Time to go home.

Is heroism possible for everyone? Should it be? What kinds of stories do we tell when we talk about heroes and what do these stories reveal about how we view ourselves? This book takes up these questions and more by reflecting on twenty-first century American television shows. Among the shows examined are Only Murders in the Building, Game of Thrones, The Good Lord Bird, The Boys, and Severance. What we find is an entertainment landscape unsure about what a hero is or even what qualifies as heroic. In a nation uncertain about heroism, we see a dramatic rise in the popularity of the anti-hero and even in worlds without heroes. This fragmented variety highlights how the American political mind is similarly fragmented in what it believes are its highest aspirations—and its deepest anxieties. It is this fragmentation that may help us understand why twenty-first century entertainment has elevated the heroic to the supernatural while simultaneously democratizing heroism to the point where anyone may become one. A Hero in All of Us?: Heroism and American Political Thought as Seen on TV explores this multifaceted landscape to better understand how Americans view their heroes and themselves.

In 2013, the "MS in the 21st Century" (MS21) initiative established a consensus statement for multiple sclerosis (MS) standards of care, with an overall vision including "Full access to personalised treatment, with reimbursement, to achieve freedom from disease." This update considers progress made since 2013 and priority areas for further improvement. A Delphi process with two rounds of anonymised voting was used to develop updated consensus statements based on three key themes: (1) optimising current MS care provision; (2) facilitating shared decision-making and patient education; and (3) continuing MS research and development. Voting panels (n=30), including people living with MS (PwMS), MS patient advocacy group (PAG) representatives and healthcare professionals (HCPs) indicated agreement using a sliding scale [1 (strongly disagree) to 5 (strongly agree)] and free-text feedback. Statements were revised after each voting round, with the consensus threshold set a priori as≥75% agreement. There was a 70% response rate at each round of voting, with respondents representing 13 countries. Seven original principles were expanded to 14, with emerging themes including unmet care needs in ageing PwMS, MS prevention, and treatments for progressive MS and remyelination. The top priority for both HCPs and PwMS/PAG representatives was "access to quick and decisive treatment after diagnosis." For PwMS to be unburdened by symptoms, professionals and stakeholders within the MS community should work together to meet the updated MS21 vision, including access to appropriate care, greater PwMS involvement in decisions, and further research and development to address unmet needs in MS.

Improving Patient Outcomes by Standardizing Care

Current concepts in gender affirmation surgery

Cardiac surgery developed rapidly in the seventies and eighties of the last century, followed by a period of stabilisation and finally a numerical decline in 21st century. Coronary bypass surgery has been largely supplanted by percutaneous interventions, arrhythmia surgery has been replaced by percutaneous ablation and implantable defibrillators, correction of simpler congenital anomalies is also accomplished by catheter techniques, and we are now observing the emergence of transcatheter aortic valve replacement, which is rapidly overtaking surgical valve repair. On the horizon are mitral and tricuspid repairs; even some short-term circulatory assistance devices are being employed by transcutaneous approach. This development has important consequences for cardiosurgical training: minimally invasive procedures are becoming standard of care, catheter training in a heart laboratory (“wire skills”) is becoming essential, education in interpretation of advanced imagining techniques: magnetic resonance imaging, angio- and multislice computed tomography, and 2D and 3D echo must be introduced, and surgeons must be also trained in endoscopic and robotic surgery for advanced minimally invasive interventions.

The practice of medicine does not occur in a vacuum. We work within a culture and a society, and we owe it to the society that our services are of a standard that will ensure their use by patients and one in which carers will have confidence in our abilities to look after their loved ones. Society expects certain standards of care and skills from its clinicians and as in any contract we, in turn, expect things from society. However, as such a contract is not specifically written down but is instead a virtual and an implicit one, some factors become crucial in understanding the relationship between society and the psychiatrist. Here, I propose to highlight some of the components of such a contract and how we renew this in the 21st century.

