Targeting intratumoral microbiome: the MONARCH Trial takes aim at anaerobes in rectal cancer

“They’re called ‘trials’ for a reason” a very experienced clinical academic once told me during a difficult oversight meeting for a study I was leading. This randomised controlled trial (RCT) of an intervention used during emergency bowel surgery was struggling with recruitment rates after the pandemic and we were discussing ways to get things back on track. With some intensive efforts from all involved – and a fair amount of stress - we did manage to finish participant recruitment. Unperturbed, I even took on co-leadership of another emergency perioperative trial, CAMELOT, exploring rectus sheath catheter infusions for post-laparotomy analgesia.

Many of those interested in research and quality improvement for patients undergoing emergency surgery have felt compelled by the obvious health burden: 30,000 emergency laparotomy cases each year in the UK, with a 10% mortality rate at one month after surgery. The latter seems to have stubbornly plateaued after an initial improvement soon after our national audit rolled out. Yet most perioperative research is still directed at those undergoing elective surgery, with much lower overall risks. This is clearly a patient group that remains under-served, and with a lot to gain from even small improvements in postoperative outcomes. But formally evaluating new treatments in this setting is not without challenge.

Superficial venous intervention has transformed the treatment of varicose veins, offering patients minimally invasive solutions with excellent short-term outcomes. Yet, despite technical advances, an important question remains unresolved: Should pharmacological thromboprophylaxis be routinely prescribed to prevent postoperative deep vein thrombosis (DVT)?

The THRIVE trial (THRomboprophylaxis In superficial endovenous interVEntion) is the first randomised controlled study designed to address this uncertainty.1 By generating robust clinical evidence, THRIVE has the potential to influence international practice and shape future guideline recommendations.

Varicose veins are common, affecting up to 45% of the UK population and are associated with reduced physical and mental health-related quality of life.2,3 Symptomatic varicose veins are now routinely treated with endovenous thermal ablation, non-thermal ablation or mechanochemical techniques.4 While effective, these procedures carry a recognised risk of venous thromboembolism (VTE).

Knee osteoarthritis is one of the most common musculoskeletal conditions, affecting almost one in five people over the age of 45 in the UK — around 4 million people. For many, it means living with chronic pain, limited mobility, and a gradual decline in quality of life. At its most severe, the only effective option is knee replacement surgery.

But what about those who aren’t yet at that stage? Despite trying physiotherapy, anti-inflammatories, and combinations of painkillers, many patients remain stuck in a treatment gap. Their pain is poorly controlled, yet surgery is not an option.

A new approach — genicular artery embolisation (GAE) — might offer hope. The procedure blocks small blood vessels around the knee that are thought to drive inflammation and pain. Early studies have hinted at benefit, but the evidence so far is mixed: one small trial showed no improvement, while another found a modest reduction in pain. Despite this uncertainty, the technique is already being used internationally.