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In the period since multi-agency working became the dominant approach to tackling domestic abuse, there has been ongoing development and innovation. However, little is known about what tends to enhance or inhibit the roll-out of such initiatives. This article examines the process of building an enhanced flagship multi-agency model for policing domestic abuse. We report on results from semi-structured interviews, observations of meetings and an online survey with stakeholders who were involved in the development of the principles underlying a new multi-agency risk assessment conference (MARAC) process. The participants representatives from policing, third sector, health, and probation organisation-described positive benefits of the process, whilst challenges coalesced around the focus on and engagement of perpetrators, and the problem of assessing the dynamics of risk.

This article discusses ‘special observation’, a practice used in inpatient units and in mental health and learning disability services. I present some perspectives on this practice from women detained on locked wards, and staff members. Despite the many valid criticisms, I show that constant observations can be used as a way to harness engagement and to improve relationships between staff and residents.

The international FOxTROT trial, recently published in the Journal of Clinical Oncology, (ref awaited) is the first randomised controlled trial testing neoadjuvant chemotherapy (NAC) with oxaliplatin and 5-fluorouracil in locally advanced but operable colon cancer. 1053 patients with operable, radiologically staged T3-T4, N1-2, M0 colon cancer were recruited from over 100 sites in the UK, Sweden and Denmark. Patients were randomised to 6 weeks of planned chemotherapy before resectional surgery, followed by adjuvant chemotherapy; or upfront surgery followed by adjuvant chemotherapy (total 18 weeks in both arms). NAC was safe and, compared with standard treatment, there was no increase in surgical complications, a higher R0 rate (95% vs 89%, p0.001), and significant primary and nodal pathological downstaging. The trial met its primary endpoint with fewer patients experiencing recurrent or residual disease at 2 years with NAC compared with control: (16.8% vs 21.2%, risk ratio=0.74, p=0.042). Rapid translation of these results into patient benefit is expected, particularly as the chemotherapeutic agents are already used routinely and do not incur any additional cost or toxicity. However, offering NAC as standard care for advanced colon cancer requires adaptations to current treatment pathways so presents organisational challenges. To date, the Leeds Cancer Centre, St James's University Hospital, UK has commenced 64 patients on the novel pathway following presentation and adoption of the FOxTROT results. Here, we describe our experience and share strategies developed across the MDT to minimise impact on person hours, service capacity and budget, whilst building patient safety and confidence.

Purpose Finding a balance between the provision of quality individualized care and the ongoing education of junior doctors had been flagged as a concern at a large National Health Service (NHS) teaching hospital in the north of England. In response to this, the organization introduced an intervention designed to improve educational culture by providing support to educators, leaders and clinical staff. Design/methodology/approach This paper features themed results from eight in-depth interviews with educators, consultants and junior doctors to describe and evaluate the process and impact. Findings Factors that contributed to a positive educational environment included trainees and educators feeling valued, the presence of supportive leaders and the provision of a safe space for learning. Perceived barriers included time constraints, differing motivation and the generic format of formal education. Participants reflected on how the Wrap Around project helped improve the workplace educational culture and offered suggestions for further improvement including the provision of ongoing feedback to learners about their performance. Originality/value Research aimed at recognizing and resolving the perceived tensions between the priorities of education and health-care delivery has been flagged as a gap in the literature. The authors argue that developing and enhancing collaborative leadership and educational culture within an organization can reduce these tensions for those working on the front line. Future work should focus on addressing the perceived distinction between the two within services.

