Search

Uncovering the mechanisms behind animal space use patterns is of vital importance for predictive ecology, thus conservation and management of ecosystems. Movement is a core driver of those patterns so understanding how movement mechanisms give rise to space use patterns has become an increasingly active area of research. This study focuses on a particular strand of research in this area, based around step selection analysis (SSA). SSA is a popular way of inferring drivers of movement decisions, but, perhaps less well appreciated, it also parametrises a model of animal movement. Of key interest is that this model can be propagated forwards in time to predict the space use patterns over broader spatial and temporal scales than those that pertain to the proximate movement decisions of animals. Here, we provide a guide for understanding and using the various existing techniques for scaling up step selection models to predict broad-scale space use patterns. We give practical guidance on when to use which technique, as well as specific examples together with code in R and Python. By pulling together various disparate techniques into one place, and providing code and instructions in simple examples, we hope to highlight the importance of these techniques and make them accessible to a wider range of ecologists, ultimately helping expand the usefulness of SSA.

BACKGROUND AND AIMS: Digital single-operator cholangioscopy (d-SOC) with cholangioscopic biopsy sampling has shown promise in the evaluation of indeterminate biliary strictures. Some studies have suggested higher sensitivity for visual impression compared with biopsy sampling, although assessors were not blinded to previous investigations. We aimed to investigate the diagnostic accuracy and interobserver agreement (IOA) of d-SOC in the visual appraisal of biliary strictures when blinded to additional information. METHODS: A multicenter, international cohort study was performed. Cholangioscopic videos in patients with a known final diagnosis were systematically scored. Pseudonymized videos were reviewed by 19 experts in 2 steps: blinded for patient history and investigations and unblinded. RESULTS: Forty-four high-quality videos were reviewed of 19 benign and 25 malignant strictures. The sensitivity and specificity for the diagnosis of malignancy was 74.2% and 46.9% (blinded) and 72.7% and 62.5% (unblinded). Cholangioscopic certainty of a malignant diagnosis led to overdiagnosis (sensitivity, 90.6%; specificity, 33%), especially if no additional information was provided. The IOA for the presence of malignancy was fair for both assessments (Fleiss' κ = .245 [blinded] and κ = .321 [unblended]). For individual visual features, the IOA ranged from slight to moderate for both assessments (κ = .059-.400 vs κ = .031-.452). CONCLUSIONS: This study showed low sensitivity and specificity for blinded and unblinded d-SOC video appraisal of indeterminate biliary strictures, with considerable interobserver variation. Although reaching a consensus on the optical features of biliary strictures remains important, optimizing visually directed biopsy sampling may be the most important role of cholangioscopy in biliary stricture assessment. ispartof: GASTROINTESTINAL ENDOSCOPY vol:94 issue:6 pages:1059-1068 ispartof: location:United States status: published

Background COVID-19 pandemic is an unprecedented global medical emergency. National and international gastrointestinal societies recommended that any endoscopic activity during the lockdown phase of the pandemic should be limited to emergency or non-deferrable procedures only. We assessed the financial implications and impact on endoscopy activity of the lockdown phase in a tertiary referral endoscopy unit. Methods The number of endoscopy procedures canceled and performed in our endoscopy unit during our "delay phase" (16-22/03/2020) and "lockdown phase" (23/03-29/05/2020) was reviewed and compared with endoscopy activity conducted during the same period in 2019. The financial impact was subsequently analyzed. Results Between 16/03/2020 and 29/05/2020, 683 procedures were canceled and 365 non-deferrable procedures were performed. In contrast, in 2019, 3437 procedures were performed over the same timeframe, resulting in a revenue contraction of approximately €2,062,857. We estimated that the number of lists required to recuperate the canceled endoscopic activity, ranges from 103-155, depending on the level of personal protective equipment required and mitigating policy relating to COVID-19. Conclusion Our results highlight that COVID-19 pandemic had a substantial negative impact on our endoscopy activity and on the revenue generated by our endoscopy unit.

There is much controversy regarding enhanced recovery for recipients of liver transplants from deceased and living donors. The objectives of this Review were to summarise current knowledge on individual enhanced recovery elements on short-term outcomes, identify key components for comprehensive pathways, and create internationally accepted guidelines on enhanced recovery for liver-transplant recipients. The ERAS4OLT.org collaborative partnered by the International Liver Transplantation Society performed systematic literature reviews on the effect of 32 relevant enhanced perioperative recovery elements on short-term outcomes, and global specialists prepared expert statements on deceased and living donor liver transplantation. The Grading Recommendations, Assessment, Development and Evaluations approach was used for rating of quality of evidence and grading of recommendations. A virtual international consensus conference was held in January, 2022, in which results were presented, voted on by the audience, and discussed by an independent international jury of eight members, applying the Danish model of consensus. 273 liver transplantation specialists from 30 countries prepared expert statements on elements of enhanced recovery for liver transplantation based on the systematic literature reviews. The consensus conference yielded 80 final recommendations, covering aspects of enhanced recovery for preoperative assessment and optimisation, intraoperative surgical and anaesthetic conduct, and postoperative management for the recipients of liver transplants from both deceased and living donors, and for the living donor. The recommendations represent a comprehensive overview of the relevant elements and areas of enhanced recovery for liver transplantation. These internationally established guidelines could direct the development of enhanced recovery programmes worldwide, allowing adjustments according to local resources and practices.

