Richard J. E. Skipworth

Background and Purpose: In advanced cancer, associations among changes in body composition, cardiac wasting and prior cardiotoxic anticancer therapy have not been investigated. Experimental Approach: Using bioelectrical impedance analysis (BIA), body composition was measured in 206 patients with mostly advanced cancer without known cardiovascular disease or infection (stage III/IV: 84%, prior cardiotoxic anticancer therapy: 55%). Left ventricular (LV) mass was assessed by transthoracic echocardiography and grouped by presence of cardiac wasting according to previously established sex‐specific thresholds for LV mass adjusted for height ² (2 for women, 2 for men). BIA measurements (indexed to height ² ) included fat mass index (FMI), fat‐free mass index (FFMI), skeletal muscle mass index (SMMI), visceral fat index (VFI), total body water index (TBWI) and extracellular water index (ECWI). Key Results: Patients with cancer and cardiac wasting ( n = 88) were younger (57±15 vs 62±13 years) and more often women (68% vs 29%) compared to those without cardiac wasting ( n = 118). Patients with cardiac wasting had significantly lower FMI (−12%), FFMI (−14%), SMMI (−16%), VFI (−46%), TBWI (−13%) and ECWI (−14%). For women, FFMI was significantly associated with LV mass/height ² ( r = 0.41) and VFI for men ( r = 0.40). In the multivariable linear regression analysis, FFMI was the strongest significant predictor of cardiac wasting, with no significant interaction by sex or previous cardiotoxic therapy. Conclusions and Implications: Cardiac wasting in advanced cancer is associated with lower FFMI and VFI independent of prior cardiotoxic therapy.

Purpose of review: The physiological consequences of malnutrition are well-established, yet the disruption to psychological well-being, identity and interpersonal relationships is less known and equally significant. This review focuses on recent multidimensional evidence on malnutrition in incurable cancer, particularly the psychological, social and relational effects. Recent findings: Malnutrition and cachexia carry physical, psychological and relational consequences. For those with incurable cancer, this can lead to social isolation. Furthermore, it can also cause distress, guilt, anxiety and conflict around encouraging intake between those with incurable cancer and their caregivers. Qualitative studies indicate unmet needs resulting from reduced access to specialised nutritional care. Individualised dietary counselling is one of the most effective interventions for managing nutritional intake and addressing individual needs and concerns, thereby improving quality of life. Summary: Those living with incurable cancer face complex nutritional challenges that affect their physical health, emotional well-being and interpersonal relationships. Tailored nutritional care can offer benefits aside from weight gain – it can reduce anxiety, improve quality of life and support adjustment and family understanding, which could help alleviate eating-related distress in those with incurable cancer. Recent findings highlight that individualised nutritional care – encompassing the management of nutrition impact symptoms, emotional support, alignment with personal goals and caregiver support – is essential to high-quality, supportive and palliative care. Nutritional screening and care should be integrated into oncological care, addressing holistic multimodal nutritional needs.

Background: Cognitive non-technical skills (NTS), including situation awareness and decision-making, are critical determinants of surgical outcomes. Current NTS assessments depend on expert human observation, which is resource-intensive and difficult to scale. To address this, we investigated whether surgical gestures, derived from annotated video of the surgical field, could serve as objective indicators of cognitive NTS. Methods: A data set of 40 open-source laparoscopic appendicectomy videos was annotated for temporal (for example surgical gestures) and spatial (for example coordinates of actions) indicators of surgical NTS. Using the Non-Technical Skills for Surgeons (NOTSS) tool, 12 expert observers independently assessed decision-making (1–4) and situation awareness (1–4). Multivariable linear regression analysed video-derived indicators predictive of NTS. Results: Across all videos, a total of 10 385 events were annotated, generating 87 374 data points. The mean cognitive NOTSS rating was 5.6 (s.d. 0.8) out of 8, with decision-making and situation awareness highly correlated (r = 0.8, P < 0.001). The final multivariable model explained 39.6% of the variance in expert cognitive NOTSS ratings, identifying five predictors: dexterity index, events during the final operative phase, coagulating events, dropping actions, and actions targeting the small bowel. Conclusion: This study provides evidence that non-technical skills can be inferred from silent video of the surgical field alone. These findings lay the foundations for scalable, automated tools to evaluate surgeons’ cognitive processes offering new avenues to improve surgical training, performance and outcomes.

Background: Surgical training relies heavily on subjective performance evaluation, which is resource-intensive and prone to assessor bias. Advances in digital surgery offer opportunities for objective assessment. While validity evidence for data-driven assessments increases, strategies for implementation in surgical training remain scarce. The aim of this study was to leverage stakeholder insights to develop an implementation framework for integrating data-driven surgical sabermetrics into training curricula. Methods: Structured workshops were conducted at two international surgical conferences (the Association of Surgeons of Great Britain and Ireland Congress, Edinburgh, May 2025 and the International Conference on Surgical Education and Training, Edinburgh, June 2025). Delegates participated in facilitated discussions, interactive polling, and group concept-mapping exercises to explore opportunities, delivery modalities, access rights, and contextualization for surgical performance metrics. Stakeholder perceptions were used to iteratively develop an implementation framework, balancing applicability to current training pathways and capturing the nuances of data-driven insights. Results: A total of 54 surgical trainees and trainers from 13 countries contributed. Opportunities centred on enhancing objective feedback, assessing non-technical skills, and tracking trainee progression. Video-based delivery and real-time feedback were prioritized for technical skills, dashboards were prioritized for non-technical and cognitive skills, and structured reports were prioritized for performance-based metrics. Supervising surgeons and training leads were identified as essential users of trainee data, with integration of multimodal data (for example surgeon physiology, case complexity) deemed essential for contextualization. Conclusion: This study presents an implementation framework for surgical sabermetrics in training. The framework provides practical guidance on delivery, access, and integration of performance metrics, supporting data-driven feedback to optimize trainee development, advance surgical education, and improve patient outcomes.

