Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact.

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis.

BACKGROUND: Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes. METHODS: The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling. RESULTS: Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001). DISCUSSION: Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.

Developing a curriculum for advanced fellowship training in complex cancer for the UK.

AIM: Surgery for complex colorectal cancer is elaborate: preoperative assessment, patient selection, radiological interpretation, operative strategy, operative technical skills, operative standardization, postoperative care and management of complications are all critical components. Given this complexity, training that encompasses all these crucial aspects to generate suitably edified surgeons is essential. To date, no curriculum exists to guide training in advanced and recurrent pelvic malignancy, particularly for complex colorectal cancer. Such a curriculum would potentially offer numerous advantages, not only for individual surgeons but also for research, governance, international collaboration and benchmarking. The aim of this study was to design and develop a framework for a curriculum for fellowship training in complex colorectal cancer that encompasses pelvic exenteration surgery. METHOD: Kern described a six-step method for curriculum design that is now widely adopted in medical education. Our study utilizes steps 1-4 of Kern's method to develop a syllabus and assessment framework for curriculum development for fellowship training in complex colorectal cancer encompassing pelvic exenteration. A literature review was conducted to address step 1, followed by targeted needs assessment in step 2 by conducting focus groups with trainees, fellows and experts to identify learning needs and goals with objective setting for step 3. An expert consensus group then voted on these recommendations and developed educational strategy recommendations as step 4. For the purposes of brevity, 'pelvic exenteration' in the text is taken to also encompass extended and multivisceral resections that fall under the remit of complex [colorectal] cancer. RESULTS: Step 1 of Kern's method identified a gap in the literature on curricula in complex cancer surgery. Step 2 identified key areas regarded as learning needs by trainees, including anatomy, hands-on experience and case volume. Step 3 defined the goals and objectives of a fellowship curriculum, defined in six domains including theoretical knowledge, decision-making, technical skills, postoperative management and continuing professional development. Finally, as a prelude to stages 5 and 6, a strategy for implementation and for feedback and assessment was agreed by an expert consensus meeting that defined case volume (a minimum of 20 pelvic exenteration operations within a fellowship period) and coverage of this syllabus with derived metrics. CONCLUSIONS: Our working group has developed a curriculum framework for advanced fellowship training in complex cancer in the UK. Validation is needed through implementation, and affirmation of its utility, both nationally and internationally, must be sought.

Exposing human primary dermal fibroblasts to particulate matter induces changes associated with skin aging.

With a large proportion of the world's population living in areas where air quality does not meet current WHO guidelines, combined with the knowledge that pollutants can interact with human skin, it is now of even greater importance that the effects of air pollutant exposure on human skin be investigated. To evaluate the damaging effects of a known component of air pollution (particulate matter) on human primary dermal fibroblasts. These studies were undertaken by exposing primary human dermal fibroblasts to different concentrations of particulate matter and analyzing the effects over time using resazurin reduction assays. Immunofluorescence microscopy was used to determine if particulate matter caused activation of the aryl hydrocarbon receptor, and phosphorylation of histone H2AX, a known marker of double-strand DNA breaks. Dot blotting was also used to analyze expression changes in secreted MMP-1, MMP-3, and TGFß. Particulate matter was found to dose-dependently increase cellular viability, activate the aryl hydrocarbon receptor, increase double-strand DNA breaks, and increase the expression of MMP-1, MMP-3, and TGFß. With the potential of air pollutants such as particulate matter to not only modulate the expression of proteins implicated in skin aging, but also affect cells at a genetic level, brings a pressing need for further investigation so protective strategies can be implemented.

Exploring cation disorder in mixed-metal pyrochlore ceramics using 17 O NMR spectroscopy and first-principles calculations.

