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Introduction Joint Advisory Group (JAG) certification in endoscopy is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update standards for training and certification in flexible sigmoidoscopy (FS).Methods A modified Delphi process was conducted between 2019 and 2020 with multisociety representation from experts and trainees. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on FS training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer-reviewed by national stakeholders for incorporation into the JAG FS certification pathway.Results In total, 41 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (17), assessment of competence (7) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (A) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, rectal retroversion >90%, polyp retrieval rate >90%, patient comfort Conclusion The UK standards for training and certification in FS have been updated to support training, uphold standards in FS and polypectomy, and provide support to the newly independent practitioner.

Introduction In the UK, endoscopy certification is awarded when trainees attain minimum competency standards for independent practice. A national evidence-based review was undertaken to update and develop standards and recommendations for colonoscopy training and certification.Methods Under the oversight of the Joint Advisory Group (JAG), a modified Delphi process was conducted between 2019 and 2020 with multisociety expert representation. Following literature review and Grading of Recommendations, Assessment, Development and Evaluations appraisal, recommendation statements on colonoscopy training and certification were formulated and subjected to anonymous voting to obtain consensus. Accepted statements were peer reviewed by JAG and relevant stakeholders for incorporation into the updated colonoscopy certification pathway.Results In total, 45 recommendation statements were generated under the domains of: definition of competence (13), acquisition of competence (20), assessment of competence (8) and postcertification support (4). The consensus process led to revised criteria for colonoscopy certification, comprising: (1) achieving key performance indicators defined within British Society of Gastroenterology standards (ie, unassisted caecal intubation rate >90%, rectal retroversion >90%, polyp detection rate >15%+, polyp retrieval rate >90%, patient comfort Conclusion The UK standards for training and certification in colonoscopy have been updated, culminating in a single-stage certification process with emphasis on polypectomy competency (SMSA Level 2+). These standards are intended to support training, improve standards of colonoscopy and polypectomy, and provide support to the newly independent practitioner.

BackgroundRestorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch surgery is difficult as the procedure is performed infrequently. This study presents an institutional initiative to promote standardisation of multidisciplinary care in IPAA surgery.MethodsA dedicated pathway for patients who had an IPAA or are considering IPAA surgery was developed among colorectal surgeons, gastroenterologists, paediatric colorectal surgeons, inflammatory bowel disease (IBD) nurses, dietitians, stoma nurses, trainees in colorectal surgery. Pathway items were discussed and finalised via emails and videoconferences.The pathway included triaging of patients referred for IPAA surgery, preoperative IBD multidisciplinary team discussion and management plan for surgery, surgical review prior to surgery, peer to peer counselling, surgical technique, postoperative short-term and long-term follow-up, audit, research and training in IPAA surgery.ResultsA multidisciplinary preoperative pathway was developed and a stepwise approach to minimally invasive ileoanal pouch surgery was formalised. A dedicated one-stop ileoanal pouch clinic was established integrating endoscopy and imaging on the same day of the consultation with the surgical and gastroenterology team. The clinic reviewed 72 patients over 24 months, and during the same time 36 patients underwent IPAA surgery at our institution.ConclusionsWe have described our initial experience in establishing a specialist IPAA surgery pathway and have proposed outcome measures that we hope will support a subspecialty IPAA service.

While there is a widely shared sense that policy action is required for the electricity system in the United States to decarbonize, most climate policy courses focus only on a handful of federal and state policies. In reality, however, there is a web of state- and local-government-level policy choices that can serve to facilitate or hinder an energy transition, which is less discussed and researched in higher education. A new graduate course, first taught in Winter 2019 at the University of Michigan in the Ford School of Public Policy, employs a range of unique course design elements to introduce the idea of a complex web of policies and actors in the energy transition, and to provide students with practical skills to prepare them to be leaders in the transition. By interviewing students 18 months after finishing the Winter 2019 iteration of the course, in addition to surveying students enrolled in the second interaction of the course in the Fall 2020 semester, this study finds that student experiential learning and applied projects, in tandem with the instructor’s focus on local, real-world implications, was found to be effective in preparing students to be climate leaders.

