Ormskirk District General Hospital

Societal Impact StatementThe United Kingdom produces less than 20% of its fruit and ~50% of its vegetables, leaving it highly import dependent and vulnerable to supply chain disruptions. Our study maps 2085 ha of existing greenhouses, with over 70% being more than 40 years old, and identifies where modern infrastructure could expand production. Achieving 50% self‐sufficiency in greenhouse‐grown food by 2050 would require a fourfold increase and £14.1 billion investment, with a 3–7‐year return via import savings. Expansion would secure year‐round supply, reduce waste and create a resilient, climate‐ready food system. The evidence is clear: Strategic investment in greenhouses is essential for UK food security.Summary Greenhouses offer stable, year‐round fruit and vegetable production using minimal land. However, the United Kingdom currently produces less than 20% of its fruit and only ~50% of its vegetables, leaving it highly import dependent. This study maps the current distribution of greenhouses in the United Kingdom and estimates the spatial and economic requirements for reducing reliance on imports through the expansion of modern infrastructure. Spatial suitability modelling and economic analysis were combined to assess land availability, capital investment needs and return potential for scaling domestic greenhouse production. Of the 2085 ha of greenhouse space in Britain, over 70% is more than 40 years old. Achieving 100% self‐sufficiency in greenhouse‐grown fruit and vegetables would require 18,766 ha of modern infrastructure, a ninefold increase, costing around £26.6 billion. Meeting 50% self‐sufficiency would require a fourfold increase and £14.1 billion, with an estimated 3–7‐year return on investment via import savings. The south and east of England are most suitable for expansion, though production is viable UK‐wide with energy innovations and business co‐location. To improve food system resilience, greenhouses must be recognised as essential infrastructure. Achieving 50% self‐sufficiency in greenhouse‐grown food by 2050 is both attainable and strategically important. Without coordinated investment, the United Kingdom risks continued import dependence, food waste, and a fragile supply chain.

Abstract Methods This was a retrospective review of a prospectively collected and maintained data on elective TEP hernia repairs. All theatre list has been collected prospectively. All patient who had inguinal hernia repair between 2004 and 2021 has been identified from the list. The notes of all Patients who had laparoscopic hernia repair were reviewed including the operative notes, postoperative complications, and any subsequent referral to the surgical department at the Trust to see any recurrence. The data collections included age, sex, type of the mesh, fixing device, primary or recurrent, unilateral or bilateral and conversion to open procedure. Since 2014 all notes were electronic and restored on evolve application. Result All patients records were retrieved from the electronic database system. Out of this cohort, some of patients records were missing. The mesh was not fixed in primary hernia if it was small or medium size, but it was fixed in primary large direct hernia to reduce the risk of blowing in of the mesh inside the defect. Our results showed a recurrence rate with acceptable incidence of post operative pain and wound related complications compliant with the NICE guidance. Conclusion A TEP repair for both primary and recurrent inguinal hernia has a minimal recurrence rate when performed by the specialists in this area giving full attention to the details.

This correction does not affect the following equations reported in the paper, which are correct. The authors would like to thank Garnett P. McMillan for identifying the error and letting the authors know.

Chronic irritation caused by urinary catheter may predispose to metaplastic changes in the bladder and very rarely, nephrogenic metaplasia. A 53-year-old lady with T-2 paraplegia and urethral catheter drainage for 27 years presented with haematuria. MRI of pelvis, performed seven years ago, showed a 10 cm intramural fibroid within the anterior aspect of the uterine body which was pushing the collapsed urinary bladder containing the Foley catheter to the left. The patient decided to avoid surgery to remove the fibroid at that time. Ultrasound scan of the urinary bladder done now, revealed a polypoidal lesion in the left superolateral wall. Superficial enhancing lesion with no invasion of the bladder wall was seen in the CT urography. Cystoscopy showed extensive catheter reaction, and in the centre, a slightly more papillary area, which was resected. Histology revealed inflamed bladder mucosa showing tubular and papillary structures lined by cuboidal epithelial cells; the features were of nephrogenic metaplasia. The tubular and papillary structures were lined by cells showing positive immunohistochemical staining for CK7 and PAX8. Catheter reaction and nephrogenic metaplasia was found in the left superolateral wall of the bladder where the large uterine fibroid was pushing the balloon of the catheter against the bladder wall for more than seven years. The patient decided to undergo surgery to remove the large fibroid and thereby prevent further pressure effects upon the urinary bladder.

