This is a repository copy of Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH) : a stepped-wedge cluster-randomised trial. The Lancet. ISSN 0140-6736 https://doi.org/10.1016/S0140-6736(18)32521-2 eprints@whiterose.ac.uk https://eprints.whiterose.ac.uk/ ReuseThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND) licence. This licence only allows you to download this work and share it with others as long as you credit the authors, but you can't change the article in any way or use it commercially. More information and the full terms of the licence here: https://creativecommons.org/licenses/ Implications of all the available evidenceDespite the success of some smaller projects, there was no survival benefit from a national quality improvement programme to implement a care pathway for patients undergoing emergency abdominal surgery. To succeed, large national quality improvement programmes need to allow for differences between hospitals and ensure teams have both the time and resources needed to improve patient care.

Primary hepatic neuroendocrine carcinoma is an extremely rare tumor of the liver. We herein describe a case of primary hepatic neuroendocrine carcinoma with lymph node metastases, coexisting with hepatocellular carcinoma, on a background of hepatitis C cirrrhosis, in a 72-year-old man. Abdominal ultrasonography and computed tomography (CT) showed a tumor (3 cm in diameter) in Couinaud's hepatic segment 8 (S8) with regional lymph node metastases. Whole-body CT, magnetic resonance imaging (MRI), and endoscopy did not reveal primary lesions outside the liver. Feridex MRI and [(18)F]fluorodeoxyglucose positron emission tomography were strongly suspicious of malignancy. A limited hepatectomy with regional lymph node dissection was performed. Histopathology, immunohistochemistry, and electron microscopy confirmed a diagnosis of primary neuroendocrine carcinoma on a background of liver cirrhosis. A tumor (1.5 cm in diameter) found in hepatic S5 at operation was also simultaneously resected, and histologically diagnosed to be hepatocellular carcinoma. We also review previous reports of hepatic neuroendocrine carcinoma and discuss hypotheses for the histogenesis of these tumors as well as prognostic implications. Given the background cirrhosis and coexisting hepatocellular carcinoma, we speculate that one of the hepatocellular carcinomas underwent neuroendocrine differentiation.

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IMPORTANCEThe COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage. OBJECTIVETo create an evidence-and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic. EVIDENCE REVIEWA literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives. FINDINGS The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes;(2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide. CONCLUSIONS AND RELEVANCELeaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

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