This paper develops a multi-scalar geography of youth volunteering in Uganda. A growing body of research has explored the geographies of volunteering in the global North and international volunteering and development. However, despite the mainstreaming of volunteers as development actors, less attention has been paid to the unique local and national geographies of volunteering in global South settings. This paper explores how and why different ideas and practices of volunteering take shape and prominence in Uganda and how this impacts patterns of youth inclusion, inequality and opportunity. Analysing data on volunteering by young refugees in Uganda, we develop a multi-scalar geography to situate volunteering at the interface of ‘global’ volunteering policy and knowledges, aid and development architectures, youth unemployment, community institutions and local socio-economic inequalities. Through this, we reveal how programmed and audited forms of youth volunteering oriented to youth skills and employability are privileged. We show how this articulates with local inequalities to create uneven access to volunteering opportunities and practices. Through our approach, we show how a multi-scalar geography of volunteering enables us to build richer, more nuanced conceptualisations of volunteering in the global South that address the different ways global discourses, local histories, community organisations and social inequalities come together across space and time to produce uneven geographies of volunteering in particular places.

Central nervous system tumours are the leading oncology cause of paediatric mortality. The aim of this research was to identify stages within the diagnostic process of a primary paediatric brain tumour that could be improved resulting in better outcomes.The electronic medical records of Queensland Children's Hospital patients with central nervous system tumours between the 17/12/2014 till 11/12/2019 were retrospectively accessed. Time intervals of symptom onset to first medical review,location, time till medical imaging,subspecialty or neurosurgical review, timing of surgery, diagnosis and mortality status were recorded then analysed.A total of 168 patients were included. Mean age to 7.5, 65% male, with pilocytic astrocytoma representing 31%. 71.4% of the population were from a major city as determined by Remoteness Area classification, ABS, with 19% inner regional and 9.5% being outer regional and remote. The average time from first medical review to diagnostic imaging was significantly different when comparing remoteness classification (p = 0.044). There was also a statistically significant difference in the duration of time from medical imaging to specialist review comparing major city and outer regional/remote (p = 0.016) and inner regional versus outer regional/remote areas (p = 0.026).Delays in imaging in outer regional and remote Queensland are contributing to a delay in diagnosis and intervention in paediatric brain tumours. Service provision for neurosurgery in outer regional and remote Queensland is currently on par with inner regional and city areas. Suspicion of paediatric brain tumours is needed with clear referral pathways for general practitioners to access diagnostic imaging.

This paper examines work in cultural and human geography that theorises temporality in terms of events. Moving from humanist phenomenology, to non-representational and assemblage theories and current geographies of encounter, it suggests these accounts of events tend to analyse the past and future through the lens of the present. Building upon these literatures and the work of Tristan Garcia, the paper argues for an expanded notion of the event, where past and future events can be considered as both distinct from, and linked to, the present moment. Here, time comes to be defined as the ordering and stacking of events, where events are understood as sites of comprehension, in which entities are differentiated. The paper suggests this position is useful in order to trace temporal causality across and between entities and events. Tracing the causality of entities and their ordering and stacking across events enables a closer analysis of what the paper terms the temporal power of non-human things. To illustrate this argument, examples from an ESRC project on digital gaming and in-game purchasing are analysed.

Precision immuno-oncology approaches are needed to improve cancer care. We recently demonstrated that in patients with metastatic melanoma, an increase of clonality or diversity of the T cell receptor (TCR) repertoire of peripheral T cells following one cycle of immunotherapy is coincident with response to immune-checkpoint blockade (ICB). We also identified a subset of peripheral CD8Fifty patients with metastatic melanoma treated with first-line anti-PD-1 ICB were included. We analysed TCR repertoire and peripheral TWe observed a correlation between TWe demonstrate that immunotherapy-induced immune-awakening patterns in patients with melanoma are age-related and may impact patient response to ICB, and thus have implications for biomarker development and planning of personalised therapeutic strategies.

