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Introduction: Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE). Methods: Program participants were surveyed by telephone after their ED visit about their substance use, overdose risk knowledge, history of witnessed and personal overdoses, and actions in a witnessed overdose including use of naloxone. Results: A total of 415 ED patients received OE or OEN between January 1, 2011 and February 28, 2012. Among those, 51 (12%) completed the survey; 37 (73%) of those received a naloxone kit, and 14 (27%) received OE only. Past 30-day opioid use was reported by 35% OEN and 36% OE, and an overdose was reported by 19% OEN and 29% OE. Among 53% (27/51) of participants who witnessed another individual experiencing an overdose, 95% OEN and 88% OE stayed with victim, 74% OEN and 38% OE called 911, 26% OEN and 25% OE performed rescue breathing, and 32% OEN (n=6) used a naloxone kit to reverse the overdose. We did not detect statistically significant differences between OEN and OE-only groups in opioid use, overdose or response to a witnessed overdose. Conclusion: This is the first study to demonstrate the feasibility of ED-based opioid overdose prevention education and naloxone distribution to trained laypersons, patients and their social network. The program reached a high-risk population that commonly witnessed overdoses and that called for help and used naloxone, when available, to rescue people. While the study was retrospective with a low response rate, it provides preliminary data for larger, prospective studies of ED-based overdose prevention programs. [West J Emerg Med. 2015;16(3):381–384.]

Abstract Introduction Physician-review websites (PRWs) are commonly used by patients while searching for a surgeon. There is no current literature investigating the factors that contribute to online one-star reviews of musculoskeletal oncology surgeons. This retrospective study aims to identify these factors to determine areas of care affecting patient’s subjective reviews. Methods Patient ratings and comments regarding musculoskeletal oncology surgeons from the Musculoskeletal Tumor Society (MSTS) were collected from Vitals.com. One-star reviews with comments were then classified as either operative or nonoperative. These complaints were then further classified based on content including wait time, uncontrolled pain, time spent with the physician, surgical outcomes, medical staff/institutional complaints, and bedside manner. Results A total of 169 reviews (375 complaints) from 181 physicians were included. Of these complaints, 198 were from patients in the operative category while 177 were from patients in the nonoperative category. Bedside manner was the most common complaint. Operative patients reported higher instances of uncontrolled pain in their reviews, whereas nonoperative patients more frequently cited wait time. No significant difference in the complaints that mentioned the amount of time spent with the physician, bedside manner, a disagreement with the plan, or the medical staff or institution was found. Conclusion Online one-star reviews of musculoskeletal oncology surgeons on Vitals.com referenced both surgical and non-surgical aspects of patient encounters, with bedside manner being the most popular complaint overall. Surgical patients were more likely to complain of uncontrolled pain whereas non-operative patients were more likely to complain of wait time. Type of study Outcomes 2c.

Background: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major treatment of colorectal peritoneal carcinomatosis (CPC). The aim was to determine the disease-free survival (DFS) and overall survival (OS) of patients undergoing CRS–HIPEC for CPC and factors associated with long-term survival (LTS). Methods: consecutive CPC patients who underwent CRS–HIPEC at a HIPEC center between 2007 and 2021 were included. Actual survival was calculated, and Cox proportional hazards models were used to identify factors associated with OS, DFS and LTS. Results: there were 125 patients with CPC who underwent primary CRS–HIPEC, with mean age of 54.5 years. Median follow-up was 31 months. Average intraoperative PCI was 11, and complete cytoreduction (CC-0) was achieved in 96.8%. Median OS was 41.6 months (6–196). The 2-year and 5-year OS were 68% and 24.8%, respectively, and the 2-year DFS was 28.8%. Factors associated with worse OS included pre-HIPEC systemic therapy, synchronous extraperitoneal metastasis, and PCI ≥ 20 (p < 0.05). Progression prior to CRS–HIPEC was associated with worse DFS (p < 0.05). Lower PCI, fewer complications, lower recurrence and longer DFS were associated with LTS (p < 0.05). Conclusion: CRS and HIPEC improve OS in CPC patients but they have high disease recurrence. Outcomes depend on preoperative therapy response, extraperitoneal metastasis, and peritoneal disease burden.