Characterising the local structures (e.g., the cation distribution) of mixed-metal ceramics by NMR spectroscopy is often challenging owing to the unfavourable properties (low γ, large quadrupole moment and/or low abundance) of many metal nuclei. 17 O is an attractive option owing to the prevalence of oxygen within ceramics. The moderate γ and small quadrupole moment of 17 O mean that the greatest barrier to accessing the information available from this nucleus is isotopic enrichment. We explore the challenges of ensuring uniform isotopic enrichment with 17 O2 (g) for the pyrochlore solid solutions, Y2 Snx Ti2-x O7 , La2 Snx Zr2-x O7 and La2 Snx Hf2-x O7 , demonstrating that high enrichment temperatures (900 °C for 12 hr) are required. In addition, for sites with very high symmetry (such as the tetrahedral OY4 and OLa4 sites with CQ ≈ 0 present here), we demonstrate that quantitative 17 O NMR spectra require correction for the differing contributions from the centreband of the satellite transitions, which can be as high as a factor of ~3.89. It is common to use first-principles calculations to aid in interpreting NMR spectra of disordered solids. Here, we use an ensemble modelling approach to ensure that all possible cation arrangements are modelled in the minimum possible number of calculations. By combining uniform isotopic enrichment, quantitative NMR spectroscopy and a comprehensive computational approach, we are able to show that the cation distribution in Y2 Snx Ti2-x O7 is essentially random, whereas in La2 Snx Zr2-x O7 and La2 Snx Hf2-x O7 , OLa2SnZr and OLa2SnHf sites are slightly energetically disfavoured, leading to a weak preference for clustering of like cations.

Associations Between Mutations in MSH6 and PMS2 and Risk of Surveillance-detected Colorectal Cancer.

BACKGROUND & AIMS: Lynch syndrome is the most common inherited cause of colorectal cancer (CRC). Contemporary and mutation-specific estimates of CRC-risk in patients undergoing colonoscopy would optimize surveillance strategies. We performed a prospective national cohort study, using data from New Zealand, to assess overall and mutation-specific risk of CRC in patients with Lynch syndrome undergoing surveillance. METHODS: We performed a prospective study of 381 persons with Lynch syndrome in New Zealand (98 with Lynch-syndrome associated variants in MLH1, 159 in MSH2, 103 in MSH6, and 21 in PMS2). Participants were offered annual colonoscopy starting at age 25 y, and those who underwent 2 or more colonoscopies before December 31, 2017 were included in the final analysis. Patients with previous colonic resection, history of CRC or diagnosis of CRC at index colonoscopy were excluded. RESULTS: Study participants underwent 2061 colonoscopies during 2296 person-y; the median observation-period was 4.43 y and mean-age at enrollment was 43 y. Eighteen patients developed CRC (8 with variants in MLH1, 8 in MSH2, and 2 in MSH6) after a median follow-up period of 6.5 y (range 1-16 y). Eighty-three percent of patients had a surveillance colonoscopy in preceding 24 months before diagnosis of CRC; 94% were diagnosed with stage 0-II CRC and there was no CRC-related mortality. The overall-risk of developing CRC in the 5 y after first surveillance colonoscopy was 2.49% (95% CI, 1.18-5.23); cumulative risks for CRC in patients with Lynch syndrome-associated variants in MLH1, MSH2, or MSH6 by age 70 y were 17.7%, 17.8%, and 8.5%, respectively. Age-adjusted CRC-risk in patients with variants in MSH6 was lower than in MLH1 (hazard ratio, 0.2; 95% CI, 0.04-0.94; P = .02). Of patients with CRC, 33% had an adenomatous polyp resected from same segment in which a colorectal tumor later developed. CONCLUSIONS: The risk of CRC in patients with Lynch syndrome-associated mutations in MSH6 or PMS2 was significantly lower than in patients with mutations in MLH1. Incomplete adenomatous polyp resection might be responsible for one third of surveillance-detected CRCs.

A Study of Through-Space and Through-Bond JPP Coupling in a Rigid Nonsymmetrical Bis(phosphine) and Its Metal Complexes.

