370 results found
Objectives: Through knee amputation (TKA) is an umbrella term for several different surgical techniques, which may affect clinical and functional outcomes. This makes it hard to evaluate the benefits and need for a TKA approach. This paper seeks to: (1) Determine the number of TKAs performed compared with other major lower limb amputations (MLLA) in England over the past decade; (2) identify the theoretical concepts behind TKA surgical approaches and their potential effect on functional and clinical outcomes; and (3) provide a platform for discussion and research on TKA and surgical outcomes.Methods: National Health Service Hospital Episodes Statistics were used to obtain recent numbers of MLLAs in England. EMBASE and MEDLINE were searched using a systematic approach with predefined criteria for relevant literature on TKA surgery.Results: In the past decade, 4.6% of MLLA in England were TKAs. Twenty-six articles presenting TKA surgical techniques met our criteria. These articles detailed three TKA surgical techniques; the classical approach, which keeps the femur intact and retains the patella; the Mazet technique, which shaves the femoral condyles into a box shape; and the Gritti-Stokes technique, which divides the femur proximal to the level of the condyles and attaches the patella at the distal cut femur.Conclusions: TKA has persisted as a surgical approach over the past decade, with three core approaches identified. Studies reporting clinical, functional, and biomechanical outcomes of TKA frequently fail to distinguish between the 3 distinct and differing approaches, making direct comparisons difficult. Future studies that compare TKA approaches to one another and to other amputation levels are needed.
Jani C, Mouchati C, Abdallah N, et al., 2022, Trends in Prostate Cancer Mortality in the United States of America, by State and Race, from 1999 to 2019: estimates from the Centers for Disease Control WONDER Database, Prostate Cancer and Prostatic Diseases
Sugand K, Ali R, Goodall R, et al., 2022, Trends in Neck of Femur Fracture Incidence in EU15+ Countries from 1990-2017, Injury
NIHR Global Health Unit on Global Surgery, COVIDSurg Collaborative, 2022, Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries., Lancet, Vol: 400, Pages: 1607-1617
BACKGROUND: The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. METHODS: First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. FINDINGS: In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness
Normahani P, Burgess L, Norrie J, et al., 2022, Study protocol for a multicentre comparative diagnostic accuracy study of tools to establish the presence and severity of Peripheral Arterial Disease in people with Diabetes Mellitus: the DM PAD study, BMJ Open, Vol: 12, Pages: 1-9, ISSN: 2044-6055
Introduction:Peripheral arterial disease (PAD) is a key risk factor for cardiovascular disease, foot ulceration and lower limb amputation in people with diabetes. Early diagnosis of PAD can enable optimisation of therapies to manage these risks. Its diagnosis is fundamental though challenging in the context of diabetes. Although a variety of diagnostic bedside tests are available, there is no agreement as to which is the most accurate in routine clinical practice. The aim of this study is to determine the diagnostic performance of a variety of tests (audible waveform assessment, visual waveform assessment, ankle brachial pressure index (ABPI), exercise ABPI and toe brachial pressure index (TBPI)) for the diagnosis of PAD in people with diabetes as determined by a reference test (computed tomography angiography (CTA) or magnetic resonance angiography (MRA)). In selected centres, we also aim to evaluate the performance of a new point-of-care duplex ultrasound scan (PAD-scan).Methods and analysis:A prospective multicentre diagnostic accuracy study (ClinicalTrials.gov Identifier NCT05009602). We aim to recruit 730 people with diabetes from 18 centres across the United Kingdom (UK), covering primary and secondary healthcare. Consenting participants will undergo the tests under investigation. Reference tests (CTA or MRA) will be performed within six weeks of the index tests. Imaging will be reported by blinded consultant radiologists at a core imaging lab, using a validated scoring system, which will also be used to categorise PAD severity. The presence of one or more arterial lesions of 50% stenosis, or tandem lesions with a combined value of 50%, will be used as the threshold for the diagnosis of PAD. The primary outcome measure of diagnostic performance will be test sensitivity.Ethics and Dissemination: The study has received approval from the National Research Ethics Service (NRES) (REC reference 21/PR/1221). Results will be disseminated through research presentatio