In developed countries the incidence of anal squamous cell carcinoma (SCC) has been rising; especially in women over the age of 60 years who present with more advanced disease stage than men. Historically, anal SCC screening has focused on people living with Human Immunodeficiency Virus (HIV) (PLWH) who are considered to be at the highest risk of anal SCC, and its precancerous lesion, anal squamous intraepithelial lesion (SIL). Despite this, women with vulval high-grade squamous epithelial lesions (HSIL) and SCCs have been shown to be as affected by anal HSIL and SCC as some PLWH. Nevertheless, there are no guidelines for the management of anal HSIL in this patient group. The ANCHOR trial demonstrated that treating anal HSIL significantly reduces the risk of anal SCC in PLWH, there is therefore an unmet requirement to clarify whether the screening and treatment of HSIL in women with a prior genital HSIL is also beneficial. This review presents the current evidence supporting the screening, treatment, and surveillance of anal HSIL in high-risk women with a previous history of genital HSIL and/or SCC.

Introduction the frequency of distal femur fractures in the elderly is rapidly increasing. A study of these fractures was conducted in our center in order to evaluate the comorbidities and the mortality associated with this entity. Material and methods all the distal femur fractures by low energy in patients over 65 years old at a tertiary center were included, between January 2010 and December 2016. Baseline characteristics, the type of fracture, comorbidities, and functional status before admission, were collected. The relationship of each of these variables to the final functional class, immediate and late complications and mortality during the follow-up. Fifty-nine patients were included, with a median age of 85.3 years (IQR 78.6–91.6). Fifty-one patients were women. In 10 patients, the fractures were atraumatic (postural change mainly in non-walking patients), and in 54 of the cases were treated surgically (6 with retrograde intramedullary nailing and 48 with lateral locking plate). The median time to surgery was 4.5 days (IQR 2–6) and 14 patients were operated within 48 hours. The median follow-up was 26.3 months. Results fourteen patients died during the first year of follow-up. Factors independently associated with death during the first year after the fracture were: conservative treatment, and the inability to ambulate before the episode. The absence of certain comorbidities, such as chronic heart disease, and cancer, and an age under 80 years, behaved as protective factors. Conclusion low-energy distal femur fractures comprise a severe injury in the elderly and are associated with high mortality. Surgical treatment showed better outcomes in terms of survival, with no significant differences depending on the type of fracture, the type of implant or the median time to surgery.

Background We implemented a systematic multidisciplinary process to engage new outpatients with cancer in selecting and preparing a medical decision-maker. Measures Templated advance care planning notes and medical power of attorney documents were used in the electronic health record by the third office visit. Intervention Patients were coached to meet with social work from a “culture of yes,” viewed a video about the importance of selecting a prepared medical a decision-maker in English or in Spanish, and referenced cards containing simple explanations of advance directives when responding to advance directive questions. Outcomes A total of 351 patients were evaluated. By visit 3, there was no increase in documented social work advance care planning notes in intervention or scanned medical power of attorney documents in the electronic health record. Conclusions/Lessons Learned This systematic multidisciplinary approach did not engage new outpatients with cancer in preparing a medical decision-maker. More active physician involvement and varied ways of engagement are needed.