The surgical management of adult spinal deformities (ASDs) involves a wide variety of complex and technically challenging operative techniques. Despite numerous publications examining the relationship between surgeon experience and outcomes in ASD, no systematic review or meta-analysis exists. This first-time systematic review and meta-analysis examines the impact of surgeon experience on the surgical parameters and complication rates for the surgical management of ASD. Four databases were used for the initial search of this study from database inception until 22 September 2023. The inclusion criteria required articles that examined the outcomes for surgery for ASD, stratified outcomes by surgeon experience and/or the learning curve as a proxy for surgeon experience, and utilized adult patients (>18 years of age). Seven articles met the criteria for final inclusion. Patients in the Experienced Surgeon group had statistically significantly lower levels of EBL with no significant difference in operative time after surgery for ASD compared to patients in the Inexperienced Surgeon group via a meta-analysis of three articles. Patients in the Experienced Surgeon group had a statistically significantly lower total complication rate compared to patients in the Inexperienced Surgeon group via a meta-analysis. Increased surgeon experience resulted in lower levels of EBL, without a significant difference in the operative time after surgery for ASD.

Abstract Background Women who engage in sex work and use drugs (WSWUD) experience disproportionate HIV risks. Substance use treatment bridge clinics offer an opportunity to increase HIV pre-exposure prophylaxis (PrEP) delivery to WSWUD, but research on best practices is lacking. Therefore, we explored facilitators and barriers to PrEP across the PrEP care continuum in these settings. Methods Bridge clinic and affiliated harm reduction health service providers and WSWUD from Boston were recruited using passive and active outreach between December 2021 and August 2022. Participants were invited to take part in semi-structured phone or in-person interviews to explore HIV prevention and PrEP care experiences overall and within bridge clinic settings. Deductive codes were developed based on HIV risk environment frameworks and the Information-Motivation-Behavioral Skills model and inductive codes were added based on transcript review. Grounded content analysis was used to generate themes organized around the PrEP care continuum. Results The sample included 14 providers and 25 WSWUD. Most WSWUD were aware of PrEP and more than half had initiated PrEP at some point. However, most who initiated PrEP did not report success with daily oral adherence. Providers and WSWUD described facilitators and barriers to PrEP across the steps of the care continuum: Awareness, uptake, adherence, and retention. Facilitators for WSWUD included non-stigmatizing communication with providers, rapid wraparound substance use treatment and HIV services, having a PrEP routine, and service structures to support PrEP adherence. Barriers included low HIV risk perceptions and competing drug use and survival priorities. Provider facilitators included clinical note templates prompting HIV risk assessments and training. Barriers included discomfort discussing sex work risks, competing clinical priorities, and a lack of PrEP adherence infrastructure. Conclusion WSWUD and bridge clinic providers favored integrated HIV prevention and substance use services in harm reduction and bridge clinic settings. Harm reduction and bridge clinic programs played a key role in HIV prevention and PrEP education for WSWUD. Effective behavioral and structural interventions are still needed to improve PrEP adherence for WSWUD.

Background Good quality shared decision-making (SDM) conversations involve people with, or at risk of osteoporosis and clinicians collaborating to decide, where appropriate, which evidence-based medicines best fit the person’s life, beliefs, and values. We developed the improving uptake of Fracture Prevention drug treatments (iFraP) intervention comprising a computerised Decision Support Tool (DST), clinician training package and information resources, for use in UK Fracture Liaison Service consultations. Two primary objectives to determine (1) the effect of the iFraP intervention on patient-reported ease in decision-making about osteoporosis medicines, and (2) cost-effectiveness of iFraP intervention compared to usual NHS care. Secondary objectives are to determine the iFraP intervention effect on patient reported outcome and experience measures, clinical effectiveness (osteoporosis medicine adherence), and to explore intervention acceptability, mechanisms, and processes underlying observed effects, and intervention implementation. Methods The iFraP trial is a pragmatic, parallel-group, individual randomised controlled trial in patients referred to a Fracture Liaison Service, with nested mixed methods process evaluation and health economic analysis. Participants aged ≥50 years (n=380) are randomised (1:1 ratio) to one of two arms: (1) iFraP