Otunla AA, Shanmugarajah K, Salciccioli JD, et al., 2022, Symptomatic atherosclerotic vascular disease and graft survival in primary kidney transplant recipients - Observational analysis of the united network of organ sharing database., Transpl Immunol, Vol: 75
OBJECTIVES: The aim of this study was to investigate whether symptomatic atherosclerotic vascular disease (SAVD) was associated with graft survival in primary kidney transplant recipients. SUMMARY BACKGROUND DATA: Recipient atherosclerotic vascular disease is associated with increased mortality rates amongst renal transplant patients. However, its relationship with graft survival has not been well studied. METHODS: This retrospective observational analysis was performed using data for adult kidney transplant recipients between 11/09/2000 and 28/02/2020 extracted from the UNOS national organ transplantation database. Patients were divided into two groups based on recipient history of symptomatic atherosclerotic disease (angina or peripheral vascular disease). Risk-adjusted outcomes were assessed by multivariate Cox regression analysis adjusting for both donor and recipient characteristics. RESULTS: 11,771 adult kidney transplant recipients from the UNOS database were eligible for analysis (1543 had a history of SAVD, 10,228 did not have a history of SAVD). After adjusting for confounders, positive SAVD status was associated with an adverse effect on graft survival at both 1 year (HR 1.35, p < 0.001) and 10 years (HR 1.15, p < 0.001). CONCLUSIONS: SAVD should be considered an independent risk factor for poor prognosis in patients undergoing kidney transplant.
Houdmont J, Daliya P, Adiamah A, et al., 2022, Identification of Surgeon Burnout via a Single-Item Measure, Occupational Medicine, ISSN: 0962-7480
Yang D, Borsky K, Jani C, et al., 2022, Trends in keratinocyte skin cancer incidence, mortality and burden of disease in 33 countries between 1990 and 2017, British Journal of Dermatology, ISSN: 0007-0963
Gueroult A, Al-Balah A, Shalhoub J, et al., 2022, Nickel hypersensitivity and endovascular devices: a systematic review and meta-analysis, Heart, Vol: 108, Pages: 1707-1715, ISSN: 1355-6037
Objective Nickel allergy is common; endovascular specialists are often confronted with nickel allergic patients ahead of the implantation of endovascular devices, many of which are nickel-containing. Our aim was to elucidate whether nickel hypersensitivity is significantly associated with worse or adverse outcomes after placement of a nickel-containing endovascular device.Methods Inclusion criteria were: endovascular and transcatheter procedures for coronary, structural heart, neurovascular and peripheral vascular pathology involving nickel-allergic patients. All adverse outcomes were included as defined by included studies. A systematic review and meta-analysis were undertaken using a random-effects model. Searches of MEDLINE and EMBASE were conducted for articles published 1947–2019.Results 190 records were identified, 78 articles were included for qualitative synthesis and 15 met criteria for meta-analysis. Patch-test confirmed nickel allergy was associated with an increased risk of adverse outcomes following implantation of a nickel-containing endovascular device (n=14 articles, 1740 patients; OR 2.61, 95% CI 1.41 to 4.85). This finding further was observed in coronary (n=12 articles, 1624 patients; OR 1.94, 95% CI 1.16 to 3.23) and structural heart subgroups (n=2 articles, 83 patients; OR 52.28, 95% CI 1.31 to 2079.14), but not in the neurovascular subgroup (n=1 article, 33 patients; OR 3.04, 95% CI 0.59 to 15.72) or with a patient-reported history of nickel allergy (n=2 articles, 207 patients; OR 2.14, 95% CI 0.23 to 19.70).Conclusions Patch-tested nickel allergy is associated with an increased risk of adverse outcomes following endovascular device implantation and alternative treatment options should be considered. Specialists faced with patients’ self-reporting nickel allergy should consider proceeding to diagnostic patch-testing.