Identification of mismatch repair (MMR)-deficient colorectal cancers (CRCs) is recommended for Lynch syndrome (LS) screening, and supports targeting of immune checkpoint inhibitors. Microsatellite instability (MSI) analysis is commonly used to test for MMR deficiency. Testing biopsies prior to tumour resection can inform surgical and therapeutic decisions, but can be limited by DNA quantity. MSI analysis of voided urine could also provide much needed surveillance for genitourinary tract cancers in LS. Here, we reconfigure an existing molecular inversion probe-based MSI and BRAF c.1799T > A assay to a multiplex PCR (mPCR) format, and demonstrate that it can sample >140 unique molecules per marker from

Purpose Anal intraepithelial neoplasia (AIN) is the accepted precursor of anal squamous cell carcinoma (ASCC). There has long been a hypothesis that treating AIN may prevent ASCC. Many different treatment modalities have been suggested and studied. We conducted this systematic review to evaluate their efficacy and the evidence as to whether we can prevent ASCC by treating AIN. Methods MEDLINE and EMBASE were electronically searched using relevant search terms. All studies investigating the use of a single treatment for AIN that reported at least one end outcome such as partial or complete response to treatment, recurrence after treatment and/or ASCC diagnosis after treatment were included. Results Thirty studies were included in the systematic review investigating 10 treatment modalities: 5% imiquimod, 5-fluorouracil, cidofovir, trichloroacetic acid, electrocautery, surgical excision, infrared coagulation, radiofrequency ablation, photodynamic therapy and HPV vaccination. All treatment modalities demonstrated some initial regression of AIN after treatment; however, recurrence rates were high especially in HIV-positive patients. Many of the studies suffered from significant bias which prevented direct comparison. Conclusions Although the theory persists that by inducing the regression of AIN, we may be able to reduce the risk of ASCC, there was no clinical evidence within the literature advocating that treating AIN does prevent ASCC.

Palliative medicine is specialized medical care for people with serious illness. Serious illness is one with high risk of mortality that negatively affects quality of life or function or is burdensome in symptoms, treatments, or caregiver stress. Palliative care improves symptom management and addresses the needs of patients and families, resulting in improved patient and caregiver quality of life and reduced symptom burden and health care utilization. Hospice is palliative care for patients with a prognosis of 6 months or less and is appropriate when goals are to avoid hospitalization and maximize time at home for patients who are dying.

Our understanding of how checkpoint inhibitors (CPIs) affect T cell evolution is incomplete, limiting our ability to achieve full clinical benefit from these drugs. Here, we analyzed peripheral T cell populations after one cycle of CPI treatment and identified a dynamic awakening of the immune system, as revealed by T cell evolution in response to treatment. We sequenced T cell receptors in plasma cell-free DNA and peripheral blood mononuclear cells and performed phenotypic analysis of peripheral T cell subsets from patients with metastatic melanoma treated with CPIs. We found that early peripheral T cell turnover and T cell receptor repertoire dynamics identified which patients would respond to treatment. Additionally, the expansion of a subset of immune effector peripheral T cells we call TIE cells correlated with response. These events are prognostic and occur within 3 weeks of starting immunotherapy, raising the potential for monitoring patients’ responses by using minimally invasive liquid biopsies. Marais and colleagues report that checkpoint inhibitor treatment of patients with melanoma leads to dynamic changes in peripheral T cells and expansion of immune effector cells. This awakening of the immune system occurs early after treatment and could be exploited in the clinic.

BACKGROUND: The present case report describes a complication after a percutaneous spine surgery technique that is highly uncommon in clinical practice: a bone cement cardiac embolism. This rare complication emphasizes the importance of this case, which is also interesting considering the midterm follow-up. Documented cardiac embolisms published in the literature (which are scarce) describe the acute phase of these cases but lack follow-up. There are no systematic reviews on this topic, only case-by-case presentations, and surgeons are not aware of its real implications. CASE: We report a case of an 84-year-old man who developed sudden thoracic and spinal pain associated with 82% saturation and dyspnea a few hours after 4-level thoracic spine vertebroplasty and kyphoplasty. Imaging revealed multiple bone cement embolisms in his lung and heart. Because the patient was hemodynamically stable, cardiologists recommended conservative treatment with low molecular weight heparin, without embolus removal. At 4-year follow-up, the patient remained asymptomatic. CONCLUSION: Cardiac cement embolization following percutaneous techniques represents a life-threatening situation that should be ruled out if the patient presents symptoms during the early postoperative period. Treatment may vary from conservative to emergency open-heart surgery.