A series of representative late d-block metal complexes bearing a rigid bis(phosphine) ligand, iPr2P-Ace-PPh2 (L, Ace = acenaphthene-5,6-diyl), was prepared and fully characterized by various techniques, including multinuclear NMR and single-crystal X-ray diffraction. The heteroleptic nature of the peri-substituted ligand L allows for the direct observation of the JPP couplings in the 31P{1H} NMR spectra. Magnitudes of JPP are correlated with the identity and geometry of the metal and the distortions of the ligand L. The forced overlap of the phosphine lone pairs due to the constraints imposed by the rigid acenaphthene skeleton in L results in a large 4 JPP of 180 Hz. Sequestration of the lone pairs, either via oxidation of the phosphine or via metal chelation, results in distinct changes in the magnitude of JPP. For tetrahedral d10 complexes ([LMCl2], M = Zn, Cd, Hg), the JPP is comparable to or larger than (193-309 Hz) that in free ligand L, although the P···P separation in these complexes is increased by ca. 0.4 Å (compare to free ligand L). The magnitude of JPP diminishes to 26-117 Hz in square planar d8 complexes ([LMX2], M = Ni, Pd, Pt; X = Cl, Br) and the octahedral Mo0 complex ([LMo(CO)4], 33 Hz). Coupling deformation density calculations indicate the through-space interaction dominates in free L, while in metal complexes the main coupling pathway is via the metal atom.

Analysis of lesion localisation at colonoscopy: outcomes from a multi-centre U.K. study.

BACKGROUND: Colonoscopy is currently the gold standard for detection of colorectal lesions, but may be limited in anatomically localising lesions. This audit aimed to determine the accuracy of colonoscopy lesion localisation, any subsequent changes in surgical management and any potentially influencing factors. METHODS: Patients undergoing colonoscopy prior to elective curative surgery for colorectal lesion/s were included from 8 registered U.K. sites (2012-2014). Three sets of data were recorded: patient factors (age, sex, BMI, screener vs. symptomatic, previous abdominal surgery); colonoscopy factors (caecal intubation, scope guide used, colonoscopist accreditation) and imaging modality. Lesion localisation was standardised with intra-operative location taken as the gold standard. Changes to surgical management were recorded. RESULTS: 364 cases were included; majority of lesions were colonic, solitary, malignant and in symptomatic referrals. 82% patients had their lesion/s correctly located at colonoscopy. Pre-operative CT visualised lesion/s in only 73% of cases with a reduction in screening patients (64 vs. 77%; p = 0.008). 5.2% incorrectly located cases at colonoscopy underwent altered surgical management, including conversion to open. Univariate analysis found colonoscopy accreditation, scope guide use, incomplete colonoscopy and previous abdominal surgery significantly influenced lesion localisation. On multi-variate analysis, caecal intubation and scope guide use remained significant (HR 0.35, 0.20-0.60 95% CI and 0.47; 0.25-0.88, respectively). CONCLUSION: Lesion localisation at colonoscopy is incorrect in 18% of cases leading to potentially significant surgical management alterations. As part of accreditation, colonoscopists need lesion localisation training and awareness of when inaccuracies can occur.

Systematic review of health-related quality of life issues in locally recurrent rectal cancer.

The standardization of surgical techniques supplemented with appropriate neoadjuvant chemoradiation has led to the decline in local recurrence rates of rectal cancer (LRRC) from 25-50% to 5-10%. The outcomes reported for surgical intervention in LRRC is encouraging, however, a number of controversies exist especially in the ultra-advanced and palliative setting. Incorporating health-related quality of life (HRQoL) outcomes in this field could supplement traditional clinical endpoints in assessing the effectiveness of surgical intervention in this cohort. This review aimed to identify the HRQOL themes that might be relevant to patients with LRRC. A systematic review was undertaken to identify all studies reporting HRQoL in LRRC. Each study was evaluated with regards to its design and statistical methodology. A meta-synthesis of qualitative and quantitative studies was undertaken to identify relevant HRQoL themes. A total of 14 studies were identified, with 501 patients, with 80% of patients undergoing surgery. HRQoL was the primary endpoint in eight studies. Eight themes were identified: physical, psychological and social impact, symptoms, financial and occupational impact, relationships with others, communication with healthcare professionals and sexual function. The impact on HRQoL is multifactorial and wide ranging, with a number of issues identified that are not included in current measures. These issues must be incorporated into the assessment of HRQoL in LRRC through the development of a validated, disease-specific tool.