Benson R, Nandhra S, The VERN COVER Collaborative, et al., 2022, Recovery of vascular services and adaptation of clinical practice in Europe following the initial COVID-19 pandemic peak, EJVES Vascular Forum
Hammond-Haley M, Hartley A, Al-Khayatt BM, et al., 2022, Trends in the incidence and mortality of infective endocarditis in high-income countries between 1990 and 2019., Int J Cardiol
BACKGROUND: Infective endocarditis (IE) remains a life-threatening disease with high morbidity and mortality. OBJECTIVES: To describe temporal trends in IE incidence, mortality and survival over the last 30 years. METHODS: Nineteen high-income countries (the 'EU 15+') were included. Age-standardised and sex-stratified incidence rates (ASIRs) and mortality rates (ASMRs) for IE were extracted from the Global Burden of Disease (GBD) database between 1990 and 2019, and mortality to incidence ratios (ASMIRs) were calculated. Trends were analysed using Joinpoint regression analysis. RESULTS: ASIRs were higher in males than females and increased in both sexes in all countries between 1990 and 2019. A recent steep rise in ASIRs was noted in several countries including the UK, the USA and Germany. ASMRs increased for both sexes in all countries except Finland and Austria. The largest increase in ASMR was observed in females in Italy (+246%). ASMIRs were generally higher in females compared to males, with large increases in ASMIRs (indicating worsening survival) at the end of the 20th century, but more recent stabilisation or decline across the study cohort. CONCLUSIONS: While the incidence and mortality of IE have increased over the last 30 years, recent data suggest that these trends have plateaued or reversed in most countries studied. However, a recent surge in incidence in several countries (including the USA and UK) is of concern, while unfavourable outcomes in females also merit attention. More encouragingly, this analysis provides the first indication of improving IE survival at population level, supporting recent advances in diagnosis and treatment.
The Vascular and Endovascular Research Network VERN COVER Study Collaborative, Shalhoub J, 2022, The impact of the COronaVIrus Disease 2019 (COVID-19) pandemic on the clinical management of patients with vascular diseases - Findings from Tier 3 of the COVID-19 Vascular sERvice (COVER) Study, Journal of the Vascular Societies Great Britain and Ireland
Jasionowska S, Turner B, Machin M, et al., 2022, Systematic review of exercise therapy in the management of post-thrombotic syndrome, Phlebology, ISSN: 0268-3555
Eves J, Sudarsanam A, Shalhoub J, et al., 2022, Augmented reality in vascular and endovascular surgery: a scoping review, JMIR Serious Games, Vol: 10, ISSN: 2291-9279
Background: Technological advances have transformed vascular intervention over recent decades. In particular, improvements in imaging and data processing have allowed for the development of increasingly complex endovascular and hybrid interventions. Augmented reality (AR) is a subject of growing interest within surgery, with potential to improve clinicians’ understanding of 3D anatomy and aid the processing of real-time information. This paper hopes to elucidate the potential impact of AR technology in the rapidly evolving field of vascular and endovascular surgery.Objective: The aim of this review was to summarise the fundamental concepts of augmented reality technologies, and to conduct a scoping review of the impact of AR and mixed reality within vascular and endovascular surgery.Methods: A systematic search of MEDLINE, Scopus and Embase was performed in accordance with the Preferred Reporting Items on Systematic Reviews and Meta-analysis (PRISMA) guidelines. All studies written in English from inception until 8th of January 2021 were included in the search. Combinations of the following keywords were used in the systematic search string: (‘augmented reality’ OR ‘hololens’ OR ‘image overlay’ OR ‘daqri’ OR ‘magic leap’ OR ‘immersive reality’ OR ‘extended reality’ OR ‘mixed reality’ OR ‘head mounted display’) AND (‘vascular surgery’ OR ‘endovascular’). Studies were selected by a blinded process between two investigators and assessed with data quality tools.Results: AR technologies have had a number of applications across vascular and endovascular surgery. The majority of studies use 3D imaging of CT angiogram-derived images of vascular anatomy to augment the clinicians anatomical understanding during procedures. A wide range of AR technologies have been employed, with ‘heads up’ fusion imaging and AR head-mounted disp
