) of recommendations made by the National Institute of Health and Clinical Excellence (NICE), which are based on outcomes research.1 In the USA, The Patient Protection and Affordable Care Act created the Patient-Centered Outcomes Research Institute, to further assess options for prevention, diagnosis and treatment of disease.

Background and Objectives: Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. Methods: Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days). Results: Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] = 2.02; 95% confidence interval [CI], 1.05–3.90; P = .027), and blood loss of >500 mL (OR = 3.114; 95% CI, 1.501–6.462, P = .002). Conclusions: Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ∼2.5 hours and 5-hour duration.