Editor—We thank Quinlan and Macintyre1 for their interest in our recent editorial on weak and strong opioids.2 We highlighted the misappropriation of the WHO analgesic ladder for cancer-related pain3 by Big Pharma in promoting the overuse, and misuse, of opioids in the management of all types of pain in a drive to promote sales and increase profits. Thus, there is the need to consider the type and cause of the pain, and to provide an evidence-based analgesic regimen rather than assuming that the pain will simply be optimally managed by prescribing according to the analgesic ladder.

Opioids have a vital role in alleviating pain from cancer and surgery. Despite good intentions, it is now recognised that the original WHO Cancer Pain Relief guidance from 1986, in which opioids were classified as either weak or strong, has been both inadvertently and purposefully misused, thereby contributing to harm from opioid use and misuse. However, the recommendation in the 2018 update of the WHO analgesic ladder that a combination of a high-potency opioid with simple analgesics is better than alternative analgesics for the maintenance of pain relief is also applicable to patients who require short-term opioids. Furthermore, because potential harm through opioid use and misuse is intrinsic to all opioids, whether weak or strong, we argue that the arbitrary classification of opioids either as weak or strong should be discontinued, as this description is not helpful to either prescribers or consumers.

Biomaterials are playing an increased role in the regeneration of damaged or absent bone tissue in the context of trauma, non-union, infection or congenital abnormality. Restoration of not only the physical scaffold that bone provides, but also of its homeostatic functions as a calcium store and hematopoietic organ are the gold standards of any regenerative procedure. Bioactive glasses are of interest as they can bond with the host bone and induce further both bone and blood vessel growth. The composition of the bioactive glasses can be manipulated to maximize both osteogenesis and angiogenesis, producing a 3D scaffolds that induce bone growth whilst also providing a structure that resists physiological stresses. As the primary endpoints of studies looking at bioactive glasses are very often the ability to form substantial and healthy tissues, this review will focus on the methods used to study and quantify osteogenesis and angiogenesis in bioactive glass experiments. These methods are manifold, and their accuracy is of great importance in identifying plausible future bioactive glasses for clinical use.

Introduction Patients with pelvic trauma are at high risk of thromboembolic complications, but effective methods of prophylaxis are still to be accepted widely. The incidence of venous thromboembolism (VTE) has been reported to be as high as 61%, which represents the commonest cause of morbidity and mortality in this cohort. New oral anticoagulants are now available and may be used instead of LMWH injections for extended prophylaxis. Rivaroxaban has not been comprehensively considered in the previous pelvic and acetabular trauma literature, but its known benefits include increased patient compliance, especially in the minority of patients who are unable to self-administer injections, and that it does not require monitoring. Materials and methods All patients referred to our pelvic trauma service between 2015 and 2020 were considered for this study, exclusion criteria involved those patients who had contraindications to rivaroxaban, those who were referred to our service but were never managed at our centre and those managed by other teams (e.g. neurosurgery). Operative patients were initially managed with LMWH until 24 h post-operatively when they started rivaroxaban. Conservatively managed patients started Rivaroxaban straight away. Data were collected on demographics, injury mechanism, fracture classification and clinically relevant VTE and bleeding events up until 3 months post discharge. Results The overall incidence of VTE was 2%. These represented 3 DVTs and 3 PEs, and occurred in patients who were managed operatively. No major bleeding events were observed. There were two minor bleeding events, both occurring in patients who were managed conservatively with rivaroxaban alone, and they did not require further intervention. 90% of patients surveyed expressed preference for oral prophylaxis. Reported compliance with rivaroxaban was 100%. Conclusion Our data show that this VTE regimen protocol is safe and effective in this group of injured patients and is at least non-inferior to the standard prophylaxis of LMWH alone.

Abstract Introduction Severe-Acute-Respiratory-Syndrome-Coronavirus-2 is a novel, highly infectious virus that has spread throughout the world causing respiratory disease (COVID-19). COVID-19 was declared a global pandemic by the World Health Organisation in March 2020. The UK has been severely affected with around 70000 deaths recorded by December 2020. Surgical practice during this pandemic has changed, as peri-operative infections carry significant mortality and morbidity burden. Method Theatre timing from a large volume hospital specifically for HPB-Transplant dedicated theatres were assessed to evaluate the impact of the national/local COVID-19 protocols on service delivery. “Pre-COVID period” was defined by auditing times from ward-to-theatre, anaesthetic induction-to-start of procedure and end of procedure-to-transfer out of theatre for 2 consecutive weeks in October/November 2019. “COVID period-1” and “COVID period-2” were defined as two consecutive weeks during the UK government-imposed lockdown in April and November 2020, respectively. Results Under the care of the HPB-Transplant team pre-COVID 56 individuals were treated in 30 sessions. Only 16 patients (28.6% of capacity) in 12 sessions were treated in COVID period-1 and 48 patients were treated (85.7% of capacity) in 30 sessions in COVID period-2. Similar times were observed in transferring patients to theatre (p-value=0.265) and induction of anaesthesia (p-value=0.698) across the 3 periods. Significant delays were observed in transferring patients out of theatre during COVID period-1, that returned to near normal timing during COVID period-2 (16.6±12.8 Vs 39.4±10.9 Vs 17.6±10.5 min; p-value = <0.00001). Conclusions Despite returning to near normal theatre timings in COVID period-2, we treat fewer patients, adversely affecting waiting lists.