A 58-year-old female presented with a right axillary mass, which was confirmed as Stage IB BRAF-mutant melanoma based on the histology of the resected mass. The patient’s history included a left upper arm melanoma that was resected in 2012; an allograft renal transplant secondary to polycystic kidney disease from a deceased donor, which they had undergone in 2009; and immunosuppressive therapy, which they had been on since the transplant took place. The patient relapsed 8 months after axillary clearance. Dual immunotherapy is the first-line treatment for BRAF-mutant melanoma, but it has been associated with high rates of solid organ graft rejection in systematic reviews. For this reason, targeted therapy with dabrafenib and trametinib was commenced in the first instance, which halted disease progression for 10 months. On progression, dual immunotherapy was again discussed, and the patient fully consented regarding risks of graft loss. They had an excellent treatment response, and their renal graft remains functional.

We acknowledge funding from Mitacs Canada, the Canadian Association of Zoos and Aquariums, Canadian Wildlife Federation, Environment and Climate Change Canada, Hauser Bears, Natural Sciences and Engineering Research Council of Canada, Polar Bears International, Polar Continental Shelf Project, Quark Expeditions, United States Department of the Interior (Bureau of Ocean Energy Management), and World Wildlife Fund Canada. 1. The energetic gains from foraging and costs of movement are expected to be key drivers of animal decision-making, as their balance is a large determinant of body condition and survival. This fundamental perspective is often missing from habitat selection studies, which mainly describe correlations between space use and environmental features, rather than the mechanisms behind these correlations. 2. To address this gap, we present a novel parameterisation of step selection functions (SSFs), that we term the energy selection function (ESF). In this model, the likelihood of an animal selecting a movement step depends directly on the corresponding energetic gains and costs, and we can therefore assess how moving animals choose habitat based on energetic considerations. 3. The ESF retains the mathematical convenience and practicality of other SSFs and can be quickly fitted using standard software. In this article, we outline a workflow, from data gathering to statistical analysis, and use a case study of polar bears Ursus maritimus to demonstrate application of the model. 4. We explain how defining gains and costs at the scale of the movement step allows us to include information about resource distribution, landscape resistance and movement patterns. We further demonstrate this process with a case study of polar bears and show how the parameters can be interpreted in terms of selection for energetic gains and against energetic costs. 5. The ESF is a flexible framework that combines the energetic consequences of both movement and resource selection, thus incorporating a key mechanism into habitat selection analysis. Further, because it is based on familiar habitat selection models, the ESF is widely applicable to any study system where energetic gains and costs can be derived, and has immense potential for methodological extensions. Postprint

Changes in UK government coastal and flooding policies in the last twenty-five years, have resulted in a reappraisal of all coastal defence schemes with a focus on a strategic analysis to ensure that all schemes provided the greatest net benefit. This strategy and the emphasis on adaptive management, particularly in the second wave of shoreline management plans (SMPs), provoked a reaction from local communities who felt their voice was largely being ignored as they became aware of SMP policies that increased their perceived risks but did not offer appropriate compensation. The formation of Coastal Action Groups (CAGs), has been a key community response and enabled diverse communities to feel that they can collectively participate in the ongoing planning process. Using a combination of questionnaire surveys and semi-structured interviews, this paper analyses the nature and effectiveness of CAGs. Although initially formed as opposition groups, the shared ideology of CAG members has resulted in the character of these groups evolving to units that embrace a broader range of social justice issues. It is argued that well led, well-supported, well-resourced and tactically astute CAGs have tended to be the most effective pressure groups. In reality however, CAGs have had relatively limited effects in changing the decisions of local SMPs, but have had great impacts in challenging the concept of meaningful public engagement in the coastal planning process, ultimately leading to more participatory approaches.

Hemorrhagic cholecystitis is a potentially deadly and difficult to recognize entity. It is associated with cystic artery pseudoaneurysm and is usually seen in the setting of acute calculous cholecystitis. We report two cases of hemorrhagic cholecystitis with arteriographic findings of cystic artery pseudoaneurysms that were successfully embolized using microcoils, facilitating subsequent cholecystectomy. Both cases had unusual presentations of gallbladder rupture with hemoperitoneum, the latter of which was atypical occurring in the absence of gallstones. We believe when hemorrhagic cholecystitis is suspected, a two-step therapeutic approach should be employed with embolization of the bleeding cystic artery followed by cholecystectomy. A comprehensive literature review and discussion of hemorrhagic cholecystitis will be provided.

Energetics are a key driver of animal decision-making, as survival depends on the balance between foraging benefits and movement costs. This fundamental perspective is often missing from habitat selection studies, which mainly describe simple correlations between space use and environmental features. To address this gap, we present a new model, the energy selection function (ESF), to assess how moving animals choose habitat based on energetic considerations, thus incorporating a key aspect of evolutionary behaviour into habitat selection analysis. We outline a workflow, from data-gathering to statistical analysis, and demonstrate the model’s utility with a case study of polar bears. Our findings show how cost-minimization may arise in species that inhabit environments with an unpredictable distribution of energetic gains. Because of its close links to existing habitat selection models, the ESF is widely applicable to any study system where energetics can be derived, and has immense potential for methodological extensions.

Development of tools and methods to aid in the research of fixed-wing Unmanned Aerial Vehicles (UAVs) is presented. A Remote-Controlled (RC) model aircraft is used as the target airframe. The flight simulator X-Plane 10 is used for the grey-box modelling and MATLAB/Simulink is used for the white-box modelling. XFLR5 is utilised to obtain crucial aerodynamic data. The process of constructing the flight model on X-Plane 10 via a set of software tools and the development of a 12-state, six-degrees-of-freedom MATLAB/Simulink based simulation are demonstrated. The method presented demonstrates useful applicability.

