Introduction: Laparoscopic fundoplication (LF) has been emerging as the procedure of choice for selected patients with symptomatic and problematic reflux disease. The aim of this study was to investigate post-operative complications associated with LF. Furthermore, we wanted to look at the impact of a surgeon’s learning curve on post operative morbidity and investigate patient satisfaction after LF. Methods: A single surgeon’s series of 75 patients who underwent laparoscopic fundoplication were included in the study. The data was collected prospectively but analysed retrospectively. A satisfaction survey was performed with one to eight years follow-up. Results: Laparoscopic fundoplication was associated with a learning curve. One of the major aims of the study was to record post-operative complications. Interestingly, post-operative dysphagia occurred in up to 40/75 of our patients. Our initial policy was to perform an OGD and dilate prophylactically; however, this was abandoned halfway through the study as it was found that the dysphagia settled in all patients with conservative management. Conclusion: Our study confirms a real learning curve for LF. Furthermore, it has also clearly highlighted that post operative dysphagia is common and affects a significant number of patients. In our study we found that this was best managed conservatively.

Racism at work - a crime in anyone’s language” 1 The Civil Rights Act 1964 remains of the greatest achievements in United States (US) history. It had implications internationally, making racial discrimination illegal, but its effectiveness in the employment domain remains contestable 2. The worldwide existence of workplace racism has attracted controversy and this is drawn out by psychiatry’s attempt to understand the nature of the problem 3. Discrimination at work, based on a person’s race, comes in different guises and can have negative consequences on both individuals and organisations 1. Despite legislation to protect individuals substantial progress needs to be made to eradicate the problem.

What is racism?

Summary: Ventilator Associated Pneumonia (VAP) is pneumonia occurring in a patient within 48 hours or more after intubation with an endotracheal tube or tracheostomy tube and which was not present before. It is also the most common and fatal infection of ICU. VAP increases length of ICU stay by 28% and each incidence of VAP is estimated to generate an increased cost of £6000- £22000. The NICE in collaboration with NPSA is examining four technical patient safety solutions for the prevention of VAP. The Department of Health published a ‘High impact intervention’ for ventilated patients in June 2007. Eliminating or reducing the unnecessary use of antibiotics should be the primary goal in reducing antibiotic-resistant nosocomial infections.

Several recent reports have described osteonecrosis of the jaws (ONJ) associated with the use of bisphosphonates. Osteonecrosis of the jaws is recognized as a serious complication of bisphosphonate therapy, more commonly with the intravenous form of the drugs. However, there is limited scientific understanding about the association between osteonecrosis of the jaws and bisphosphonates. Primary care physicians treating bone diseases with bisphosphonate need, therefore, to be aware of this potential risk and plan the prophylaxis, early diagnosis and prevention of potential consequences. In this article, I review the literature on this newly described complication, with particular focus on systemic and local predisposing pathologies, preventive measures suggested before and during therapy with oral bisphosphonates, and the frequent clinical presentation of the oral lesions. The expert panel recommendations for the management of care of patients who develop ONJ are summarized also. ONJ has been linked with high-dose intravenous bisphosphonate use in patients with bony cancers and the observation has been extended at a much lower incidence to patients on oral bisphosphonates taken for osteoporosis. The benefit-risk ratio is still heavily weighted towards therapy but primary care physicians need to be aware of this link. The risk is greatest in those with poor oral health who are undergoing dental surgery. If there is doubt, then a review by an experienced oral surgeon is appropriate.

Growth factors and their receptor play a major part in normal growth and differentiation and also in tumour development and progression. Mutations or over- expression of growth factor receptors is associated with aggressive cancers and poor prognosis for patients. Growth factor receptors are transmembrane tyrosine kinase proteins that transduce growth factor signals imparted by their binding to specific receptors leading ultimately to the induction of cell proliferation. HER2 is a human epidermal growth factor receptor. Approximately 25% of breast cancers show HER2 gene amplification and this correlates with aggressive behaviour and poor prognosis. The deployment of Herceptin (Trastuzumab), a humanised chimeric antibody against HER2, to treat HER2+ patients, has emerged as a successful approach to the treatment of breast cancers that over-express HER2 and are resistant to tamoxifen. These patients could benefit from anti-oestrogen therapy combined with blockade of HER2 signalling. Post-menopausal patients with advanced breast cancer appear to benefit significantly from this combination therapy. Combination of Herceptin with chemotherapy might yield considerable benefits in terms of reduction of recurrence and mortality. The efficacy of conjugates of anti-HER2 antibodies with cytotoxic drugs to achieve targeted delivery of the cytotoxic agents is being evaluated. The toxicity associated with the administration of monoclonal antibodies has been recognized. Cardiotoxicity, pulmonary toxicity and infusion-related problems such as anaphylaxis occur, albeit infrequently, with monoclonal antibody therapies. The EGFr (epidermal growth factor receptor) inhibitor Lapatinib (Tykerb) is a protein kinase inhibitor (a 4-anilinoquinazoline derivative), which inhibits growth factor signalling by binding to the ATP-binding pocket of both EGFr and HER2 receptor proteins. Lapatinib has shown much promise in clinical trials in patients with advanced metastatic breast cancer and is believed to have little cardiac toxicity. A strategy similar to that adopted with EGF family growth factor receptors has been used to target the vascular endothelial growth factor receptor (VEGFr) and inhibit signalling by VEGF. Avastin (Bevacizumab) is a humanised monoclonal anti-VEGFr antibody. Avastin combined with Paclitaxel improves progression-free survival and response rate in patients with advanced breast cancer. However, on account of possible side effects, Avastin has not received general approval.

Overall, the widely held view has been that alveolar hypoxia is the main pathophysiologic cause of vasoconstriction in obese patients living at sea level or higher altitudes. In 1947, Motley et al demonstrated that breathing a gas mixture containing 10% oxygen induced a rise in pulmonary artery pressure (PAP).3 Papers dating back more than three decades have documented increases in PAP associated with hypoxemia related to sleep disordered breathing (SDB). It is well known that apneic episodes during sleep are associated with transient elevations in PAP, which return to baseline when breathing resumes after relief of obstruction. Earlier studies suggested that daytime hypoxemia attributable to abnormal lung function was the main cause of pulmonary hypertension in patients with sleep apnea. Whether transient hypoxemias and associated elevations in PAP with obstructive events during sleep are adequate to produce daytime resting “fixed” pulmonary vascular disease, or whether daytime hypoxemia is required remains unclear. It is also less certain whether daytime pulmonary arterial hypertension also occurs in OSA patients without underlying pulmonary or cardiac disease. Additionally, studies have shown that the severity of SDB as measured by apnea-hypopnea index (AHI) and the PAP elevations often fail to correlate.