Background The reporting of randomised controlled non-inferiority (NI) drug trials is poor with less than 50% of published trials reporting a justification of the NI margin. This is despite the introduction of the Consolidated Standards of Reporting Trials (CONSORT) extension on reporting of NI and equivalence in randomised trials. It is critical to set the appropriate NI margin as this choice dictates the conclusions of the trial. Methods to estimate the margin are heterogeneous but generally based on clinical judgement and statistical reasoning, and hence tailored to each clinical situation. Yet an appraisal of NI in clinical trials has not been undertaken. Therefore the aim of this systematic review is to assess the reporting and methodological quality of defining the NI margin. Surgical NI trials have been chosen as our prototype to assess this. Methods We will conduct a systematic review of published randomised controlled trials in abdominal surgery that use an NI design. Key eligibility criteria will be: surgical intervention in at least one trial arm; adult patients and a sample size of 100 or more. Ovid MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials will be searched from inception until the date of the search. Identified studies will be assessed for reporting according to the CONSORT recommendations. The outcomes are the description of the methods for defining the NI margin, and the robustness of the NI margin estimation. The latter will be based on simulations using alternative assumptions for model parameters. The results of the simulation will be compared with the trial authors’ conclusions. Anticipated results The review will describe and appraise the design and reporting of surgical NI trials including shortcomings thereof and allow a comparison with pharmaceutical trials. These findings will inform researchers on the appropriate design and pitfalls when conducting surgical randomised controlled trials with an NI design and promote thorough and standardised reporting of study findings. Ethics and dissemination Ethical approval is not required and any changes to the protocol will be communicated via the registration platform. The final manuscript will be submitted to a journal for publication and the findings will be disseminated through conference presentations to inform researchers and the public.

Introduction The efficiency of multidisciplinary teams (MDTs) in cancer care hinges on facilitating clinicians’ cognitive processes as they navigate complex and uncertain judgements during treatment planning. When systems and workflows are not designed to adequately support human judgement and decision-making, even experts are prone to fallible reasoning due to cognitive biases. Incomplete integration of information or biased interpretations of patient data can lead to clinical errors and delays in the implementation of treatment recommendations. Though their impact is intuitively recognised, there is currently a paucity of empirical work on cognitive biases in MDT decision-making. Our study aims to explicate the impact of such biases on treatment planning and establish a foundation for targeted investigations and interventions to mitigate their negative effects. Methods and analysis This is a qualitative, observational study. We employ cognitive ethnography, informed by the Distributed Cognition for Teamwork framework to assess and evaluate MDT decision-making processes. The study involves in-person and virtual field observations of hepatopancreaticobiliary and upper gastrointestinal MDTs and interviews with their members over several months. The data generated will be analysed in a hybrid inductive/deductive fashion to develop a comprehensive map of potential cognitive biases in MDT decision processes identifying antecedents and risk factors of suboptimal treatment planning processes. Further, we will identify components of the MDT environment that can be redesigned to support decision-making via development of an MDT workspace evaluation tool. Ethics and dissemination This project has received management and ethical approvals from NHS Lothian Research and Development (2023/0245) and the University of Edinburgh Medical School ethical review committee (23-EMREC-049). Findings will be shared with participating MDTs and disseminated via a PhD thesis, international conference presentations and relevant scientific journals.

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Significant variation exists in the outcomes used in cancer cachexia trials, including measures of body composition, which are often selected as primary or secondary endpoints. To date, there has been no review of the most commonly selected measures or their potential sensitivity to detect changes resulting from the interventions being examined. The aim of this systematic review is to assess the frequency and diversity of body composition measures that have been used in cancer cachexia trials. MEDLINE, Embase and Cochrane Library databases were systematically searched between January 1990 and June 2021. Eligible trials examined adults (≥18 years) who had received an intervention aiming to treat or attenuate the effects of cancer cachexia for >14 days. Trials were also of a prospective controlled design and included body weight or at least one anthropometric, bioelectrical or radiological endpoint pertaining to body composition, irrespective of the modality of intervention (e.g., pharmacological, nutritional, physical exercise and behavioural) or comparator. Trials with a sample size of n = 11 561) followed by bioimpedance analysis (BIA)‐based estimates (23 trials, n = 3140). Sixteen trials (n = 3052) included dual‐energy X‐ray absorptiometry (DEXA)‐based endpoints, and computed tomography (CT) body composition was included in eight trials (n = 841). Discrepancies were evident when comparing the efficacy of interventions using BIA‐based estimates of lean tissue mass against radiological assessment modalities. Body weight, BIA and DEXA‐based endpoints have been most frequently used in cancer cachexia trials. Although the optimal endpoints cannot be determined from this review, body weight, alongside measurements from radiological body composition analysis, would seem appropriate. The choice of radiological modality is likely to be dependent on the trial setting, population and intervention in question. CT and magnetic resonance imaging, which have the ability to accurately discriminate tissue types, are likely to be more sensitive and provide greater detail. Endpoints are of particular importance when aligned with the intervention's mechanism of action and/or intended patient benefit.

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