intervention (iFraP-i) or (2) comparator usual NHS care (iFraP-u) and are followed up at 2-weeks and 3-months. The primary outcome is ease of decision-making assessed 2 weeks after the consultation using the Decisional Conflict Scale (DCS). The primary objectives will be addressed by comparing the mean DCS score in each trial arm (using analysis of covariance) for patients given an osteoporosis medicine recommendation, alongside a within-trial cost-effectiveness and value of information (VoI) analysis. Process evaluation data collection includes consultation recordings, semi-structured interviews, and DST analytics. Discussion The iFraP trial will answer important questions about the effectiveness of the new ‘iFraP’ osteoporosis DST, coupled with clinician training, on SDM and informed initiation of osteoporosis medicines. Trial registration ISRCTN 10606407, 21/11/2022 https://doi.org/10.1186/ISRCTN10606407

Background: Screening first-degree relatives (FDRs) of patients with premature coronary artery disease (CAD) is recommended but not routinely performed. Objectives: To assess the diagnostic yield and impact on clinical management of a clinical and imaging-based screening program of FDRs delivered in the setting of routine clinical care. Methods: We recruited FDRs of patients with premature CAD with no personal history of CAD and prospectively assessed for: 1) cardiovascular risk and presence of significant subclinical atherosclerosis (SA) defined as plaque on carotid ultrasound, stenosis >50% or extensive atherosclerosis on coronary computed tomography angiography, or coronary artery calcium scores >100 Agatston units or >75% percentile for age and sex; 2) utilization of preventive medications and lipid levels prior enrolment and after completion of the assessment. Results: We assessed 132 FDRs (60.6% females), mean (SD) age 47(17) years old. Cardiovascular risk was high in 38.2%, moderate in 12.2%, and low in 49.6% of FDRs. SA was present in 34.1% of FDRs, including 12.5% in low, 51.9% in moderate, and 55.0% in high calculated risk groups. After assessment, LLT was initiated in 32.6% of FDRs and intensified in 16.0% leading to mean (SD) LDL-C decrease of 1.07(1.10) mmol/L in patients with high calculated risk or SA. LLT was recommended to all patients with high calculated risk, but those with SA were more likely to receive the medications from pharmacies (93.3% vs 60.0%, p = 0.006). Conclusion: Screening the FDRs of patients with premature CAD is feasible, may have high diagnostic yield and impact risk factor management.

Abstract Background Recovery from addiction is frequently equated with abstinence. However, some individuals who resolve an addiction continue to use substances, including via substitution (i.e., increased use of one substance after eliminating/ reducing another). Substitution may play a distinct role during early recovery (≤ 1 year), as this period is marked by dramatic change and adjustment. Cannabis is one of the most used substances and is legal for medical and recreational use in an increasing number of states. Consequently, cannabis an increasingly accessible substitute for substances, like fentanyl, heroin, cocaine and methamphetamine, with higher risk profiles (e.g., associated with risk for withdrawal, overdose, and incarceration). Methods Fourteen participants reported that they had resolved a primary opioid or stimulant addiction and subsequently increased their cannabis use within the previous 12 months. Using grounded theory, the interviewer explored their experiences of cannabis use during early recovery. Data were analyzed in three stages: line by line coding for all text related to cannabis use and recovery, focused coding, and axial coding to generate a theory about recovery with cannabis substitution. The motivational model of substance use provided sensitizing concepts. Results & discussion The final sample included eight men and six women ranging in age from 20 to 50 years old. Three participants resolved an addiction to methamphetamine and the remaining 11, an addiction to opioids. Participants explained that cannabis was appealing because of its less harmful profile (e.g., no overdose risk, safe supply, few side effects). Participants’ primary motives for cannabis use included mitigation of psychiatric symptoms, withdrawal/ cravings, and boredom. While cannabis was effective toward these ends, participants also reported some negative side effects (e.g., decreased productivity, social anxiety). All participants described typical benefits of recovery (e.g., improved self-concept, better relationships) while continuing to use cannabis. Their experiences with and beliefs about substitution suggest it can be an effective strategy for some individuals during early recovery. Conclusions Cannabis use may benefit some adults who are reducing their opioid or stimulant use, especially during early recovery. The addiction field’s focus on abstinence has limited our knowledge about non-abstinent recovery. Longitudinal studies are needed to understand the nature of substitution and its impact on recovery over time.