Thoracic spine stab injury with a retained knife.

A female was admitted to a Major Trauma Centre with an isolated thoracic spine stab injury involving a retained knife. The patient was haemodynamically stable with an unremarkable peripheral neurological examination. A CT scan with three-dimensional image reconstruction showed the knife blade lodged in the T11 vertebra with its tip close to the spinal cord, aorta and inferior vena cava. A multidisciplinary trauma team, including anaesthetists, vascular, neurosurgeons and general surgeons, agreed on the treatment strategy. The lodged knife was safely withdrawn in the operating theatre with the patient in a prone position under sedation and local anaesthesia. Following the procedure, neurological examination remained normal, and an MRI scan revealed no spinal cord injury. We discuss the management of penetrating spinal injuries, the importance of detailed preoperative imaging, timely multidisciplinary input and how to safely remove a knife when a prone position prevents standard airway management.

Mechanistic Insights into Cs-Ion Exchange in the Zeolite Chabazite from In Situ Powder X-Ray Diffraction.

Zeolites contain extraframework cations that are exchangeable under favorable aqueous conditions; this is the fundamental feature for their application in water purification and necessary to produce cation forms for other applications such as catalysis. Optimization of the process is common, but there is little fundamental understanding based on real-time experiments of the mechanism of exchange for most zeolites. The sodium and potassium forms of zeolite chabazite selectively uptake Cs+ by ion exchange, leading to its application in removing radioactive 137Cs+ from industrial nuclear waste streams, as well as from contaminated environments in the aftermath of the Fukushima and Three Mile Island accidents. In this study, in situ synchrotron powder X-ray diffraction patterns have been collected on chabazite as it undergoes Cs-ion exchange. Applying Rietveld refinement to these patterns has revealed the time-resolved structural changes that occur in the zeolite as exchange progresses, charting the changes in the spatial distribution of the extraframework cations and water molecules in the structure during the reaction. Ultimately, a detailed mechanistic understanding of how this dynamic ion-exchange reaction occurs has been obtained.

Cohort study to characterise surgical site infections after open surgery in the UK's National Health Service.

OBJECTIVE: To characterise surgical site infections (SSIs) after open surgery in the UK's National Health Service. DESIGN: Retrospective cohort analysis of electronic records of patients from Clinical Practice Research Datalink, linked with Hospital Episode Statistics' secondary care datasets. SETTING: Clinical practice in the community and secondary care. PARTICIPANTS: Cohort of 50 000 adult patients who underwent open surgery between 2017 and 2022. OUTCOME MEASURES: Incidence of SSI, clinical outcomes, patterns of care and costs of wound management. RESULTS: 11% (5281/50 000) of patients developed an SSI a mean of 18.4±14.7 days after their surgical procedure, of which 15% (806/5281) were inpatients and 85% (4475/5281) were in the community after hospital discharge. The incidence of SSI varied according to anatomical site of surgery. The incidence also varied according to a patient's risk and whether they underwent an emergency procedure. SSI onset reduced the 6 months healing rate by a mean of 3 percentage points and increased time to wound healing by a mean of 15 days per wound. SSIs were predominantly managed in the community by practice and district nurses and 16% (850/5281) of all patients were readmitted into hospital. The total health service cost of surgical wound management following SSI onset was a mean of £3537 per wound ranging from £2542 for a low-risk patient who underwent an elective procedure to £4855 for a high-risk patient who underwent an emergency procedure. CONCLUSIONS: This study provides important insights into several aspects of SSI management in clinical practice in the UK that have been difficult to ascertain from surveillance data. Surgeons are unlikely to be fully aware of the true incidence of SSI and how they are managed once patients are discharged from hospital. Current SSI surveillance services appear to be under-reporting the actual incidence.