Liver transplant is a life-saving treatment with 1-year and 5-year survival rates of 90% and 70%, respectively. However, organ demand continues to exceed supply, such that many patients will die waiting for an available organ. This article reviews for the general gastroenterologist the latest developments in the field to reduce waiting list mortality and maximise utilisation of available organs. The main areas covered include legislative changes in organ donation and the new ‘opt-out’ systems being rolled out in the UK, normothermic machine perfusion to optimise marginal grafts, a new national allocation system to maximise benefit from each organ and developments in patient ‘prehabilitation’ before listing. Current areas of research interest, such as immunosuppression withdrawal, are also summarised.

The call for banning p-values by the editors of a noted scientific journal in 2015 continues to frustrate statisticians. While such controversies typically surface around a specific statistical con...

Cetacean communities face significant threats from adverse interactions with human activities such as bycatch, vessel collision, and environmental pollution. Monitoring of marine mammal populations can help to assess and safeguard marine biodiversity for future generations. Traditional surveys can be costly and time-consuming to undertake, but we explore the ability of citizen science to inform environmental assessments and subsequent conservation management. We use data collected from platforms of opportunity within the Bay of Biscay to investigate spatial changes in cetacean diversity, with the aim of identifying hotspots which may be suitable for further investigation and conservation. Seventeen species of cetaceans were recorded over a ten year period, many of which are data deficient in European waters (e.g. Bottlenose dolphin, Short-beaked common dolphin, Striped dolphin, Risso's dolphin, Long-finned pilot whale, Killer whale, Northern bottlenose whale, Cuvier's beaked whale, Sowerby's beaked whale and True's beaked whale). Biodiversity (determined by Simpson's Diversity index) ranged from 0.19 to 0.77. The central and southern areas of the survey area indicated the highest biodiversity (0.65–0.77), and these locations may benefit most from protection as Important Marine Mammal Areas. We present a case for this designation, and discuss the benefits and limitations of citizen science for informing conservation action.

Brexit, the UK's planned withdrawal from the EU, has significant implications for UK fisheries, potentially creating both opportunities and challenges regarding future governance of some of the most important fisheries in the EU. This paper presents findings of discussions with key industry representatives from two of Scotland's largest ports – Peterhead and Fraserburgh. The views of these stakeholders give a unique perspective on the opportunities and challenges provided by Brexit. Views are reported on the current management system, the importance of the EU as an export market and how industry stakeholders believe fisheries should be governed if the UK leaves the Common Fisheries Policy (CFP). Despite the view from stakeholders that the current distribution of fishing rights in UK waters is unbalanced, and the view that the CFP has moved from a positive to a negative for the industry, the implications of these results suggest that this part of the industry is not focussed solely on a quick removal from the CFP that returns 100% of fishing rights and control of UK waters, but instead seeks an improved management system that allows for the long term sustainability of the sector.

This paper presents the results of interviews conducted with stakeholders in the North East Scotland commercial fishing industry who operate with Fixed Quota Allocation (FQA) units under the United Kingdom’s (UK’s) fisheries management system. The results derived from these interviews provide a view of the FQA system from those operating within it and identify strengths and weaknesses of the system. The implications of these results are that the FQA system, and the introduction of FQA units, led to increased investment and efficiency within the North East Scotland ‘over 10 m′ sector. This, however, has led to a consolidation of quota and the raising of barriers to entry. These may threaten the future of the industry and its traditional links to its coastal communities but the situation is complicated by concerns that any changes to the system to address these threats risks destabilising the economic structure of the industry which is built on the asset value of FQA units. The UK Government has indicated that the system will endure post-Brexit so it may be that any additional quota realised from exiting the European Union (EU) is applied to a system where those who will benefit most understand that it may risk the industry’s future. This paper calls for more research into the FQA system, with those who work with FQA units and those who do not, to ensure that the socioeconomic impacts of this system are better understood in order that future management safeguards the stability of the industry into the future.

A 60-year-old male liver transplant recipient presented to his local hospital with left-sided partial seizures following a few days of generalised headache. He had undergone transplantation for primary sclerosing cholangitis 4 years earlier and maintained on tacrolimus monotherapy immunosuppression. He had no other comorbidities of note and worked as an arable farmer. At last follow-up, he had been well with preserved graft function and afternoon trough tacrolimus levels of 2–4 ng/mL. Over the preceding 4 weeks, he had been investigated locally for weight loss and a productive cough, where CT of the chest showed calcified mediastinal and hilar lymphadenopathy. Bronchoscopy samples were negative for acid-fast bacilli and he had been empirically treated for assumed community acquired pneumonia. Initial seizure management was with intravenous diazepam and phenytoin. On transfer to our centre, he was noted to be dysarthric with persisting 4/5 left upper limb weakness and nystagmus to all extremes of gaze. Blood tests were significant for mild anaemia (haemoglobin 90 g/L) and elevated C reactive protein (134 mg/L). The peripheral white cell count was 6.6×109/L. Biochemical liver graft function was normal and the 8am trough tacrolimus level was low at 2 ng/mL.CT head revealed bilateral ring enhancing cerebral lesions with surrounding vasogenic oedema but no mass effect. On MRI these exhibited restricted diffusion and marked perilesional oedema, suggestive of infection. Cerebrospinal fluid (CSF) analysis was as follows: white cell count 3, protein 0.57 g/L (normal range Nocardia farcinica.