1. Sneha Butala, MD* 2. Lauren Pronman, DO*,† 3. Michelle Baechtold, MD‡ 4. Timmie R. Sharma, MD‡ 5. Rebecca Fish, MD§ 6. Qin Yao, MD§ 1. *Department of Pediatrics and 2. §Division of Neonatology and Perinatal Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH 3. †Department of Genetics and Genomics and 4. ‡Department of Dermatology, University Hospitals Cleveland Medical Center, Cleveland, OH A 24-year-old gravida 2 para 1 woman presents at 32 weeks’ gestation with vaginal bleeding concerning for placental abruption. The prenatal history is unclear because the mother obtained most of her prenatal care in Mexico. She precipitously gives birth to a female infant via breech vaginal delivery. On delivery, the infant is intubated and given 1 dose of surfactant due to respiratory failure. Apgar scores are 2 and 3 at 1 and 5 minutes, respectively. The birthweight is 1,900 g. A chest radiograph demonstrates diffuse severe alveolar opacity in bilateral lung fields consistent with severe respiratory distress syndrome. The infant is transported to a tertiary center and develops worsening hypoxia requiring 100% oxygen. The blood gas on admission reveals severe mixed respiratory and metabolic acidosis. The infant receives additional doses of surfactant and a prolonged period of respiratory support. The severity of the infant’s respiratory distress syndrome is disproportionate to the degree of prematurity. Pertinent physical examination findings include mottling of the skin with thick white scale. The scale is symmetrical, involving the scalp, shoulders, and extremities (Figs 1 and 2). External ear canals are not visible; they may be absent or occluded by the scale, which is also found around the nares. Thin erosions in rectangular shapes on her abdomen are noted where cardiac leads have been placed. Erosions are also found on the right side of the face near the endotracheal tube securement device and on the bilateral dorsum of feet. Auscultation of the lungs reveals coarse breath sounds and diffuse crackles bilaterally, without increased work of breathing, retractions, or nasal flaring. There is no collodion membrane, ectropion (outturning of the eyelids), or eclabium (outturning of the lips) present. Figure 1. Thick adherent scales and erosions on day 1. Figure 2. Thick adherent scales and erosions at 4 weeks. The complete blood …

Aim: Discussions regarding sex after colorectal and pelvic floor surgery are often overlooked by clinicians. This is the first patient designed and delivered study to explore sexual function and practices after colorectal surgery. The aim was to explore the questions about sex that matter to patients and their partners following colorectal or pelvic floor surgery through a patient and public involvement survey. The results of this work will underpin the creation of a sex patient reported outcome measure. Methods: An anonymous online survey tool (Survey Monkey™) was disseminated via social media (Twitter, Facebook). Thematic analysis was applied to 130 free text comments posted by participants to identify key themes. Results: Some 632 individuals completed the survey. Most respondents were women (80% n = 507), 49.5% (n = 312) were married and 14% (n = 87) identified as LGBT+ (lesbian, gay, bisexual and transgender +). Indications for surgery varied: 34% were treated for ulcerative colitis (n = 214); 31% Crohn's (n = 196); 17% (n = 109) cancer; and 17% (n = 110) for perianal fistula. For patients who had a stoma formed (85%, n = 540), over half (51%, n = 324) lived with their stoma for 1–5 years. Respondents reported substantial alterations to their preferences for sexual positions, sexual activity and body confidence following surgery. Most respondents indicated that they were not offered advice about sex by a healthcare professional. Conclusions: The survey showed a substantial impact on the mechanics of sex following colorectal surgery. Few patients were offered preoperative information regarding sex, which has implications for informed consent. This study demonstrates a clear unmet need, voiced by patients, that open dialogue is necessary preoperatively to discuss sexual (dys)function.

Aim: Surgical site infection (SSI) is a common complication following emergency laparotomy, occurring in around 25% of patients in UK practice. The adoption of single-use negative-pressure dressings (SUNPDs) has been proposed as a prophylactic method of reducing the rate of SSI. The primary aim of the randomized controlled trial (RCT) described herein is to determine if a SUNPD reduces SSI at 30 days after an emergency laparotomy. Method: The Single Use Negative pRessure dressing for Reduction In Surgical site infection following Emergency laparotomy (SUNRRISE) study is an international, multicentre, pragmatic, phase III RCT with internal feasibility phase. As stated, the primary aim is to determine if a SUNPD reduces SSI at 30 days postoperatively. Patients will be randomized in a 1:1 ratio to receive either a SUNPD or a dressing of the surgeon's preference. Outcome assessors will be blinded to treatment allocation. The primary outcome measure is SSI within 30 days of surgery as defined by the US Centers for Disease Control criteria. A total of 840 patients will be required to detect a relative reduction of 40% in SSI rates (from 25% to 15%) with 90% power accounting for a 20% attrition rate. Discussion: SUNRRISE is an international, multicentre RCT evaluating the prophylactic use of SUNPD in primary closed emergency laparotomy wounds for the reduction of SSI. Our hypothesis is that a SUNPD is superior to the surgeon's preference of dressing in reducing SSIs at 30 days. The findings may influence dressing choice following emergency abdominal surgery in the future.