Objective: Multiple sclerosis (MS) has a multi-factorial etiology involving genetic factors. Fingolimod (Gilenya ®,FTY720) modulates the G-protein-coupled sphingosine 1-phosphate (S1P) receptors, S1PR1, 2, 3, 4 and 5. Variationin the human S1PR1 coding sequence results in heterogeneity in the function of the receptor. Interleukin-17, producingCD4+ T cells, tends to be increased after treatment with Fingolimod. The aim of the study was to investigate single-nucleotidepolymorphisms (SNPs) in the S1PR1 gene or interleukin-17 (IL-17) levels in a small group of Iranian relapsing-remittingMS patients treated with Fingolimod.Materials and Methods: In this case-control study, the genomic DNA of 94 MS patients treated with Fingolimod wasextracted and Sanger sequencing was performed on polymerase chain reaction (PCR) products to detect variants inthe S1PR1 gene. Quantification of IL-17 from the serum of the patients was performed using a commercially availableenzyme-linked immunosorbent assay (ELISA).Results: Among 94 relapsing-remitting MS patients treated with Fingolimod, 69 (73.4%) were responders and 25(26.6%) were non-responders. There were four novel and five common SNPs in the S1PR1 gene and no significantassociation between SNP genotype and drug response was detected. In a subset of 34 patients, there was no significantdifference in IL-17 serum concentrations before or after treatment and no association with S1PR1 polymorphisms wasdetermined.Conclusion: This study is the first in Iran to investigate association between SNPs of the S1PR1 gene or IL-17 levelswith fingolimod response in a small group of Iranian relapsing remitting MS patients. There was no association withS1PR1 gene SNPs or IL-17 levels before or after treatment.

Abstract Background Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others’ trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff. Methods We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley’s compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience). Results Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others’ well-being emerged as a motivator to engage in post-overdose outreach work – with staff trying to understand others’ perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others’ trauma – made more difficult when exposures overlapped with staff members’ personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams. Conclusion Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.

Background This research concerns improving the National Health Service health services trans adults need. These include the national specialist Gender Identity Clinics that support people making a medical transition. Not all trans people need to make a medical transition, and transition can take many different paths. Waits to be seen by Gender Identity Clinics are, however, several years long, and there may be significant problems of co-ordination between different aspects of transition-related care, and between transition-related care and general health care. Objectives The main objectives were to understand: Which factors make services more or less accessible and acceptable to the variety of trans adults? How initiatives for providing more person-centred and integrated care can be successfully implemented and further improved? Design, data sources and participants An online and paper screening survey was used to gather data on demographics and service use of trans people across the United Kingdom, with 2056 responses. Researchers used survey data to construct five purposive subsamples for individual qualitative interviews, identifying groups of people more likely to experience social exclusion or stigma. There were 65 online interviews. In addition, 23 trans Black people and people of colour attended focus groups. Six case studies were completed: four on initiatives to improve care and two on experiences of particular trans populations. Fifty-five service provider staff and 45 service users were interviewed. Results The following undermine person-centred co-ordinated care and can lead to experiences of harm: lack of respectful treatment of trans people by general practitioner practices; inadequate funding of services; lack of support during waiting; the extended and challenging nature of Gender Identity Clinic diagnostic assessments, sometimes experienced as adversarial; breakdowns in collaboration between Gender Identity Clinics and general practitioner practices over hormone therapy; lack of National Health Service psychological support for trans people. Case studies indicated ways to improve care, although each has significant unresolved issues: training in trans health care for general practitioners; third-sector peer-support workers for trans people who come to National Health Services; gender services taking a collaborative approach to assessing what people need, clarifying treatment options, benefits and risks; regional general practitioner-led hormone therapy clinics, bringing trans health care into the mainstream; psychology services that support trans people rather than assess them. Limitations Some contexts of care and experiences of particular groups of trans people were not addressed sufficiently within the scope of the project. While efforts were made to recruit people subject to multiple forms of stigma, there remained gaps in representation. Conclusions and future work The findings have significant implications for commissioners and providers of existing National Health Services gender services, including recently established pilot services in primary care. In particular they point to the need for assessments for access to transition care to be more collaborative and culturally aware, implying the value of exploring informed consent models for accessing transition-related care. Further research is needed to investigate how far the findings apply with particular subpopulations. Study registration This study is registered as Research Registry, no. 5235. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/51/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 28. See the NIHR Funding and Awards website for further award information. Plain language summary This research concerns improving the range of National Health Service health services that trans adults need. Trans people have a different gender from that assigned at birth or in early childhood. Not all need to make a medical transition to express their gender, and transition can take many different forms, including hormone therapy, various kinds of surgery, and other procedures such as hair removal. At the time of writing, trans people over 17 who need to make a medical transition can seek care at one of the United Kingdom’s 10 specialist National Health Service Gender Identity Clinics. However, people must wait a very long time before they are seen. Through 110 in-depth interviews, as well as focus groups attended by 23 people, this research explored recent experiences of trans people receiving various kinds of health care. A further 55 interviews investigated the views of National Health Service and voluntary-sector staff involved in delivering trans health care. All of this has led to insights about how services can be improved, and the development of online courses for healthcare staff and for people who use services or support those who use services. The research indicates what can lead to experiences of poor care that is not ‘joined up’: lack of respectful treatment of trans people by general practitioner practices; inadequate funding of services; lack of support while waiting; the extended and difficult nature of Gender Identity Clinic diagnostic assessments; breakdowns in collaboration between Gender Identity Clinics and general practitioner practices over hormone therapy; lack of National Health Service psychological support for trans people. The research indicates some important ways to improve care: training in trans health care for general practitioners; third-sector peer-support workers for trans people who come to National Health Service services; gender services taking a collaborative approach to assessing what people need, clarifying treatment options, benefits and risks; regional general practitioner-led hormone therapy clinics, bringing trans health care into the mainstream; psychology services that support trans people rather than assessing them. Scientific summary Background Throughout this report we use the term trans to refer to the diverse people whose gender identities do not correspond to how they were assigned at birth or in early life. The term includes non-binary people. This research concerns improving the range of NHS health services that trans adults need. These include services intended to support people in making a medical transition, and many other services relevant to wider aspects of physical and mental health and well-being. Not all trans people need to make a medical transition, and transition can take many different paths, including hormone therapy, various types of surgery and other procedures such as hair removal. At the time of writing, trans people over 17 years of age who need to make a medical transition can seek care at one of the UK’s 10 specialist NHS Gender Identity Clinics (GICs), sometimes also known as Gender Identity Services (GIS). In recent years, people encounter very long waiting times before they are seen. Further, issues of co-ordination arise between different aspects of transition-related care and also between transition-related care and general health care. Because of the barriers to accessing NHS care they need within an acceptable timescale, many trans people in the UK, who can afford to, turn to private providers of hormone therapy and gender-related surgery, both within the UK and abroad. Many also access private provision of procedures that are important to their transition which are not offered by the NHS, such as facial feminisation surgery. This research has sought to build on initiatives to improve care and its integration, including those involving third-sector lesbian, gay, bisexual, transgender, queer and intersex, plus (LGBTQI+) organisations working in partnership with primary care organisations or with GICs. It has also explored how lessons about the effective integration of trans health care can best be implemented in the context of an NHS that is still coping with the impact and consequences of the coronavirus disease discovered in 2019 (COVID-19) pandemic. Research questions The research addresses the following questions: What is the range of models recently used in the UK for providing integrated care for meeting the specific health and well-being needs of trans people? Which factors make services more or less accessible and acceptable to the variety of trans adults who need them? In the different integrated service models, how effective are the different aspects of services and their interaction in meeting the needs of people at different stages of their gender transition and at different ages? What lessons emerge as to how models for providing integrated care can be successfully implemented and further improved in meeting the needs of trans people, within limited resources and continuing constraints resulting from the COVID-19 pandemic? Research design and methods The overall research design is a multicomponent and mixed-methods study of current realities and initiatives to improve health care for trans people, leading to the identification of areas for improvement and the production of educational materials. The research took place over a period of 2.5 years, from March 2019 to September 2021, with a 6-month pause during the initial phases of the COVID-19 pandemic, from March to October 2020. The educational materials stemming from the research take the form of open-access online learning materials. There are separate sets of learning materials for general practitioners (GPs), for mental health professionals and for members of the public. These are available from late 2023. The research plan involved the extensive involvement of the Improving Care for Trans Adults (ICTA) patient and public involvement (PPI) group, of trans people. They were consulted about the content of the research instruments and participant information sheets, as well as on sampling priorities. They were involved in commenting on the analysis