Introduction Pancreatic stents (PS) are increasingly used to aid biliary cannulation and reduce the risk of pancreatitis during endoscopic retrograde cholangiopancreatography (ERCP). Proximal PS migration is uncommon (reported in 2–5%) but poses a significant problem due to the risk of pancreatitis and pain. We describe our experience in the endoscopic management of migrated PS. Methods A retrospective review of all ERCPs at our tertiary unit from January ’13 –February ‘19 was performed to identify cases of migrated PS. Results Twelve patients were identified; 10 received PS placement at other UK hospitals, 1 abroad and 1 at our unit. PS indications were prophylaxis of post-ERCP pancreatitis (PEP) in 9 and following pancreatic endotherapy in 3 (one for sphincter dysfunction, one for ductal stricture and one for cyst drainage). The migrated PS were 5 cm (n=11) or 7 cm (n=1) long with diameter of 3Fr (n=1), 5Fr (n=10) and 7Fr (n=1). Seven were straight and 5 single pigtail. 9 PS migrated after reported correct placement (of which 6 (67%) were straight). Two were inadvertently deployed within the pancreatic duct (PD); in one case there was no information regarding placement. The site of PS migration was within the pancreatic head (n=3), body (n=3) and tail (n=6). After MDM review one patient was referred directly for surgery where a PD stricture precluded endoscopic access. Endoscopic removal was attempted in 11 patients and successful in 9 (82%). 7 patients required two procedures. The median interval from stent placement to retrieval was 5 weeks (range 2–20). All patients had a previous pancreatic sphincterotomy. Techniques used for successful retrieval were: stent grabbers (n=3), extraction balloon/stent grabbers (n=1), snare/stent grabbers (n=2) and pancreatoscopy with SpyBiteTM forceps (n=3). Endoscopic removal was unsuccessful in 2/11 patients where pigtail stents had hooked into a side branch. In all cases a 5 cm/5Fr prophylactic PS was placed post retrieval and 8 received rectal diclofenac (one contraindicated). Mild post-ERCP pancreatitis (PEP) occurred in one case. Conclusions Endoscopic retrieval of proximally migrated PS was successful in 82% of patients. Migrated PS retrieval is challenging, and should only be attempted by endoscopists experienced in pancreatic endotherapy following case review within a specialist MDM. The mechanism of migration is unclear and spontaneous proximal migration of an appropriately placed single pigtail PS is unlikely to occur. Apparent migration in these cases most likely arises from incorrect deployment, potentially due to difficulty distinguishing the stent from the pushing device, emphasising the need for caution during PS placement. The optimal retrieval technique depends upon PS type, position, and PD anatomy. In our experience use of an extraction balloon alone was never successful. Failure of endoscopic retrieval was highest with pigtail stents and those >2 cm from the papilla.

Background Endoscopic ultrasound (EUS)–guided transmural drainage is the preferred treatment for symptomatic pancreatic walled-off necrosis (WON). Lumen apposing metal stents (LAMS) are increasingly used, although their advantage over plastic stents remains unclear. Placement of a plastic pigtail stent within the LAMS may help maintain patency and help avoid the need for subsequent endoscopic necrosectomy. We aim to describe the success and complication rates for the use of LAMS in the management of WON. Methods All patients undergoing EUS-guided cystgastrostomy using LAMS for WON between July 2015-January 2019 were included. Data collected included procedural technique, rates of technical and clinical success and complications. All patients had up to date CT or MR scans and all were reviewed in the specialist MDM prior to intervention. Results 40 patients underwent LAMS placement for WON, 75% male, median age 53 years (range 23–79). The aetiology of pancreatitis was: gallstones (n=17), alcohol (n=12), idiopathic (n=9) and post-ERCP (n=2). Mean collection size on pre-procedure imaging was 12 cm (range 4–22). 21 (52.5%) procedures were performed under general anaesthesia, 14 (35%) propofol sedation and 5 (12.5%) conscious sedation. LAMS were placed from the stomach (n=38, 95%) or duodenum (n=2, 5%) and were successfully deployed in 39 (98%). LAMS diameter was 8 mm (n=7), 10 mm (n=5), 12 mm (n=1), 15 mm (n=24) and 20 mm (n=3). Pigtail stents were placed within the LAMS in 14 cases (35%) but did not significantly alter the need for subsequent endoscopic necrosectomy (28% with pigtail stent vs 27% without). Follow up CT demonstrated a reduction in collection size in all cases with a mean maximal diameter of 2.6 cm (0–5 cm). Successful drainage was achieved in 98% at 3 months (1 patient died from complications of acute pancreatitis, unrelated to stent placement) and no patient required percutaneous or surgical drainage. There were two complications; 1) late migration of the gastric flange into the collection, presenting with sepsis 6 weeks post insertion and successfully retrieved following placement of a second LAMS and 2) buried gastric flange, leading to delayed LAMS removal and successfully retrieved 7 months post insertion after transmural tract dilation using large diameter biopsy forceps. Median time to LAMS removal was 51 days (range 26–80). LAMS remained in situ for 21 months in one patient lost to follow-up but was removed without complication. Conclusion Transmural drainage of pancreatic WON using LAMS has excellent rates of technical and clinical success with few complications. Unlike in other published series, we did not observe any late bleeding complications. In our cohort, placement of a pigtail stent through the LAMS did not negate the need for subsequent endoscopic necrosectomy.