There are currently limited trials comparing the efficacy and safety of different glucocorticoid replacement regimens for treating 21-hydroxylase deficiency CAH in children and adults and we were unable to draw any firm conclusions based on the evidence that was presented in the included trials. No trials included long-term outcomes such as quality of life, prevention of adrenal crisis, presence of osteopenia, presence of testicular or ovarian adrenal rest tumours, subfertility and final adult height. There were no trials examining a modified-release formulation of HC or use of 24-hour circadian continuous subcutaneous infusion of hydrocortisone. As a consequence, uncertainty remains about the most effective form of glucocorticoid replacement therapy in CAH for children and adults. Future trials should include both children and adults with CAH. A longer duration of follow-up is required to monitor biochemical and clinical outcomes.

IntroductionSuccessful health care organisations have understood the need to engage with clinicians, with a resulting desire for clinical leaders to emerge and be trained.Sustainability and transformation plans (STPs)The development of sustainability and transformation plans has highlighted the need for clinical leaders to be engaged at every level of each regional plan. The plans are based around a geographical area rather than being focussed on pre-existing organisations, so-called place-based plans. Health care place-based plans need place-based clincal leaders.Examples of clincial place-based leadershipClinical leaders have existed across boundaries before STPs were developed, for example in Canterbury District Health Board in New Zealand or closer to home in Wales.ConclusionWe discuss the benefits that removing organisation boundaries could have on clinical care, believing that as patients cross organisational boundaries so should their health care and so should clinical leaders.

Encourage older women to attend balance training Falls are a major problem for older people because they are so common and can result in injury and loss of quality of life. Age associated decline in muscle strength and the nervous system can lead to a sense of unsteady walking. In turn, this can lead to a loss of confidence in moving and, for some people, serious falls. We have known for some time that strength and balance training is effective in preventing falls and improving mobility and confidence.1 Most studies have lasted a maximum of a year period, and programmes require investment of time and effort from older people.1 This is not always a popular option.2 The linked article by El-Khoury and colleagues (doi:10.1136/bmj.h3830) provides important advances and reassurance and should help older people decide whether investment in exercise is worth it and what type of exercise to invest in.3 The logic of improving balance and unsteadiness to reduce falls is borne out once again in this well conducted trial including women from a broad geographical area of France. As not …

Aims Adequate sick day management at home may reduce the risk of progression to diabetic ketoacidosis (DKA) and admission to hospital. The UK does not have a consensus guideline for sick day management advice to children and young people with Type 1 Diabetes. Children’s diabetes services vary in their practice of education and advice in the use of urine or blood ketone monitoring during illness. The aim of this project was to look at the variation of management of diabetes during illness.<br/><br/>Methods A survey was conducted by the Association of Children’s Diabetes Clinicians (ACDC) who sent out questionnaires to all units managing children and young people with Type 1 Diabetes including: local sick day management rules, out of hours diabetes support for families and information about the local diabetes service.<br/><br/>Results Table 1 90/127 (71%) of the units responded to the survey. There were 13 tertiary centres. Median number of children per service was 165 (range 73–450). The majority of units (96%) have a sick day management guideline in place.<br/><br/>Conclusion There was a wide variation in the practice of monitoring and advice given during illness. All guidelines advised increased doses of insulin during sick days but there was no consensus on how to calculate increased doses. There were also variations in the use of ketone testing and frequency on blood glucose monitoring. Some units still use urine ketone testing routinely. There is a need for evidence based National guidance to be in place.

Eosinophilic gastroenteritis is a heterogeneous and curable disease of the gastrointestinal tract. The diagnosis is rare, with an approximate incidence of 1/100 000. The pathophysiology is based on infiltration of the eosinophils involving various parts of gastrointestinal system, but also different layers of the wall. The authors present a case of the eosinophilic gastroenteritis, which is characterised by the predominant subserosal type associated with asthma, ascites and bilateral pleural effusion. In patients with asthma and abdominal symptomatology, eosinophilic gastroenteritis should be considered as a possible diagnosis. These two atopic conditions may occur more frequently than generally expected, especially in the presence of protein-losing gastroenteropathy.▶ Consider a diagnosis of eosinophilic gastroenteritis in patients with atopy and gastrointestinal symptoms.▶ Histological demonstration of the gastrointestinal tract and/or ascites.▶ Exclude other causes of eosinophilia such as parasites, Churg-Strauss syndrome, hypereosinophilic syndrome.