and draft reports throughout the project. The whole project was focused on health inequalities and equality, diversity and inclusion (EDI). The PPI group played an important role in keeping such concerns foregrounded. The research design consisted of the following main elements: Desk research on current arrangements across the UK for providing transition-related care and for recognising the distinctive needs of trans people within general health care. This addressed RQ1. It also informed the selection of initiatives to improve care studied. An investigation of factors associated with service use and non-use. This addressed RQ2. An initial online and paper screening survey was used to gather data on demographics and service use across the UK, and received over 2056 responses, compared to a target of 500. It was promoted widely by the project partners and through LGBTQI+ networks and organisations. Response options included offering to be interviewed, with over 800 people putting themselves forward. Researchers used data on demographics and service use to construct five purposive subsamples, to be invited for individual qualitative interviews. The underlying rationale was to identify groups who were more likely to experience social exclusion or stigma in everyday life, and who were also more likely to experience difficulties in accessing and receiving health care. The experience of these groups would be an indication of the priorities for improving services to make them more inclusive and more effective in addressing health inequalities. In discussion with the PPI group, the following five groups were identified as priorities for subsamples of trans service users: older people and trans ‘elders’ (e.g. historic transitioners); disabled or chronically ill people; people with a low income or low educational qualifications; people living in rural areas; Black people and people of colour. This gave rise to 65 interviews, most lasting between 1 and 3 hours, and all carried out online. An initiative to recruit more trans Black people and people of colour (TBPoC) resulted in a further 23 people attending focus groups to cover the same topics as in interviews. All of the interviews and focus groups were audio-recorded and transcribed, and then the transcriptions were anonymised. Case studies of service experiences and initiatives to improve integration of care. This was to address RQ3 and contribute to answering RQ4. Six case studies were undertaken: Case Study 1: third-sector gender-outreach workers attached to a GIC Case Study 2: primary care liaison and psychology services within a GIC Case Study 3: primary care training and accreditation for trans health care Case Study 4: the Welsh Gender Service Case Study 5: trans healthcare experiences in Northern Ireland Case Study 6: healthcare experiences of trans people with mental health concerns or conditions Fifty-five staff and 45 service users were interviewed across these case studies. The staff were invited to participate because of their role and experience relevant to the initiative being studied. The service users were invited to participate based on their having participated in the national screening survey of trans adults’ healthcare experiences described above and indicated that they both had experience of the services being studied and were willing to be interviewed. Interviews were audio-recorded and transcribed, and then the transcriptions were anonymised. Thematic analysis was used to analyse accounts of experiences of using services, and accounts of practices in delivering and improving them, the achievements and benefits resulting, and the issues or challenges encountered. This included the analyses and comparison of the six case studies and the five purposive subsamples. A 1-day online workshop attended by all project partners, an Advisory Group of NHS clinicians, third-sector organisations and representatives of trans communities, the PPI group and study steering group members was held in July 2021 to review the emerging findings. Research findings The analysis of the purposively sampled qualitative interviews and focus groups with trans service users revealed a significant body of experience of poor care, although there were also more positive experiences. Regardless of the extent to which these experiences represent those of the total UK population of service users, they allowed the identification of factors which undermine person-centred, co-ordinated care, make it difficult for trans people to access care, or which lead to problematic, unacceptable and even harmful experiences of care. Poor experiences of care included: lack of understanding within GP practices of trans identities and respectful treatment of trans people, their health concerns and of the referral routes for transition-related care; waiting times of several years for GIC appointments once referrals have been made; the extended nature of GIC diagnostic assessments, which can seem to doubt that trans people know their own minds and be experienced as infantilising; breakdowns in collaboration between GICs and GP practices over the management of hormone therapy; difficulties of receiving psychological support within a GIC system that is experienced as seeing a mental health condition as a reason for delaying gender-affirming treatment; general mental health services that appear unwilling to treat trans people apparently simply because they are trans. When experienced either separately or in combination, these factors can cause iatrogenic harm; that is, harm from the healthcare system itself. Analysis of the initiatives to improve the integration of care revealed both benefits and unresolved issues. Training in trans health care for GPs can lead to trans people feeling welcomed and respected, to less stressful experiences of obtaining a GIC referral and more effective management of hormone therapy, when recommended by a GIC or, if needed prior to this, for harm reduction. However, the impact of training across the staff within a GP practice can be variable, often resulting in an uncertain quality of care. Third-sector peer-support workers attached to a gender service can deliver