Objective Diffuse cutaneous systemic sclerosis (SSc) is a highly heterogeneous disease. A provisionally approved Composite Response Index in diffuse cutaneous SSc (CRISS) was developed as a 1‐year outcome measure for clinical trials. Our goal was to further validate the CRISS by examining agreement between CRISS definitions for improved/non‐improved with physicians' evaluation of disease. Methods Patient profiles from a large observational cohort were created for 50 random diffuse cutaneous SSc patients of <5 years disease duration with improved CRISS scores after 1 year and 50 with non‐improved CRISS scores. Profiles described disease features used during the initial CRISS development at baseline and at 1 year. Each profile was independently rated by 3 expert physicians. Majority opinion determined whether a patient was improved or not improved, and kappa agreement with the CRISS cutoff of 0.6 was calculated. Results Patients had mean ± SD disease duration of 2.2 ± 1.3 years. There was substantial agreement between the physician majority opinion about each case and the CRISS (κ = 0.76 [95% confidence interval (95% CI) 0.64–0.88]). The agreement between each individual physician opinion and the CRISS was also substantial (κ = 0.70 [95% CI 0.62–0.78]). All CRISS non‐improvers were also rated as non‐improved by physician majority; however, 12 CRISS improvers were rated as non‐improved by physicians. Conclusion There was substantial agreement between the dichotomous CRISS rating and physician assessment of diffuse cutaneous SSc patients after 1 year. This supports the use of a CRISS cutoff at 0.6 for improvement versus non‐improvement, although the CRISS tended to rate more patients as improved than did physicians.

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The Oil and Gas industry today faces the ȢEnergy Trilemma,Ȣ that is satisfying the growing global demand for energy, in conjunction with increasing societal pressure to decarbonise whilst also reducing costs. The decarbonisation of Oil and Gas assets is often perceived to be a capital-intensive process, which will make operations more difficult and impact profitability. Whilst this may be true for the more aggressive/ambitious mitigation schemes, there are solutions that can significantly improve the bottom line. Many of these solutions can be easily implemented, without significant disruption, and result present material GHG reductions. This paper highlights the opportunities for Oil and Gas operators to identify, fund, and execute energy transition projects that have successfully decarbonised assets. The decarbonisation methodology builds on lessons learned in identifying low carbon transition pathways for other high emitting industries. The process begins with a framework and evaluation model to assess a wide set of potential carbon reduction technologies that Oil and Gas companies can use to achieve carbon reduction. The key evaluation and prioritisation tool is the marginal abatement model which incorporates low carbon transition scenario planning with extended functionality aimed at providing insights to successfully achieve the targeted reduction and the potential impact of these scenarios on future financial performance. Following the evaluation and prioritisation methodology, this paper will review two decarbonisation case studies that have identified positive cashflow outcomes. The first is the application of a hybrid energy system installed at a remote onshore site to reduce reliance on diesel. The second considers reductions in the cold venting operations on a complex offshore facility to reduce fugitive emissions. The first case study demonstrates how an energy transition programme resulted in the phased delivery of a complete hybrid energy system which integrated wind power, diesel generation, and several energy storage systems including hydrogen electrolysis, storage and fuels cells, as well as lithium ion batteries and flywheel technology, all managed by a custom microgrid controller to power this remote production site whilst reducing GHG emissions. This case study shows how experience and investment in another industry can be exploited in the Oil and Gas industry. The lessons from the first phase were applied to make the second phase more economic, resulting in significant operating cost savings and the reduction in GHG emissions is 10,530 tCO2-eq per annum. The second case study offers an approach to decarbonisation which can be applied more generally in the context of operational efficiency. The ease with which the project can be executed was also assessed to ensure minimum operational downtime during the implementation phase. Our paper concludes that energy transition initiatives, if approached by combining deep techno-economical expertise, coupled with the experience from a wide range of industries, can provide attractive commercial opportunities for upstream and midstream operators. These projects whist meeting decarbonisation goals also make suitable candidates for emerging energy transition financing initiatives.

This article describes the clinical audit of the Outpatient Medical Management of Miscarriage Guideline (Guideline 2) within the Gynaecology Emergency Department (GED) at a single site dedicated Gynaecology and Maternity Hospital in the UK, the Liverpool Women's NHS Foundation Trust. Clinical audits are quality improvement processes used to identify areas of improvement against a set criterion and, as a result, implement any required change(s) ( National Institute for Health and Care Excellence, 2002 ). An audit ensures that the guidelines have been followed to certify safe, effective treatment for women who have suffered a first trimester missed miscarriage and the audit described in this article analysed the success of treatment in avoiding admission to hospital and further intervention, such as surgery. The main findings of the audit were that the GED fell short on compliance rates against some standards, mainly standard 1 (performing a baseline point of care test to measure haemoglobin) and standard 5 (providing the patient with a follow-up phone call, with higher compliance levels to standards 3 and 4, which are in relation to prescribing and administering the treatment. The audit found that 15% of patients required further intervention such as admission to hospital for observation (9%) and surgical intervention to complete the miscarriage (6%). Further training in the clinical setting is required to ensure improved compliance with all standards. A checklist will also be created to ensure all standards are being met.