Inpatient Care in the 21st Century: Who Needs It?

Esophageal atresia is fundamentally important in pediatric surgery, as its treatment results create an accurate portrait of the standards of surgical care, which is provided by any medical institution. Cameron Haight performed the first successful reconstruction of the esophagus malformation relatively recently just over 70 years ago. Advances in neonatal surgery, technology and advances in neonatal intensive care have dramatically improved treatment outcomes for this disease. Current mortality from this developmental abnormality has become minimal, despite its frequent association with other malformations. A revolutionary approach to the treatment of esophageal atresia was developed by Steven Rothenberg in 1999, the pioneer and legend of pediatric minimally invasive surgery. In 1999, he revolutionized esophageal anastomosis by thoracoscopy. The innovative concept of the minimally invasive approach ensured minimal trauma to patients, thereby providing the possibility of rapid postoperative recovery of patients and reducing the length of their surgical hospital stay. This literature review raises the main controversy in the surgical treatment of esophageal atresia in the 21st century. Emphasis is placed on the study of the role of minimally invasive surgery and the treatment of concomitant abnormalities associated with gastroesophageal reflux and tracheomalacia. As part of the study, a description of all the latest technologies, advances in technical and scientific terms, solutions, exceptional experience, and competence in developing and implementing minimally invasive operations in young children. These developments changed the direction of pediatric surgery and improved the quality of surgical care for children with congenital malformation of the esophagus and how they were performed.

The diagnosis of TB depends on a collation of clinical history, examination, radiology, general investigations, and microbiology. Consequently, the differential diagnosis of TB is huge. However, a systematic approach to clinical diagnosis will avoid mistakes. As the incidence of TB falls, more effort is required to keep the possibility of TB in mind. Confirmation bias can lead to prioritising more common diagnoses, such as COPD, pneumonia, and lung cancer, despite clinical information suggesting TB. Persistence with a failing treatment is often the first step to misdiagnosis, reassessment of the diagnostic possibilities is an important safety measure. In high-risk populations or in high incidence areas, there is a tendency to trial TB treatment without ensuring adequate investigations beforehand. A retrospective audit of TB notifications can assist in recognising your local pattern of disease. The successful management of TB is a measure of the general quality of standard clinical care. <bold>Cite as:</bold> Bothamley GH, Adeoye G, Heyckendorf J, <italic>et al.</italic> The differential diagnosis of thoracic tuberculosis: a guide to under- and over-diagnosis. <italic>In:</italic> García-Basteiro AL, Öner Eyüboğlu F, Rangaka MX, eds. The Challenge of Tuberculosis in the 21st Century (ERS Monograph). Sheffield, European Respiratory Society, 2023; pp. 90–103 [<ext-link>https://doi.org/10.1183/2312508X.10024422</ext-link>].

Introduction Advancing technology has led to the opening of new channels for communication and access to information. Accordingly healthcare must keep pace with our increasing desire for choice in how we receive, interact and learn if we are to continue to strive for higher standards of care. In 2008, our group launched the first interactive DVD for patients with colorectal cancer, which described the diagnosis, treatment and follow-up of patients at our unit. This project won several awards within the UK for innovation and has led to the creation of a series of four titles which have played an important role in patient counselling/staff education within our centre. Following the feedback from this series, we were inspired to find avenues to widen the availability of these resources worldwide. This has led to the series being digitally enhanced and adapted as four interactive iOS apps currently available for worldwide download on tablet platform. Method The online applications designed as part of this initiative are: - 1. Patient Journey – the diagnosis, treatment and follow-up when diagnosed with a bowel tumour’: An educational app designed to inform, demystify and prepare patients and carers with bowel cancer for the journey ahead. 2. ‘Enhanced Recovery after Surgery (ERAS) for major bowel surgery’: An app designed to explain the concepts and benefits of ERAS to patients prior to major bowel surgery. 3. ‘Colorectal’: An educational app designed to give exposure to students/junior trainees regarding the anatomical/surgical principles of common colorectal procedures. 4. ‘Stepwise Approach for Laparoscopic Colorectal Surgery’: An interactive app to assist colorectal consultants/trainee surgeons who wish to gain proficiency in laparoscopic colorectal surgery Results Since our product launch in July 2014, there have been more than 5000 downloads worldwide. Downloads were noted across all world regions with 58% in the Asia-Pacific region, 26% in Europe and 12% in the USA and Canada. These applications are unique in that they contain extensive footage of real-life events coupled with surgical technique. This level of realism in the digital medium means the viewer can have many questions answered before their next consultation, resulting in a better informed patient ready for surgery. Conclusion These applications exemplify how utilising technology can advance practice and improve patient experience by providing an interactive format where patients can explore and understand their condition. Our vision is that this model can be used/adapted for widespread use to supplement current methods of patient/staff education, bringing the way we communicate, counsel and train into the 21 st century. Disclosure of interest None Declared.

