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Bilateral salpingo-oophorectomy is indicated for patients with suspected or confirmed gynaecological malignancy. Risk reduction surgery is indicated in patients with a significant family history or a genetic predisposition to developing breast or ovarian cancer. Bilateral salpingectomy with ovarian conservation reduces the risk of ovarian cancer, whilst preserving ovarian function. Oophorectomy prior to the menopause is associated with increased all-cause mortality and significant menopause related morbidity. Conservative measures such as weight loss, family planning and lifestyle advice could reduce the overall lifetime risk of ovarian cancer. Learning objectivesTo understand the rationale of the decision-making process for bilateral salpingo-oophorectomy or bilateral salpingectomy with ovarian conversation at the time of hysterectomy for benign disease.To understand the risk-benefit balance of performing oophorectomy in the context of risk reduction of high-risk patients compared with patients with no genetic predisposition or family history. To consider conservative risk reduction measures that do not involve oophorectomy. Ethical issuesIn the absence of family history or genetic predisposition to ovarian or breast cancer, is it ethical to perform routine oophorectomy in perimenopausal or even postmenopausal women? Is it ethical to reduce the risk of ovarian cancer while increasing allcause mortality and menopause-related morbidity? Is it ethical to offer bilateral salpingectomy as a female sterilisation procedure?

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Gastrointestinal cancer occurs in approximately 1 in 13,000 pregnancies, making up 4% of malignancies detected in pregnancy. It is a complex and challenging condition to diagnose and manage and is often only detected in its more advanced stages. This is partly due to symptoms of gastrointestinal cancer being incorrectly attributed to physiological symptoms of pregnancy, as well as concerns about the safety of diagnostic investigations in pregnancy, both of which may delay diagnosis and lead to disease progression. Challenges in management also arise from under-treatment in pregnancy due to concerns about the impact of surgery or chemotherapy on the pregnancy. We present here three cases of gastrointestinal cancer diagnosed in pregnancy in our centre and discuss the challenges and pitfalls one may encounter in the diagnosis and management of gastrointestinal malignancies in pregnancy.

The aim of this work was to engage with, empower and support junior doctors to drive quality improvement (QI) and innovation. Methods 12 junior doctors were competitively appointed as Wrexham Innovation Fellows by the Site Innovation Lead. They were provided with formal QI and innovation training, mentoring and guidance to drive change. They communicate via whataspp when possible and work together as a group to bring issues to the Site Innovation Lead. This helps to identify barriers, signpost to key players in the organisation, open doors and helps develop a robust PDSA cycle. Results The Innovation Fellows work as a team and have registered over 20 QI projects to date. 100% (12/12) of Innovation fellows feel that trainee involvement in QI and innovation is a good thing and 92% (11/12) feel that their training has been complimented through their work and support as an Innovation Fellow. Since becoming an Innovation Fellow, 75% (9/12) feel more supported by the organisation to undertake QI and Innovation and 92% (11/12) feel more engaged to undertake QI and innovation since undertaking the programme. The scheme is now expanding to include advanced nurse practitioners, pharmacists and physicians associates. Conclusions Junior doctors are in unique position to influence innovation, quality improvement (QI) and leadership across NHS organisations. Providing them with bespoke leadership and QI training can help them feel supported, drive innovation, enhance trainee satisfaction, enhance their training and deliver quality improvement and innovation that can help drive change. Other organisations should consider utilising junior doctors and allied healthcare professionals as Innovation Fellows within a structured framework to drive innovation and change.