effective practical and emotional support to people awaiting assessment and also play an important role once gender-affirming treatment has begun. However, the long wait to access transition-related care remains the key issue for service users, over which peer workers have little or no influence. They must navigate a stressful ‘dual belonging’ to trans communities and a gender service. There is also a risk that relatively low-paid trans peer workers are expected to make up for gaps or shortages within the provision of other NHS services, such as mental health services. Gender service clinicians who pursue a collaborative approach to assessment for gender-affirming treatment, with the emphasis on clarifying the treatment options, potential benefits and risks, can lead to quicker, less stressful assessment experiences for service users. The practice of clinicians extending assessments for some people raises issues as to the most appropriate criteria to apply here, in order to avoid the danger of subjecting more stigmatised groups to a more extended process. Linking regional GP-led hormone therapy clinics to a gender service allows more rapid initiation of hormone therapy following assessment, with GP prescribers able to co-ordinate transition-related and general healthcare needs. There are, however, issues in finding an approach to electronic patient records that fully supports collaboration between a gender service, regional primary care hormone clinics and a trans person’s own GP practice. Further problems persist in terms of the willingness of GP practices to take over hormone prescribing even after a period of stabilisation with the regional clinic. A psychologist team attached to a gender service, delivering individual and group sessions, can support trans people in working through problematic aspects of social transition or emotional reactions to their medical transition, as well as addressing experiences of isolation. However, tensions may exist between a therapeutic ethos and the role of a gender service in assessing people for access to gender-affirming treatment. Conclusions Learning from the national sample of interviews and the case studies of initiatives for improving care has implications for improving care within the established model of trans people accessing transition care through a tertiary GIC service. It also provides insight into how to improve the primary care gender services that were recently established by NHS England (NHSE). The findings suggest that a primary care gender service has great potential for integrating different aspects of transition-related care with each other and with other aspects of health care that a trans person needs. Key directions for future practice include: mandatory trans healthcare standards and training for primary care, as well as for NHS services in general; peer support attached to gender services, with peer workers included within the professional team, able to answer questions from the service users on behalf of the service; psychological support made available to people using gender services, with the separation of therapeutic support from diagnostic assessment; further development of collaborative forms of assessment, including revisiting of the existing diagnostic guidelines in the light of how some areas of questioning can be experienced; fundamental reconsideration of the level of funding of trans health care, to address the egregiously long, damaging waiting times that trans people experience. Increased funding should, however, take account of the findings about effective models for delivering person-centred, co-ordinated care; greater involvement of trans staff in healthcare delivery, and of representatives of trans communities in the management and shaping of gender services and health services more generally. Interviews with trans service users further indicated a widespread view that gender services should move, in the longer term, towards an informed consent model (ICM), which would dispense with the requirement for a psychological or psychiatric diagnosis before gender-affirming treatments can be accessed. Research on ICMs in the USA and Australia suggests ICMs have the potential to combine a person-centred focus on the goals of care with medical diligence and the authorisation of treatment. The findings from our case studies suggest the benefits of care practices consistent with an ICM, as well as issues that would need to be resolved in order to implement one. These potential benefits and issues require further exploration by policy-makers and clinicians, working together with trans communities. Limitations and further research Drawing on over 160 qualitative interviews, this research sought to understand the dynamics underlying experiences of poor and better care. These findings are of broader relevance to helping a wide range of health services to improve the care they provide for trans people. However, some contexts of care and needs of particular groups of trans people could not be addressed sufficiently. There were some gaps in representation of people who are subjected to multiple forms of social stigma. In particular, further research is needed regarding: The experiences of trans people at clinics that have adopted ICMs, using a similar level of qualitative detail as we were able to pursue during our ICTA interviews. What forms of assessment are appropriate for groups of trans people whom clinicians may regard as having an impaired ability to understand and consent to specific treatments, such as those with mental health conditions, those with learning difficulties, and some autistic people. These are groups who typically experience multiple forms of stigma across many settings, including health care. Research should also seek to explore what kinds of additional social and psychological support should be provided to accompany gender-affirming medical care for such groups. Study registration This study is registered as Research Registry, no. 5235. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/51/08) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 28. See the NIHR Funding and Awards website for further award information.