The current status of robotic colorectal surgery training programmes.

Robotic-assisted colorectal surgery (RACS) is steadily increasing in popularity with an annual growth in the number of colorectal procedures undertaken robotically. Further upscaling of RACS requires structured and standardised robotic training to safeguard high-quality clinical outcomes. The aims of this systematic review were to assess the structure and assessment metrics of currently established RACS training programmes. A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines was performed. Searches were performed of the Ovid Medline, Embase and Web of Science databases between 2000 and 27th November 2021 to identify studies reporting on training curricula in RACS. Core components of training programmes and their relevant outcome assessment metrics were extracted. Thirteen studies were identified, with all training programmes designed for the da Vinci platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Common elements of multimodal programmes included theoretical knowledge (76.9%), case observation (53.8%), simulation (100%) and proctored training (76.9%). Robotic skills acquisition was assessed primarily during the simulation phase (n = 4, 30.1%) and proctoring phase (n = 10, 76.9%). Performance metrics, consisting of time or assessment scores for VR simulation were only mandated in four (30.1%) studies. Objective assessment following proctored training was variably reported and employed a range of assessment metrics, including direct feedback (n = 3, 23.1%) or video feedback (n = 8, 61.5%). Five (38.4%) training programmes used the Global Assessment Score (GAS) forms. There is a broad consensus on the core multimodal components across current RACS training programmes; however, validated objective assessment is limited and needs to be appropriately standardised to ensure reproducible progression criteria and competency-based metrics are produced to robustly assess progression and competence.

Short-term outcomes of health-related quality of life in patients with locally recurrent rectal cancer: multicentre, international, cross-sectional cohort study.

BACKGROUND: Overall survival rates for locally recurrent rectal cancer (LRRC) continue to improve but the evidence concerning health-related quality of life (HrQoL) remains limited. The aim of this study was to describe the short-term HrQoL differences between patients undergoing surgical and palliative treatments for LRRC. METHODS: An international, cross-sectional, observational study was undertaken at five centres across the UK and Australia. HrQoL in LRRC patients was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-CR29 and functional assessment of cancer therapy - colorectal (FACT-C) questionnaires and subgroups (curative versus palliative) were compared. Secondary analyses included the comparison of HrQoL according to the margin status, location of disease and type of treatment. Scores were interpreted using minimal clinically important differences (MCID) and Cohen effect size (ES). RESULTS: Out of 350 eligible patients, a total of 95 patients participated, 74.0 (78.0 per cent) treated with curative intent and 21.0 (22.0 per cent) with palliative intent. Median time between LRRC diagnosis and HrQoL assessments was 4 months. Higher overall FACT-C scores denoting better HrQoL were observed in patients undergoing curative treatment, demonstrating a MCID with a mean difference of 18.5 (P < 0.001) and an ES of 0.6. Patients undergoing surgery had higher scores denoting a higher burden of symptoms for the EORTC CR29 domains of urinary frequency (P < 0.001, ES 0.3) and frequency of defaecation (P < 0.001, ES 0.4). Higher overall FACT-C scores were observed in patients who underwent an R0 resection versus an R1 resection (P = 0.051, ES 0.6). EORTC CR29 scores identified worse body image in patients with posterior/central disease (P = 0.021). Patients undergoing palliative chemoradiation reported worse HrQoL scores with a higher symptom burden on the frequency of defaecation scale compared with palliative chemotherapy (P = 0.041). CONCLUSION: Several differences in short-term HrQoL outcomes between patients undergoing curative and palliative treatment for LRRC were documented. Patients undergoing curative surgery reported better overall HrQoL and a higher burden of pelvic symptoms.