Aim Colorectal multi-disciplinary teams (CR MDTs) were introduced to enhance the cancer care pathway and allow for early investigation and treatment of colorectal cancer. However, there are no gold standards set for this process. The aim of this study is to establish recommendations on the principles, organisation, structure and output of CR MDTs internationally. Method The available literature on the role of CR MDTs from January 1999 and March 2020 in the United Kingdom (UK), United States of America (USA) and continental Europe was evaluated. Historical background, structure, core members, education, frequency, patient selection criteria, quality assurance, output and outcomes were extracted from data from the UK, USA, and continental Europe. Results Fifty studies were identified that specifically met the inclusion criteria. CR MDTs should occur at least once a month with established key members. Generally, all colorectal cancer patients should be discussed and there should be a focus on education. There are noted differences in the lead member of the CR MDT, the use of information technology and storage of MDT information in databases and quality assurance internationally. Conclusions The most common issues facing MDTs internationally include a lack of staffing and resources as well as limited information on the patient’s fitness and preference for surgery. These factors are important and urgent improvements are required in these areas in CR MDTs. Quality assurance should be a mandatory component of every CR MDT.

Chronic psychosocial stress has been indicated as a potentially important driver of U.S. health disparities. Allostatic load (AL) is an indicator of cumulative biological risk or “wear and tear” on the body resulting from repeated adaptations to life stressors. A population-level examination of AL may be particularly useful in understanding the intermediate physiological dysregulation that underlies social inequalities in health. No study has yet documented changes in allostatic load over a wide range of ages and intersecting sociodemographic groups. To address this gap, we pooled biomarker data from three U.S. longitudinal cohort studies (National Longitudinal Study of Adolescent to Adult Health, Midlife Development in the U.S., and the Health and Retirement Survey) to create an integrated dataset covering individuals ages 24 to over 95 from several birth cohorts. We conducted growth curve models to examine associations of AL trajectories with cohort and multiple dimensions of social identity. We found more recently born cohorts were associated with higher mean levels in AL as compared to earlier-born cohorts. Net of cohort, education, and other covariates, Black men and women and Hispanic men had significantly higher AL than their White counterparts. These differences were present in early adulthood and persisted at all ages. Hispanic women experienced the largest increases in AL with age, surpassing nearly all other groups at older ages. These findings contribute new knowledge about the temporal dynamics and social patterning of AL as individuals age, particularly intersecting stress exposures as an underlying and enduring source of health inequity.

Anal Squamous Cell Carcinoma (ASCC) is an HPV-related malignancy with increasing incidence in high-income economies. Although ethnicity and social deprivation are known to be risk factors in other malignancies, little is known about socioeconomic status and risk of ASCC. This is a cross-sectional study following the STROBE Statement. Demographic data from the English Clinical Outcomes and Services Dataset (COSD) were extracted for all patients diagnosed with ASCC in England between 2013 and 2018. Outcomes included ethnicity, social deprivation, staging and treatment. This study included 5457 patients. Incidence increased by 23.4% in 5 years, with female incidence increasing more rapidly than male incidence (28.6% vs. 13.5%). Men were more likely to present with early staging (p &lt, 0.001) and have surgery as their only treatment (p &lt, 0.001). The rate of incidence of Stage 1 tumours in men was 106.9%, however, women had the greatest increase in metastatic tumours (76.1%). Black Caribbean and Black African patients were more likely to present at an earlier age with later staging (p &lt, 0.001) and social deprivation was associated with younger age (p &lt, 0.001). ASCC incidence is rapidly increasing in patterns consistent with two separate populations: one male with early staging, the other female and related to social deprivation and ethnicity factors.