Objective The objective of this study is to determine the resuscitation choices at 22-24 weeks gestation, related to whether mothers received antenatal counseling and the timing relative to delivery. Study design A retrospective chart review was performed of infants inborn at 22-24 weeks, over a 5-year period. Infants were excluded if they had major birth defects, were still hospitalized, or the consult occurred before 22 weeks. Result Of 121 infants born at 220-246 weeks, 91 were born to mothers who received a neonatology consult. For 80 infants resuscitated after consult, the median time between consult and delivery was 51.7 h (range: 0.1-366.3 h). For 11 infants who received comfort care after consult, the median time between consult and delivery was 20.0 h (range: 0.8-64.4 h). Conclusions After receiving counseling on the morbidity and mortality of delivery at 22-24 weeks, most parents chose resuscitation. Overall, 12-24 h between consult and delivery, parents were more likely to choose comfort care.

IntroductionAnal cancer is rare, but its incidence is increasing. Chemoradiotherapy is the primary treatment modality. Outcomes used in anal cancer trials vary which hinders evidence synthesis. Using a systematic review, patient interviews and a 2-stage Delphi consensus survey, the first CORMAC project brought together patients and healthcare professionals from across the world to agree shared priorities and make sure that studies of chemoradiotherapy treatments for anal cancer report outcomes that are meaningful to patients and health care professionals. CORMAC-1 established an internationally ratified core outcome set (COS) of 19 outcomes across 4 domains. These 19 outcomes are an agreed minimum that all clinical trials in chemoradiotherapy anal cancer trials should report. CORMAC-2 is the next phase which seeks to reach international agreement on the definitions for the 11 core outcomes in the domains of disease activity and survival. Agreeing definitions for these core outcomes will facilitate utilisation of the core outcome set, increasing outcome standardisation across trials thereby increasing the quality of data available for clinical decision-making and ultimately enhancing patient care.MethodsThe original CORMAC systematic review will be updated, focusing on 2 of the 4 COS domains, disease activity and survival domains. An international steering committee composed of international anal cancer trial experts will be formed. The committee will review the updated search results to develop a 2-stage Delphi consensus survey. The survey will be publicised through conferences, email lists, domestic and international bodies and will target healthcare and allied healthcare professional involved in the design, running, recruitment and publication of anal cancer trials. Following the 2-stage survey, a stakeholder meeting composed of the steering committee and selection of survey participants will ratify the results and agree a final set of core outcome definitions.Ethics and disseminationCORMAC-2 results will be disseminated through journal and conference publications to inform clinical teams and patient support groups to raise awareness and implementation of the core outcome set. Results will feed into the DECREASE study and it is registered with the Core Outcome Measures in Effectiveness Trials (COMET) initiative (1,2). As per the University of Manchester ethic decision tool, no ethical approval is required. Further information is available at https://cormacstudy.wordpress.com.

All behaviours occur within a relational and circumstantial context (Milton, Mills, and Jones 2016), and from time to time everyone behaves in ways that are difficult to understand and respond to. ...

Background: Despite repeated policy initiatives an enduring number of people with learning disabilities remain resident in secure settings (also referred to as locked wards). The distance, geographic and emotional, from family and friends when resident in these settings makes relationships with staff central to people’s lives and a critical factor in residents’ ability to be in a successfully transition or ‘move on’ to make their home in the community. Materials and Methods This article uses a synthesis of evidence from two qualitative studies. Data from field notes and transcripts of interviews with people with learning disabilities resident in secure settings and with staff who worked with them were analysed. The purpose of the original studies was service improvement, however relationships, particularly with between staff and residents emerged as a significant theme in both studies. Therefore, the data was revisited to explore these relationships in more depth and comparatively between both studies. Results and Discussion The analysis identified that positive relationships with staff was critical in enabling residents to be ‘being in a good space’, something they and staff viewed as a crucial factor for moving to less secure hospital settings and ultimately being at home in the community. The analysis identified four main themes: (i) the characteristics of positive relationships. (ii) the challenges for positive relationships, (iii) how positive relationships can be encouraged and (iv) how they support people to move on. Conclusion: We conclude that flattening the hierarchy between staff and residents is key when supporting people with learning disabilities to move back into the community. There is a pressing need for research with people who have made the transition from hospital to generate retrospective narratives about what elements of these relationships are most significant in supporting a successful transition to life in the community.

This book is a comprehensively researched US-focused historical analysis of the evolution – and eventual move away from – institutional peonage. Author Ruthie-Marie Beckwith describes institutional...

Background Shame is a trans-diagnostic phenomenon which underlies a variety of mental health difficulties. People with Intellectual Disabilities (ID) are reported to be one of the most stigmatised and excluded groups in society, and are more likely to experience mental health problems than the general population. Consequently, this group may be at significant risk of shame-related distress. However, a lack of research has been conducted which investigates the experience of shame in people with ID, and there is currently a lack of interventions targeting shame in people with ID. Method Two case studies were undertaken to document the experiences of stigma, discrimination and shame in people with ID, and to explore how shame may present in this population. Results Shame was found to be a significant barrier to social inclusion and can contribute towards poor psychological health in people with ID. Conclusions The development of interventions which specifically target shame in this population are required.