Development and validation of a patient reported outcome measure for health-related quality of life for locally recurrent rectal cancer: a multicentre, three-phase, mixed-methods, cohort study.

Background: Locally recurrent rectal cancer (LRRC) occurs in 5-10% of patients following previous treatment of rectal cancer. It has a significant impact on patients' overall health-related quality of life (HrQoL). Major advances in surgical treatments have led to improved survival outcomes. However, due to the lack of disease-specific, validated patient-reported outcome measure (PROM), HrQoL, is variably assessed. The aim of this study is to develop a disease-specific, psychometrically robust, and validated PROM for use in LRRC. Methods: A multicentre, three phase, mixed-methods, observational study was performed across five centres in the UK and Australia. Adult patients (>18 years old) with an existing or previously treated LRRC within the last 2 years were eligible to participate. Patients completed the proposed LRRC-QoL, EORTC QLQ-CR29, and FACT-C questionnaires. Scale structure was analysed using multi-trait scaling analysis and exploratory factor analysis, reliability was assessed using Cronbach's and the intra-class coefficient, convergent validity was assessed using Pearson's correlation, and known-groups comparison was assessed using the student t-test or ANOVA. Findings: Between 01/03/2015 and 31/12/2019, 117 patients with a diagnosis of LRRC were recruited. The final scale structure of the LRRC-QoL consisted of nine multi-item scales (healthcare services, psychological impact, pain, urostomy-related symptoms, lower limb symptoms, stoma, sexual function, sexual interest, and urinary symptoms) and three single items. Cronbach's Alpha and Intraclass correlation values of >0.7 across the majority of scales supported overall reliability. Convergent validity was demonstrated between LRRC-QoL Pain Scale and FACT-C Physical Well Being scale (r = 0.528, p < 0.001), LRRC-QoL Psychological Impact scale with EORTC QLQ CR29 Body Image (r = 0.680, p < 0.001) and the FACT-C Emotional Well Being scale (r = 0.326, p < 0.001), and LRRC-QoL Urinary Symptoms scale with EORTC QLQ-CR29 Urinary Frequency scale (r = 0.310, p < 0.001). Known-groups validity was demonstrated for gender, disease location, treatment intent, and re-recurrent disease. Interpretation: The LRRC-QoL has demonstrated robust psychometric properties and can be used in clinical and academic practice. Funding: None.

The importance of PEOPLE who use drugs within drug policy reform debates: Findings from the UK Drug Policy Voices online survey.

BACKGROUND: Drug Policy Voices is a UK-based project designed to integrate the voices and experiences of people who use drugs (PWUD) into debates about drug policy reform. An online survey was conducted in 2020 to understand opinions connected to drug use and drug policy. We used a blended values approach combining Moral Foundations Theory (Haidt and Joseph, 2004; Haidt and Graham, 2007) and MacCoun and Reuter's (2001) four philosophical positions that underpin the drug policy. This paper asks, what values do people who use drugs hold surrounding drug use and drug policy, and what factors predict these values? METHODS: We used online-purposive sampling and achieved 1217 survey responses, which captured sociodemographic characteristics, patterns of drug use, sourcing and supply of drugs used within the last 12 months, experiences of criminal justice sanctions in connection to drugs, and experiences of alcohol or other drug treatment. In addition, we devised 37 attitudinal questions about drug use and drug policy, which included both progressive and prohibitionist value positions. RESULTS: The exploratory factor analysis revealed a six-factor solution that identified important value positions for this respondent group, which are personal autonomy, paternalism 1; paternalism 2; legal injustice 1; legal injustice 2; and neoliberal governance. Age, gender, religious beliefs, political views, identifying as a recreational drug taker, using drugs recently, and having experience of working or studying in the substance use/drug policy field are predictors of these value positions. CONCLUSION: The Drug Policy Voices survey has identified collective values and ideology connected to lived experience that illustrate a clear goal conflict with prohibitionist ideology. PWUD have valuable contributions to make to the policy reform debate, but we must acknowledge that opinions are not formed through drug-related experiences alone. The findings of this research highlight the importance of emphasising the person who uses drugs within participatory approaches.