Introduction Incidental, unexplained biliary and pancreatitic duct dilatation on imaging performed for other reasons is an increasingly common reason for EUS referral. The radiological ‘double duct’ (DD) sign is associated with pancreatobiliary (PB) malignancy, particularly in those with abnormal liver function tests (LFTs). However data regarding the yield of pathology at EUS in those with DD and normal live biochemistry are sparse. Our aim was to describe findings at EUS performed for investigation of DD in patients with normal LFTs. Methods A retrospective review was performed of EUS procedures for investigation of DD across two tertiary HPB referral centres between 2013 and 2018. Those with abnormal or unknown liver biochemistry, or where expert review of cross-sectional imaging had indicated a mass lesion, stricture or other identifiable cause were excluded. Results 46 patients were included, median age 64 years, 78% female/22% male. Long-term opiate use was documented in 17 (37%). Positive findings were identified at EUS in 10 (21.7%); chronic pancreatitis (n=5), side branch intra-ductal papillary mucinous neoplasm (IPMN) (n=2), benign papillary fibrosis (n=2) and choledocholithiasis (n=1). Ductal dilatation was not seen at EUS in 3 (6.5%) and DD was present with no cause identified in 33 (71.7%), of whom 14 (30.4%) had documented opiate use. Both cases of IPMN lacked high-risk features and the patients remained well with a minimum of 18 months surveillance. One endoscopic complication occurred in a patient without cause for DD sign identified at EUS, who sustained an endoscopic perforation requiring hepatico-jejunostomy. Two cases of ampullary carcinoma were noted during case identification in patients with minimally elevated LFTs undergoing EUS for DD. Conclusions In this cohort with DD and normal liver biochemistry there were no EUS-diagnosed malignancy and the yield of benign pathology was ∼20%, similar to that previously reported4. However, this should be interpreted with caution given the 2 cases of malignancy, not included in this cohort, found with only mild LFT abnormalities and further prospective studies are needed. References Krishna N, et al. Dilation of both pancreatic duct and the common bile duct on computed tomography and magnetic resonance imaging scans in patients with or without obstructive jaundice. Pancreas 2012;41:767–72. Kofi W Oppong, et al. Endoscopic ultrasound in patients with normal liver blood tests and unexplained dilatation of common bile duct and or pancreatic duct. Scandinavian Journal of Gastroenterology 2014;49(4):473–480.

The beaches of the Maltese Islands are limited in their extent and scale, but are remarkably diverse in their settings. Many have been affected greatly by urban encroachment and intense amenity use leading to depletion and in some cases even loss. First, this chapter presents a broad review to establish the nature of the beach resource. Secondly, a quantitative survey encompassing Malta, Gozo and Comino is presented revealing that beaches cover 11.2 ha with a total longshore frontage of 5.05 km. Detailed classifications of their geomorphological settings, human usage and human impacts upon them are also presented. Thirdly, two case studies, one rural beach (Għajn Tuffieħa beach) and one urban beach (Balluta beach), are presented to exemplify the interactions between coastal processes and human pressures. Finally, the future of Maltese beaches is considered including opportunities both to sustain and enhance the resource.

Cetacean-Based Tourism (CBT) is often confused with sustainable tourism. However, not every CBT operator has an environmental education component attached to its programme. In reality, CBT has the potential to negatively impact the animals it is targeting; thus management is required to mitigate any harmful effects from tourism activities. This paper analyses the attitudes and perceptions of the marine operators and tourists that partake in dolphin-swim activities in the Ponta do Ouro Partial Marine Reserve (PPMR) in Mozambique. Hand-out questionnaire surveys with closed and Likert scale type questions revealed that the tours are an effective means to promote pro-environmental behaviour and consequently increase compliance with the code of conduct. Nonetheless, in the PPMR, both tourists and operators presented only basic knowledge of the regulations of the reserve and of the dolphin, whale and whale shark code of conduct, indicating that there is a need for improvement. We provide recommendations for improving local management, which are also applicable at the national and international level. Overall, this paper provides knowledge and guidance for moving towards a sustainable based CBT industry in the PPMR.

Introduction Percutaneous direct cholangioscopy may expand diagnostic and treatment options where endoscopic biliary access is precluded by post-surgical anatomy. We aim to report the utility of percutaneous transhepatic cholangioscopy in patients with intrahepatic stone disease, using the SpyGlass DS cholangioscopy system. Methods Five patients underwent percutaneous cholangioscopy between July ‘17 and February ‘18. All had post-surgical duodenal anatomy and intrahepatic duct (IHD) stones, three with an associated anastomotic stricture. In all cases prior percutaneous transhepatic cholangiography (PTC) and biliary access was achieved using conventional interventional radiology techniques, with the transhepatic tract dilated to 12 F, and a drain left in situ. Results The procedures are summarised in Table 1. Five procedures were performed under general anaesthetic and one with sedation, with the patient supine. All patients received antibiotic prophylaxis. Under sterile conditions the cholangioscope was introduced percutaneously into the intrahepatic biliary tree via a peel-away sheath (12Fr in 5 cases and 11Fr in 1). Optimal stone localisation was achieved using fluoroscopy and direct visualisation, allowing application of electrohydraulic lithotripsy (EHL) using a Boston Scientific EHL probe for stone fragmentation. In one case 8 mm-10 mm sequential dilatation of an anastomotic stricture was performed. In one case a surgical stitch across the anastomosis was visualised – the likely nidus for stone formation. Stone clearance was successful in all cases where IHD stones were identified. In one case the IHD stones had cleared since the index PTC. There were no recorded procedural complications. Conclusion In this small case series direct visualisation of the biliary tree using percutaneous SpyGlass cholangioscopy was safe, successful and expanded the therapeutic capabilities of PTC. This technique could also be used to enhance the investigation and treatment of post-surgical biliary anastomotic stricturing, where retrograde endoscopic access is not feasible.