Background: The COMET Initiative promotes the development and use of ‘core outcome sets’ (COS), agreed standardised sets of outcomes that should be measured and reported in all studies in a particular clinical condition. COS are determined by consensus amongst key stakeholders, including health professionals, policymakers and patients, ensuring that the priorities and expertise of these representatives inform the choice of the most important outcomes to measure for a given condition. There is increased recognition of the need to integrate COS across the healthcare system and with existing regulatory apparatus, to ensure that outcomes being recorded are those of key relevance to important stakeholders. The aim of this study is to assess the degree of concordance between outcomes recommended in COS for research and in guidance provided by two key regulators: US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). Methods: COS for research published during 2015-2019 with patient involvement and covering drug or device interventions will be compared against relevant regulatory guidelines, matched by condition. Guidance documents matching in scope (relating to intervention and population) to a COS for research will be scrutinised to identify all suggested outcomes for comparison against the core outcomes in the corresponding COS. Discussion: This study will identify variation between outcomes suggested in FDA and EMA regulatory guidance relative to outcomes included in published COS for research, thus demonstrating the degree of representation of COS in regulatory guidance and vice versa. We will share the study findings (in particular, highlighting any lack of concordance between COS and regulatory guidance overall or for particular disease areas) and will invite feedback from FDA and EMA; we will seek to highlight where findings support the recommendations towards using well-developed COS or will make recommendations to COS developers on outcomes of importance to these key regulators.

Objective: The objectives of this nested study were to (1) assess whether changes in scores between rounds altered the final degree of consensus achieved in three Delphi surveys conducted as part of COS development projects (anal, gastric, and prostate cancer), and (2) explore participants' reasons for changing scores between rounds.Study design and setting: All Delphi surveys were conducted online using DelphiManager software and included healthcare professionals and participating patients. Participants were invited to give a free-text reason whenever they changed their score across an important threshold on a 1-9 Likert scale (1-3 not important, 4-5 important, 7-9 critically important). Reasons for score change were coded by four researchers independently using an inductive-iterative approach.Results: In all three Delphi surveys, the number of outcomes reaching criteria for consensus was greater in R2 than R1. Twelve themes and 23 subthemes emerged from 2298 discrete reasons given for score change. The most common reasons for the change were "time to reflect" (482 responses, 23%) and vicarious thinking (424, 21%), with 68% (291) of vicarious thinking attributed to seeing other participant's scores.Conclusion: Our findings support conducting a Delphi survey over the use of a single questionnaire where building consensus is the objective. Time to reflect and vicarious thinking, facilitated by seeing other participant's scores, were important drivers of score change. How results are presented to participants between rounds and the duration of and time between rounds in a Delphi survey may, therefore, influence the results and should be clearly reported.Keywords: Core outcome set development; Delphi survey; Feedback methods; Stakeholders; consensus; patient public involvement.

Determine if antenatal counseling delivered in the outpatient setting improves parental knowledge and satisfaction without contributing to anxiety. Randomized control trial at a large academic institution. Mothers at risk for preterm delivery were enrolled following routine maternal-fetal medicine (MFM) visits and randomized to early antenatal counseling of prematurity or standard counseling by MFM providers. The primary outcome was parental knowledge of prematurity. Secondary outcomes included parental satisfaction, anxiety scores, and compliance with recommended follow-up. Seventy-six women were enrolled, 38 in each group. Early counseling group had higher knowledge scores (86.3 vs 64.3, p =

AIM: Pseudomyxoma peritonei (PMP) is a rare neoplasm of the appendix, which if untreated disseminates throughout the abdominal cavity and generates considerable morbidity. Since 2002 in the UK, patients with PMP have been managed via two nationally commissioned centres. We evaluated referrals and treatment pathways over time at the Manchester centre.METHOD: Data from all patients referred with suspected PMP were prospectively collected (2002-2015). Definitive treatment was cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC). Disease burden was quantified using the Peritoneal Cancer Index (PCI: score 0-39) and complete cytoreduction (CC) defined by scores of 0/1. Novel treatment algorithms were developed for patients with low-grade appendiceal mucinous neoplasm (LAMN) localised to the peri-appendiceal tissue.RESULTS: 817 patients with confirmed PMP were referred increasing from 11 in 2002 to 103 in 2015. Disease burden was high with mean PCI of 31 in the first quartile (Q1), levelling-off to 15,15,17 thereafter (p = 0.002). The proportion of CC0/1 increased from 67% in Q1 to 77% Q2 and 74% Q3/4. Where complete cytoreduction was achieved, 5 and 10-year overall survival was 77% and 66%. The proportion of patients referred with localised LAMN increased over time reaching 25% each year since 2010 (Ptrend CONCLUSION: The establishment of a national treatment centre was associated with an initial presentation of patients with advanced disease. The programme has demonstrated a clear trend over time towards earlier referral and adoption of minimal invasive techniques for localised disease. This article is protected by copyright. All rights reserved.