Turner B, Jasionowska S, Machin M, et al., 2022, Systematic review and meta-analysis of exercise therapy for venous leg ulcer healing and recurrence, Journal of vascular surgery. Venous and lymphatic disorders, ISSN: 2213-3348
Turner B, Machin M, Jasionowska S, et al., 2022, Systematic review and meta-analysis of the additional benefit of pharmacological thromboprophylaxis for endovenous varicose vein interventions, Annals of Surgery, ISSN: 0003-4932
Ali R, Sugand K, Goodall R, et al., 2022, 12 Trends in Neck of Femur Fracture Incidence in EU15+Countries From 1990-2017, Publisher: OXFORD UNIV PRESS, ISSN: 0007-1323
Abdallah N, Mouchati C, Crowley C, et al., 2022, Trends in mortality from aortic dissection analyzed from the World Health Organization Mortality Database from 2000 to 2017, International Journal of Cardiology, Vol: 360, Pages: 83-90, ISSN: 0167-5273
Background:We assessed trends in aortic dissection (AD) death rates in 23 countries from 2000 to 2017.Methods:We extracted AD mortality data for countries with high usability data from the World Health Organization (WHO) Mortality Database and from the Center for Disease Control (CDC) WONDER Database for the United States of America (USA). Age Standardized Death Rates (ASDRs) per 100,000 population were computed. Trends were assessed by locally weighted scatter plot smoother (LOWESS) regression.Results:Between 2000 and 2017, ASDRs from AD decreased in Australia, Belgium, Croatia, Denmark, France, Italy, New Zealand, Norway, Sweden, the United Kingdom, and the USA for both sexes. Increasing AD mortality was observed in Austria, Czech Republic, Germany, Hungary, Israel, and Japan for both sexes. The largest absolute increases in ASDR were in Japan for men (+1.59) and women (+1.11). The largest percentage decreases were in Norway for men (−0.91) and in New Zealand (−0.6) for women. In 2017, the highest mortality rates were in Japan for both sexes (3.22 and 2.09, respectively). The lowest ASDR was in Kyrgyzstan for both sexes (0.16 and 0.10, respectively). ASDRs for AD in 2017 were higher for men than women in all countries included. Spain had the greatest difference between the gender's mortality rates with a 2.71-fold higher mortality average rate in men.Conclusion:We identified an overall decrease in AD mortality in most included countries, while an increase was noted in other countries including Israel and Japan.
Lawton R, Shalhoub J, Davies A, 2022, Implementation of the graduated compression as an adjunct to pharmaco-thromboprophylaxis in surgery (GAPS) trial results across the UK, Phlebology, Vol: 37, Pages: 540-542, ISSN: 0268-3555
ObjectivesTo examine uptake and dissemination of a National Institute for Health Research (NIHR) Health Technology Assessment (HTA) funded trial- Graduated compression as an Adjunct to Pharmaco-thromboprophylaxis in Surgery (GAPS) (project number: 14/140/61) amongst health professionals in the UK. To evaluate the impact of the trial on venous thromboembolism (VTE) prevention policies 7 months after publication.MethodA 12-question online survey emailed to 2750 individuals via several vascular societies, 34 VTE Exemplar Centre leads and 1 charity over a 3-month period.ResultsIn total, 250 responses were received; a 9.1% response rate. Over half of all respondents (52.4%) had read the GAPS trial results prior to completing the survey. Precisely, 77.1% said their hospital had not yet made changes or did not intend to make changes to local hospital VTE policy based on the GAPS trial.ConclusionsFindings must be interpreted in the context of the low response rate. Further in-depth interviews would aid understanding of barriers to implementing change.