Introduction Use of hospital beds as pre/post procedure accommodation places a strain upon resources and risks ‘on the day’ cancellation. Nevertheless ‘day case then home’ may be a poor option for patients undergoing complex endoscopy who live many miles away. Our centre offers Near Hospital Accommodation (NHA) in a bespoke 35-roomed hotel 100 metres from the hospital at a cost of £120/night (versus £380 per inpatient bed). We aimed to assess the safety and utility of NHA for patients within our pancreatobiliary (PB) service. Methods We undertook a retrospective audit of all PB patients who stayed in the NHA from Jan ’15 – Dec ’17. Data collected from the endoscopy database and electronic records included: procedure type, distance travelled, type of hotel room, length of stay and unplanned post-procedural hospital admissions from the NHA. Results Over a 3 year period 152 patients stayed in NHA for 169 nights, ninety-three (61%) female with median age of 62 years (range 24–81). All patients underwent therapeutic ERCP, EUS, or cholangioscopy. The decision to use NHA was based upon case complexity and travel logistics. Most patients (89%) stayed one night and 11% stayed two nights (pre and post-procedure). Median one-way distance travelled was 107 miles (range 3–299 miles) (figure 1). The total cost of NHA was £23,660, saving £40 560 over the equivalent inpatient beds. There were five unplanned admissions (3.3%), summarised in table 1. Conclusion NHA is a safe, cost-effective alternative to hospital admission for selected patients undergoing complex endoscopy. The unplanned readmission rate was low, with no serious complications. The immediate cost saving was considerable, in addition to efficiency savings from the extra bed capacity generated and reduced late cancellations. Benefits to patients include visitor-friendly, hotel-standard accommodation, reduced travelling time on the day of the procedure and saving of private hotels fees. Further studies are needed to assess if this translates into increased patient satisfaction. With increasing centralisation of specialist services and ongoing financial pressures throughout the NHS, the NHA model of care offers advantages to hospitals and patients.

Introduction Biliary anastomotic strictures (AS) occur in 5%–15% of liver transplant (LT) recipients and cause graft dysfunction and morbidity. The main alternative to surgical reconstruction is stenting at endoscopic retrograde cholangiopancreatography (ERCP), using plastic polyethylene or fully-covered self-expanding metal stents (fcSEMS). We retrospectively reviewed outcomes after ERCP for biliary AS, aiming to assess rates of success and complications. Methods Records for all patients undergoing ERCP post LT between 2013–16 were reviewed. AS were classified as early or late ( Results In total 252 ERCPs were performed (median 4/patient, range 2–10) in 62 patients, 72.6% male, age at LT 54 years (range 20–71). 48 grafts (77.4%) were donations after brain death, 13 (21.0%) after cardiac death and 1 live donor. At first endoscopy 53 (85.4%) had a native papilla. Median time from LT was 28 days (4–75) in early AS (n=29, 46.7%, 9 presenting with bile leak) vs 11.5 mths (3.4–251) in late AS (n=33, 53.2%). Biliary stents were placed in 172 ERCPs (63.4% plastic vs 36.6% fcSEMS) and AS dilated in 68 (27.0%; 60 in conjunction with stenting). Stricture resolution was achieved endoscopically in 47/55 patients with complete outcome data (85.5%). Plastic stents were placed at index ERCP in 23/26 of early AS, in whom sequential plastic ‘upstenting’ was ultimately successful in 9 (39.1%) and 12 (52.2%) proceeded to fcSEMS (stricture remodelled in all). Of late AS, 9/29 were managed with fcSEMS (88.8% successfully), 8 plastic ‘upstenting’ (75% success), 8 fcSEMS after initial plastic stent (all successful) and 2 resolved with dilatation only. The overall rate of post-ERCP pancreatitis (PEP) was 7.1% (none severe by Cotton criteria) and was higher after fcSEMS (15.9%) than plastic stenting (5.5%, p=0.024), despite similar use of NSAID prophylaxis. Compared with plastic stents, fcSEMS were more likely to migrate (36.5% vs 12.8%, p Conclusions Endoscopic management is effective in treating 85% of biliary AS. fcSEMS appear superior to sequential plastic ‘upstenting’ but are associated with higher rates of PEP and migration.

It is widely recognized that there is a need for engagement between stakeholders to establish locally accepted strategies for sustainable coastal management solutions around the world. Adaptive management approaches have emerged as one of the preferred mechanisms in coastal zone management. Central to the application of adaptive management is the effective engagement of stakeholders to encourage participatory decision-making. There are relatively few studies which have analysed the effectiveness and dynamics of stakeholder groups to establish sustainable adaptive management in practice, and identify what opportunities and challenges can arise from such collaborative approaches. This research critically evaluates stakeholder engagement in the adoption of adaptive management at East Head, England. The study has identified significant issues and opportunities that have arisen throughout the decision-making process. It has found that a major challenge has been to achieve acceptance of the mechanism of adaptive management, particularly in relation to aspects of uncertainty. However, it is of critical note that the advisory group in question has become a valuable vehicle in bringing together key stakeholders throughout all stages of the adoption of the adaptive management approach. It is suggested that this approach, has gradually reduced conflict through building knowledge, gaining trust and ultimately achieving acceptance. A widely applicable management model and recommendations for best practice are presented as derived from the views of the advisory group itself. This model has the potential to develop a more dynamic, holistic and sustainable approach to coastal governance both in the UK and at other locations further afield.