The use of midfoot wedges for the correction of flatfeet disorders, such as progressive collapsing foot disorder, has increased greatly in recent years. However, the wedge material/composition has yet to be standardized. Metallic wedges offer advantages such as comparable elasticity to bone, reduced infection risk, and minimized osseous resorption, but a comprehensive review is lacking in the literature. Therefore, the objective of this systematic review was to organize all studies pertaining to the use of metallic wedges for flatfoot correction to better understand their efficacy and safety. This systematic review adhered to PRISMA guidelines, and articles were searched in multiple databases (PubMED, SPORTDiscus, CINAHL, MEDLINE, and Web of Science) until August 2023 using a defined algorithm. Inclusion criteria encompassed midfoot surgeries using metallic wedges, observational studies, and English-language full-text articles. Data extraction, article quality assessment, and statistical analyses were performed. Among 11 included articles, a total of 444 patients were assessed. The average follow-up duration was 18 months. Radiographic outcomes demonstrated that patients who received metallic wedges experienced improvements in lateral calcaneal pitch angle and Meary’s angle, with an enhancement of up to 15.9 degrees reported in the latter. Success rates indicated superior outcomes for metallic wedges (99.3%) compared to bone allograft wedges (89.9%), while complications were generally minor, including hardware pain and misplacement. Notably, there were no infection complications due to the inert nature of the metallic elements. This review summarizes the effectiveness, success rates, and safety of metallic wedges for flatfoot correction. Radiographic improvements and high success rates highlight their efficacy. Minor complications, including pain and mispositioning, were reported, but the infection risk remained low. Our results demonstrate that metallic midfoot wedges may be a viable option over allograft wedges with proper planning. Future research should prioritize long-term studies and standardized measures.

AbstractObjective To evaluate an experiential student clinical addiction research program by analyzing its components, evaluation survey data, and scientific outputs.Methods In 1995, we established a summer research program supporting trainees to gain exposure to clinical addiction research careers. This curriculum employed a three-pronged approach that combined mentored research training, didactic education, and clinical observerships for medical students and other trainees to acquire experience with addiction medicine and research. Utilizing the Kirkpatrick model as program evaluation framework, we analyzed evaluation data from programmatic surveys (didactic seminar evaluations, overall program surveys) and conducted qualitative feedback exploration.Results Between 2007 and 2019, 56 trainees and 26 faculty mentors participated in the curriculum. To date, 25 students published 38 papers with their faculty mentor. Analysis of the past 12 years of program evaluation data demonstrated that students highly valued individually-mentored research experiences. They indicated that seminars familiarized them with the foundations of different clinical care models and career trajectories in addiction medicine. Clinical observerships provided students with patient contacts in various multidisciplinary addiction treatment settings. These experiences, perhaps most importantly hearing about patients’ lived experiences, meaningfully informed various research and didactic activities.Conclusions This summer student research program successfully introduced students to addiction medicine and research, manifested by high peer-reviewed publication productivity. While our program engaged and involved committed mentors and inspired mentees to pursue professional paths in addiction research, it did not specifically incorporate attention to equity and diversity into program planning and implementation. Going forward, the program will improve equity by increasing the recruitment of trainees from disadvantaged groups and engaging underrepresented faculty.KEY MESSAGESSummer programs can be effective in engaging medical students and trainees in research early in their trajectory and inspire them to incorporate research into their careers.Programs that integrate experiential addiction research learning, i.e. mentored research activities, didactic sessions, and clinical observerships, can provide trainees with a profound understanding of substance use disorder treatment and research.

The receptor kinase FERONIA (FER) is a versatile regulator of plant growth and development, biotic and abiotic stress responses, and reproduction. To gain new insights into the molecular interplay of these processes and to identify new FER functions, we carried out quantitative transcriptome, proteome, and phosphoproteome profiling of Arabidopsis (Arabidopsis thaliana) wild-type and fer-4 loss-of-function mutant plants. Gene ontology terms for phytohormone signaling, abiotic stress, and biotic stress were significantly enriched among differentially expressed transcripts, differentially abundant proteins, and/or misphosphorylated proteins, in agreement with the known roles for FER in these processes. Analysis of multiomics data and subsequent experimental evidence revealed previously unknown functions for FER in endoplasmic reticulum (ER) body formation and glucosinolate biosynthesis. FER functions through the transcription factor NAI1 to mediate ER body formation. FER also negatively regulates indole glucosinolate biosynthesis, partially through NAI1. Furthermore, we found that a group of abscisic acid (ABA)-induced transcription factors is hypophosphorylated in the fer-4 mutant and demonstrated that FER acts through the transcription factor ABA INSENSITIVE5 (ABI5) to negatively regulate the ABA response during cotyledon greening. Our integrated omics study, therefore, reveals novel functions for FER and provides new insights into the underlying mechanisms of FER function.