Anatomical approaches in locally advanced and recurrent pelvic malignancy.

Pelvic exenteration is a complex, technically challenging procedure requiring detailed anatomical knowledge. Understanding the complexity of the pelvis beyond TME is an essential requirement for both operative planning and execution. This paper highlights the key anatomical approaches to extended pelvic resection as relevant to the Colorectal Surgeon.

Utilising quality of life outcome trajectories to aid patient decision making in pelvic exenteration.

BACKGROUND: Shared decision-making in pelvic exenteration is a complex and detailed process, which must balance clinical, oncological and patient-reported outcomes (PROs), whilst addressing and valuing the patient priorities. Communicating patient-centred information on quality of life (QoL) and functional outcomes is an essential component of this. The aim of this systematic review was to understand the impact of pelvic exenteration on QoL PROs over a longitudinal period and to develop QoL trajectories to support decision-making in this context. METHODS: MEDLINE, Embase and Web of Science databases were searched between 1st January 2000 and 20th December 2021 Studies reporting on PROs, including QoL, in adults undergoing pelvic exenteration were included. Risk of bias was assessed using the ROBINS-I assessment tool. Data from studies reporting QoL using the same outcome measure at the same candidate timepoint were extracted and synthesised to develop a longitudinal QoL trajectory. RESULTS: Fourteen studies consisting of 1370 patients were included in this review. QoL trajectories were constructed in the domains of physical function, psychological function, role function, sexual function, body image and general and specific symptoms. Decision-making was only assessed by one study, with satisfaction with decision-making reported to be high. There is an initial decline in QoL scores in the domains of physical function, role function, sexual function, body image and general health and symptoms deteriorating during the first 3-6 months post-operatively. Psychological function is the only QoL domain that remains stable throughout the post-operative period. CONCLUSION: Mapping QoL trajectories provides a visual representation of post-operative progress, highlighting the enduring impact of pelvic exenteration on patients and can be used to inform pre-operative shared decision-making.

Recruiting to surgical trials in the emergency setting: using a mixed methods study to understand clinician and patient perspectives.

BACKGROUND: Undertaking randomized clinical trials (RCTs) in emergency surgical settings is associated with methodological and practical challenges. This study explored patients' and clinicians' perspectives associated with the conduct of an RCT comparing laparoscopic and open colorectal surgery in the acute setting. METHODS: All eligible patients screened and enrolled for the 'Laparoscopic versus open colorectal surgery in the acute setting (LaCeS)' multicentre, randomized clinical feasibility trial in five UK NHS Trusts were invited to respond to a survey. Patients and healthcare professionals were also invited to take part in semi-structured interviews. Survey and interviews explored the acceptability of the feasibility trial. Interviews were audio recorded, transcribed verbatim, and analysed using thematic analysis. Survey data were analysed descriptively to assess patient views of the trial and intervention. RESULTS: Out of 72 patients enrolled for the LaCeS RCT, survey data were collected from 28 patients (38.9 per cent), and interviews were conducted with 16 patients and 14 healthcare professionals. Thirteen out of 28 patients (46 per cent) had treatment preferences but these were not strong enough to deter participation. Twelve of the patients interviewed believed that their surgeon preferred laparoscopic surgery, but this did not deter them from participating in the trial. Half of the surgeons interviewed expressed the view that laparoscopic surgery was of benefit in this setting, but recognized that the need for research evidence outweighed their personal treatment preferences. Eight of the 14 recruiters reported that the emergency setting affected recruitment, especially in centres with fewer recruiting surgeons. Interviewees reported that recruitment was helped significantly by using surgical trainees to consent patients. CONCLUSION: This study identified specific challenges for the LaCeS trial design to address and adds significant insights to our understanding of recruiting to emergency surgical trials more broadly.