Putting accounts for more shots in a round of golf than any other type of play. The percentage of putts holed decreases as putt length increases, because golfers struggle to achieve a consistent range and direction. Range variation has been partly attributed to the ball striking the club face away from the central plane of the putter face. Tests have shown a 30 mm off-centre impact can reduce the roll distance of a putt by 13%. In this paper, changes in mass distribution of the putter body and the addition of a flexible striking surface are considered. Physical testing and Finite Element Analysis are used to produce a club design with more consistent roll distance. Redistribution of mass reduced the roll distance variation across the clubface. Combining this with a flexible impact surface reduced the variation between a central impact and one 20 mm from center to just 1%. The proposed design could significantly reduce distance variation; aiding golfers in holing putts. Future work will optimise the design and validate through physical prototyping.

Purpose The purpose of this paper is to examine geometrical design influence of various types of flying discs on their flight performance from the aerodynamics perspective. Design/methodology/approach The lift, drag and moment coefficients of the discs were measured experimentally using a wind tunnel. Three types of golf discs and four sets of simpler parametric discs were studied to analyze and isolate the effect of design factors on these aerodynamic characteristics. Full six degree-of-freedom simulations of the discs were performed to visualize their flight trajectories and attitudes. These simulations, combined with the experimental data, provide details on the well-known “S-shaped” ground-path traced by a flying disc. Findings This paper reveals two key parameters to evaluate the flight performance of a disc: its coefficient of lift-to-drag ratio (CL/CD) and, more importantly, its coefficient of pitching moment (CM). The latter influences the tendency of the disc to yaw from its intended path, and the former influences its throwing distance. Practical implications The work suggests that to optimize the flight performance of a disc, the magnitudes and gradient of its CM should be minimized and its trim-point shifted from origin, while its CL/CD should be maximized with a flatter peak. Originality/value In this paper, the design parameters and the aerodynamic characteristics of various types of flying discs are analysed, compared and discussed in depth. Recommendations of design improvements to enhance the performance of any flying disc are offered as well.

A previously healthy 23-year-old MSM presented with jaundice, systemic upset, and rash 2 months after a single episode of unprotected sexual intercourse. Liver biochemistry was grossly deranged, with markedly elevated transaminases and hyperbilirubinaemia. Serology was positive for genotype 1a hepatitis C virus (HCV) and in the absence of other causes, acute HCV infection was suspected. He was subsequently successfully treated with pegylated interferon and ribavirin for 24 weeks and made a full clinical and biochemical recovery.

Introduction Refractory ascites (RA) in end stage liver disease (ESLD) confers a poor prognosis in non-liver transplant (LT) candidates; therefore heralds a palliative stage of management. Standard care in RA is recurrent large volume paracentesis (LVP). Pathways in malignant ascites are well developed; medical ambulatory care units (ACU), long-term abdominal drains (LTAD) and palliative care input. Our aim was to assess the natural history of ascites in ESLD; particularly hospitalisation, LT referral, input from palliative care and eventual outcome. Method This was a retrospective cohort study (January 2013-December 2015). RA was defined as per EASL Practice Guidelines. Electronic hospital records from a large teaching hospital in Southeast England were reviewed and relevant data collected.c Results A total of 419 cases met search criteria; 317 were suitable for inclusion. Aetiologies of ascites were malignant (53%) and chronic liver disease (CLD) (41%). Alcohol related liver disease (ARLD) was the commonest cause of CLD requiring LVP, n=82 (63%), followed by a combination of ARLD and non-alcoholic steatohepatitis (NASH), n=16 (12%). In the CLD group 63 (48%) underwent inpatient LVP, 12 (9%) on ACU, the remainder in both areas. Of those with CLD, 49 (37%) developed RA; 18 referred for LT assessment, of whom 6 (12%) were listed or underwent LT. The commonest barrier to LT referral was alcohol recidivism, 14 (29%). Median age at development of RA was 58 years (35-86), Model for End-Stage Liver Disease (MELD) 15 (8-29). Median number of LVPs in those with RA was 13 (4-62), time to development of RA from first episode of decompensation 808 days (34–2179) and from first LVP 102 days (0–1161). There were no statistically significant differences in baseline patient demographics, liver prognostic scores or renal function between those that did and did not develop RA. At last follow up, 22 (45%) individuals with RA were alive; median survival from RA diagnosis 179 days (45–771 days). In the RA cohort, 22 (45%) had documentation suggesting their care was palliative, however only 16 (33%) were referred for palliative care input and 13 (27%) had any advanced care planning. Conclusion Approximately 40% of patients with ESLD and ascites requiring LVP developed RA. Baseline characteristics are unhelpful in predicting RA development. Since Disclosure of Interest L. Macken Conflict with: NIHR rfpb, A. Hashim: None Declared, J. Potts: None Declared, S. Verma Conflict with: NIHR rfpb

Discus, disc golf and ultimate Frisbee are all sports that utilise rotating disc projectiles. The aim of this study was to use computational fluid dynamics (CFD) examine the flow over a disc and in doing so determine which CFD model is most suited to examining the aerodynamics of sports disc projectiles. All of the CFD analysis was carried out using ANSYS-Fluent V6.3. The study initially compared experimental and CFD data of flow around a simple non-rotating parametric disc, with a thickness to diameter ratio of 0.1. Aerodynamic coefficients and surface flow visualisations were compared. Three models within ANSYS-Fluent gave steady converged solutions; standard k-å, realizable k-å and standard k-ù. The standard k-ù model gave unrealistic aerodynamic coefficients and was discounted. The two k-å models were used for the second stage of the study, simulating the flow around a disc golf disc, called a Floater. The geometry of the disc was captured using a 3D non-contact laser scanner. Aerodynamic coefficients and surface flow visualisations showed good agreement between the two k-å models. The standard k-å model was deemed the most suitable for a study of flow around a sports disc, mostly due to its more accurate simulations of the parametric disc. The results were used to further examine the flow, looking at separated flow on the discs surface with increasing angle of attack and the structure of the wake. The study identified which CFD model is most suited to the simulation of flow over a sports disc and in doing so provided a platform for using CFD for future disc aerodynamics studies.