Shalhoub J, 2022, Contracting role of graduated compression stockings in prevention of perioperative venous thromboembolism, British Journal of Surgery, Vol: 109, Pages: 669-670, ISSN: 0007-1323
Gwilym B, VERN Collaborators, PERCEIVE Collaborators, et al., 2022, Surgeons and anaesthetists predict 30-day outcomes after major lower limb amputation more accurately than most prediction tools: early results from the PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study, British Journal of Surgery, ISSN: 0007-1323
Marshall DC, Al Omari O, Goodall R, et al., 2022, Trends in prevalence, mortality, and disability-adjusted life-years relating to chronic obstructive pulmonary disease in Europe: an observational study of the global burden of disease database, 2001-2019, BMC Pulmonary Medicine, Vol: 22, ISSN: 1471-2466
IntroductionChronic Obstructive Pulmonary Disease (COPD) is associated with significant mortality and well-defined aetiological factors. Previous reports indicate that mortality from COPD is falling worldwide. This study aims to assess the burden of COPD using prevalence, mortality, and disability-adjusted life years (DALYs) between 2001 and 2019 in 28 European countries (the European Union and the United Kingdom).MethodsWe extracted COPD data from the Global Burden of Disease database based on the International Classification of Diseases versions 10 (J41, 42, 43, 44 and 47). Age-standardised prevalence rates (ASPRs), age-standardised mortality rates (ASMRs), and DALYs were analysed for European countries by sex for each year (2001–2019) and reported per 100,000 population. We used Joinpoint regression analysis to quantify changing trends in the burden of COPD.ResultsIn 2019, the median ASPR across Europe was 3230/100,000 for males and 2202/100,000 for females. Between 2001 and 2019, the median percentage change in ASPR was − 9.7% for males and 4.3% for females. 23/28 countries demonstrated a decrease in ASPRs in males, and 11/28 demonstrated a decrease in females. The median percentage change in ASMR between 2001 and 2019 was − 27.5% for males and − 10.4% for females. 25/28 and 19/28 countries demonstrated a decrease in ASMR in males and females, respectively.ConclusionIn the EU between 2001 and 2019 COPD prevalence has overall increased in females but continues to decrease in males and in some countries, female prevalence now exceeds that of males. COPD mortality in the EU has decreased overall between 2001 and 2019; however, this decrease is not universal, particularly in females, and therefore remains a substantial source of amenable mortality.
Roy Choudhury J, Ding A, Onida S, et al., 2022, O074 Metabolic phenotyping in diabetic foot ulceration, Publisher: OXFORD UNIV PRESS, ISSN: 0007-1323
Lawton R, Hunt B, Norrie J, et al., 2022, Compression Hosiery to Avoid Post-Thrombotic Syndrome (CHAPS) Trial, European Journal of Vascular and Endovascular Surgery, ISSN: 1078-5884
Salciccioli J, Marshall D, Goodall R, et al., 2022, Interstitial lung disease incidence and mortality in the United Kingdom and the European Union: an observational study, 2001-2017, ERJ Open Research, Vol: 8, Pages: 1-12, ISSN: 2312-0541
Objective: To compare the trends in age-standardised incidence and mortality from interstitial lung diseases (ILD) in the United Kingdom (UK) and the European Union (EU).Design: Observational study using data obtained from the Global Burden of Disease Study.Setting and Participants: Residents of the UK and of the twenty-seven EU countries.Main outcome measures: ILD age-standardised incidence rates per 100 000 (ASIR), age-standardised death rates per 100 000 (ASDR), and mortality-to-incidence ratio (MIRs) are presented for males and females separately for each country, for the years 2001–2017. Trends were analysed using Joinpoint regression analysis.Results: For men, in 2017, the median incidence of ILD was 7.22 (IQR 5.57–8.96) per 100 000 population. For women, in 2017, the median incidence of ILD was 4.34 (IQR 3.36–6.29) per 100 000 population. For men, in 2017, the median ASDR attributed to ILD was 2.04 (IQR 1.13–2.71) per 100 000 population. For women, the median ASDR in 2017 for ILD was 1.02 (0.68–1.37) per 100 000 population. There was an overall increase in ASDR during the observation period with a median change of +20.42% (IQR 5.44–31.40) for men and an increase of +15.44% (IQR −1.01–31.52) for women. Despite increases in mortality over the entire observation period, there were decreasing mortality trends in the majority of countries at the end of the observation period (75% for men and 86% for women).Conclusion: Over the past two decades, there have been increases in the incidence and mortality of interstitial lung diseases in Europe. The most recent trends, however, demonstrate decreases in mortality from ILD in the majority of European countries for both men and women. These data support the ongoing improvements in the diagnosis and management of ILD.