AIM: Six Phase III randomized trials have determined the effectiveness of chemoradiotherapy as primary treatment for anal squamous cell carcinoma (ASCC), but outcomes reported in these trials varied widely, hindering evidence synthesis. To improve reporting in all future trials, we aim to develop a core outcomes set (COS). As the first stage of COS development, we undertook a systematic review to summarize the outcomes reported in studies evaluating chemoradiotherapy for ASCC.METHOD: Systematic literature searches identified studies evaluating radiotherapy or chemoradiotherapy for ASCC. Outcomes and accompanying definitions were extracted verbatim and categorized into domains.RESULTS: From 5170 abstracts, we identified 95 eligible studies, reporting 1192 outcomes and 533 unique terms. We collapsed these terms into 86 standardized outcomes and five domains: survival; disease activity; life impact [including quality of life (QoL)]; delivery of care; and toxicity. The most commonly reported domains were survival and disease activity, reported in 74 (86%) and 54 (62%) studies, respectively. No outcome was reported in every publication. Over half (43/86) of the standardized outcome terms were reported in fewer than five studies, and 21 (25%) were reported in a single study only. There was wide variation in definitions of disease-free survival, colostomy-free survival and progression-free survival (PFS). Anal continence was reported in only 35 (41%) studies.CONCLUSION: Outcomes reported in studies evaluating chemoradiotherapy for ASCC were heterogenous and definitions varied widely. Outcomes likely to be important to patients, such as ano-rectal function, toxicity and QoL, have been neglected. A COS for future trials will address these issues.

Aims/Objectives/BackgroundAcademic emergency medicine (EM) is a young field in the United Kingdom (UK) with a small critical mass of clinical academics, who have protected time to conduct research alongside clinical duties. There is a little published information on the academic training available to emergency physicians.In the UK, academic clinical fellowships (ACFs) offer a structured opportunity for trainees to develop skills and experience in research alongside clinical training. We aimed to capture information on the prior experience of emergency medicine (EM) fellows, as well as how the ACFs were structured and the next career steps for fellows upon completion.Methods/DesignA ten-question survey was designed by the project steering committee and circulated UK wide to all current fellows in EM and those that completed the programme in the last five years. Fellows were identified by contacting programme leads in every region. Data was collected via SurveyMonkey® between 18thFebruary 2021 and 25th March 2021.ResultsWe approached a total of 34 EM ACFs. The survey yielded a 91% (n=31) response rate (13 current, 18 completed within 5 years). One university from Wales and ten from England have supported EM ACF schemes. 59% (n=10) of those who have completed the scheme had their clinical training extended to accommodate research time. In the remainder, fellows were expected to achieve clinical competencies in the same time as trainees who did not spend time on research. In those who had completed the ACF programme (n=18), one third of respondents are doing PhD training (n=6) and one is an academic clinical lecturer.ConclusionWe found variation in how the schemes are implemented. Future research is required to explore the experiences of those undertaking EM ACFs in more detail to identify the features of successful ACF training schemes, and whether any aspects may benefit from standardisation.

Background The move to community support for all people with intellectual disabilities is an aspiration with international significance. In this article, we draw on rich accounts from women with intellectual disabilities detained under the Mental Health Act (E&W) 1983 and staff at an National Health Service secure setting in England to explore how “moving on” is defined and perceived. Methods The study reports on an ethnographic study using the field‐notes and the 26 semi‐structured interviews with detained women and staff on three wards. Results We first explore staff conceptions of moving on, which include behavioural change and utilizing coping strategies. Then, we discuss the areas of analysis that women discussed: taking back responsibility, success in arranged relationships, acceptance of regime and resistance to progression. Conclusion The concepts of moving on were not determined by the women but by the service. We recommend further research which explores women's own rehabilitation requirements.