England is about to embark on the introduction of an integrated approach to the management of its marine environment, known as marine planning. The management of human activity in the marine environment is a central function of marine planning; therefore, stakeholder involvement will be crucial for the successful development and subsequent implementation of marine plans. The range of stakeholder activities, their connection to the marine environment and interest in its management are likely to vary considerably on a local, regional and national scale. It is realistic to assume that it will not be possible to involve every stakeholder all the time; therefore in order to develop efficient and effective stakeholder involvement during the marine planning process it is sensible to determine who to involve, when to involve them, and how to involve them from the outset. This paper discusses the role of stakeholders in the marine planning process through consideration of the results of a stakeholder analysis, which was informed by primary data collated from stakeholders within the Solent. The paper concludes with a proposed mechanism, comprising different organisational units, for managing stakeholder involvement in the marine planning process.

This article documents the development of synthetic jet actuator array hardware to augment high-lift system effectiveness in a wind tunnel model. The study involved the design, manufacture and bench test of a synthetic jet actuator array based on an inclined actuator configuration to reduce volume installation requirements without a loss in jet velocity relative to a non-inclined baseline model; incorporation of proper synthetic jet actuator systems wiring and internal synthetic jet actuator chamber pressure-sensing for actuator health monitoring. The peak velocity obtained from the inclined synthetic jet actuator array was 100 m/s, which favourably compares to the baseline array (∼90 m/s), while reducing the usable depth requirements by 50%. The final outcome of this study has been to apply the design lessons learned to develop a methodology for designing a synthetic jet actuator array with the constraints of using piezoelectric-based actuator technology for flow separation control applications.

The introduction of a marine planning system throughout English territorial waters over the next decade provides an opportunity for stakeholder input to the management of the marine environment. Stakeholder involvement has been identified as an important component of successful development and subsequent implementation of marine planning but it has to be recognised that the views and interest of stakeholders can vary greatly, thus the desire for involvement with the process is unlikely to be uniform. This paper presents the views of stakeholders within the Solent, United Kingdom on their potential involvement with the marine planning process. Interestingly, it highlights a strong variability of views within and across sectors. Assuming the situation in the Solent is typical of groups of stakeholders throughout the country, the lack of uniformity in the potential involvement from different stakeholders may present a challenge in achieving a representative and truly collaborative marine planning process.

Type IA endoleaks associated with endovascular aortic aneurysm repair are typically treated with endovascular adjuncts. Technical failure results when such maneuvers are unsuccessful, and endograft removal may, unfortunately, become necessary. The novel management of a recalcitrant type IA endoleak using the artificial embolization device, Onyx (Micro Therapeutics Inc, Irvine, Calif) is presented for the case of a nonagenarian with prohibitive surgical risk after conventional techniques had failed.

This patient case-study represents the introduction of radiotherapy in the management of extra-cranial vascular malformations, a topic with virtually no supported literature before our case study. In those patients refractory to established therapies and facing the inevitability of mutilating amputation, radiotherapy may be a viable option to preserve the limb.

Capacity building is commonly considered to be a fundamental prerequisite to successful integrated coastal management (ICM). Capacity building for ICM is an educational process, in which skills and knowledge are taught, learned and then applied, within a coastal management process. Previous research into ICM capacity building has tended to focus upon identifying the skills and knowledge required for effective ICM rather than the pedagogic elements of capacity building; that is, how the effectiveness of learning can be improved. This paper reports on a study that focuses on establishing the favoured learning style of students studying ICM in UK universities in order to consider more generally the role of pedagogy in ICM. Kolb's Learning Styles Inventory, a widely used generic learning styles test, was used to establish preferred learning styles. The results showed that ICM learners exhibited a complete range of learning styles, but that 47% were classified as ‘convergers’, who prefer to learn through practice and consider the teacher to be a facilitator and role model rather than knowledge giver. It is concluded that ICM capacity building leaders should consider pedagogic issues more fully in the design and delivery of capacity-building activities and that a specific pedagogy of ICM is required.

Ocean citizenship describes a relationship between our everyday lives and the health of the coastal and marine environment. Through our everyday lives we affect, and are affected by, the marine and coastal environment in numerous ways. As such, individuals have a responsibility to make informed lifestyle choices to minimize this impact. In doing so, the actions of individuals can contribute to the amelioration of large-scale and seemingly insurmountable geographical problems. This article outlines the concept of ocean citizenship within the context of the public understanding of marine environmental issues. The article draws heavily on the experience of the National Maritime Museum as an important contributor to the development of ocean citizenship in the United Kingdom. Specifically, the Planet Ocean initiative will be examined, in which the Museum has adopted a multimodal approach to public engagement through exhibitions, educational resources, and specific research publications. The article concludes b...