Hanna L, Sounderajah V, Abdullah A, et al., 2022, Trends in thoracic aortic aneurysm hospital admissions, interventions and mortality in England between 1998 to 2020: An observational study, European Journal of Vascular and Endovascular Surgery, ISSN: 1078-5884
Marshall D, Al Omari O, Goodall R, et al., 2022, Trends in prevalence, mortality, and disability-adjusted life-years relating to Chronic Obstructive Pulmonary Disease in Europe: 2001-2019, BMC Pulmonary Medicine, ISSN: 1471-2466
Introduction:Chronic Obstructive Pulmonary Disease (COPD) is associated with significant mortality and well-defined etiological factors. Previous reports indicate that mortality from COPD is falling worldwide. This study aims to assess the burden of COPD using prevalence, mortality, and disability-adjusted life years (DALYs) between 2001-2019 in 28 European countries (the European Union and the United Kingdom).Methods: We extracted COPD data from the Global Burden of Disease database based on the International Classification of Diseases versions 10 (J41,42,43,44, and 47). Age-standardised prevalence rates (ASPRs), age-standardised mortality rates (ASMRs), and DALYs were analysed for European countries by sex for each year (2001-2019) and reported per 100,000 population. We used Joinpoint regression analysis to quantify changing trends in the burden of COPD.Results:In 2019, the median ASPR across Europe was 3230/100,000 for males and 2202/100,000 for females. Between 2001 and 2019, the median percentage change in ASPR was -9.7% for males and 4.3% for females. 23/28 countries demonstrated a decrease in ASPRs in males, and 11/28 demonstrated a decrease in females. The median percentage change in ASMR between 2001-2019 was -27.5% for males and -10.4% for females. 25/28 and 19/28 countries demonstrated a decrease in ASMR in males and females, respectively.Conclusion:In the EU between 2001 and 2019 COPD prevalence has overall increased in females but continues to decrease in males and in some countries, female prevalence now exceeds that of males. COPD mortality in the EU has decreased overall between 2001 and 2019; however, this decrease is not universal, particularly in females, and therefore remains a substantial source of amenable mortality. Funding:DCM is supported by an NIHR Academic Clinical Fellowship acknowledges support from the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre. KFC is a Senior Investigator of the National Institu
Ambler GK, Hitchman L, Benson RA, et al., 2022, Comment on: Collaborative research: population-based data and validation are necessary, BRITISH JOURNAL OF SURGERY, Vol: 109, Pages: E111-E112, ISSN: 0007-1323
Ambler G, Hitchman L, Benson R, et al., 2022, Surgical collaboratives – here to stay, British Journal of Surgery, ISSN: 0007-1323
Stather P, Bearne L, Shalhoub J, et al., 2022, The future of exercise therapy for people with intermittent claudication?, Journal of Vascular Societies Great Britain and Ireland, ISSN: 2754-0030
National Institute for Care Excellence (NICE) guideline 1471 recommends supervised exercise therapy (SET) for all patients with intermittent claudication, consisting of 2 hours of SET per week for a 3 month period. This is supported by good evidence from Cochrane reviews2,3 that SET shows improvement in mean walking performance compared with home based exercise and walking advice, with an increase of 120-210 metres, and also has comparable results to endovascular revascularisation. Despite this evidence and the guidance from NICE the provision of SET is variable, with <50% of UK hospitals providing SET and <25% meeting the NICE dose recommendation4. With centralisation of services into a hub and spoke model, the spokes are likely to have inferior access to SET. Furthermore, attendance and uptake rates to SET are often less than 25%5. Barriers associated with provision and uptake include access, time, travel and pain.
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