Much has been written about the development of emergency medicine (EM) and its impact on the medical system as a whole. It is still described as ‘new’ and very much seen as a specialty that is evolving, rather than a static domain of knowledge and skills with rigid boundaries. In reality, the fundamentals of emergency treatment in mitigating the effects of acute illness and injury go back to ancient times. This is evidenced by descriptions of the urgent management of acute pain with analgesics, splinting of injured limbs, and more sophisticated procedures, such as the removal of kidney stones and craniotomies. The treatments at that time were limited, but the application of these skills brought relief to many people (and a little pain). The practitioners were generalists and did not limit themselves to emergency treatment alone. Over the past half-century, there has been an acceleration of development in emergency medical treatments and a massive explosion in emergency medical system enhancement. This has resulted in a unique body of knowledge and skills, with the evolution of a new medical specialty specific to the delivery of emergency medical care. It is worth reflecting on the drivers for EM specialisation, where the specialty has come from, and what we can expect as the complexity of medical care increases with technological innovation and social changes associated with increasing connectivity.

The Gynecologic Oncology Group (GOG) Report

Needs assessment in continuing medical education has traditionally relied on extensive quantitative surveys of prospective participants. Program planning has thus been associated with and responsive to the felt needs of audiences. Adult educators, however, have begun to look beyond felt needs in attempting to provide quality education correlated to standards of care. Described herein is a research and planning process used to explore course directors' sentiments regarding continuing medical education (CME) needs. The process employed qualitative inquiry data collection techniques, a combination of interviews, rated scaled survey items, and focus group dialogues. The inquiry centered on a large metropolitan health center concerned with community building and institutional survival in the 21st century. Some insights for other planners regarding the advantages of action-reflection practitioner inquiry are offered; the process, outcomes, and follow-up activities that involved physicians and CME leadership in joint discourse for planning are described.

The administration of postexposure prophylaxis has become the standard of care for occupational exposures to HIV. We have learned a great deal about the safety and potential efficacy of these agents, as well as the optimal management of health-care workers occupationally exposed to HIV. This article describes the current state of knowledge in this field, identifies substantive questions to be answered, and summarizes basic principles of postexposure management.

Although the common marmoset (Callithrix jacchus) has been maintained in captivity in biomedical research settings for decades, interest and use of the species as an animal model for a diverse array of purposes has increased in the 21st century. Unfortunately, the development of validated animal care standards such as nutrition, husbandry, and clinical care has not expanded with the same rapidity as the use of the species in research. The goal of this themed issue of the ILAR Journal is to review current literature relevant to topics that impact marmoset health, welfare, and use in research. As the population of captive marmosets increases worldwide, the editors urge scientists, veterinary clinicians, and colony managers to continue conducting and publishing robust studies to develop evidence-based standards related to marmoset care and use. The editors also encourage IACUCs and other institutional review bodies to seek training on topics relevant to marmoset welfare and develop related policies prior to acquiring animals as a novel species.