Mecanismos de las políticas públicas para la gestión sostenible del agua: hacia un modelo eficiente en las Islas Baleares

Tesis por compendio[ES] El manejo sostenible del agua se ha convertido en una prioridad en todo el mundo, particularmente en aquellos territorios que sufren escasez. En el litoral mediterráneo, la proliferación del turismo y el desarrollo urbanístico, junto al resto de actividades económicas han contribuido a la sobreexplotación de los recursos hídricos naturales. Las Islas Baleares no están exentas de esta problemática. El incremento de la población flotante ha ocasionado que la máxima demanda se produzca en la época estival, coincidente con el periodo de menor recarga natural. Frente a este escenario es básico fijar acciones directas que favorezcan la recuperación y la conservación del agua. Más aún, en el actual contexto de cambio climático. La investigación aborda puntos fundamentales de la gobernanza del agua analizando el marco normativo, económico y social. Su objetivo principal es establecer el diagnóstico actual de los recursos hídricos en las Islas Baleares y, aportar medidas para avanzar hacia un buen estado ecológico, químico y cuantitativo de las masas de agua. Para ello, la tesis da respuesta a los siguientes objetivos específicos: -Analizar los mecanismos de la legislación vigente y la viabilidad de los objetivos planteados de inicio en la Directiva Marco del Agua. En segundo lugar, reflexionar sobre sus logros y carencias y, por último, determinar los retos futuros a los que se enfrenta. -Valorar el manejo y el estado de las masas de agua en la Demarcación Hidrográfica de las Islas Baleares. -Evaluar los resultados de la implementación de una acción concreta de gestión de la demanda. Los resultados obtenidos muestran que las aspiraciones iniciales de la Directiva Marco del Agua no se han cumplido y su progreso ha sido lento. No obstante, se han producido grandes esfuerzos entre ciclos de planificación y la calidad de las masas de agua ha mejorado desde su puesta en vigor. En segundo lugar, se concluye que, el uso de indicadores causa-efecto se erige como un instrumento válido de ayuda a la planificación y la administración del agua. Los resultados del trabajo manifiestan que, en las estaciones desaladoras de agua marina de Palma e Ibiza se reduce la producción de desaladas en los años con una mayor recarga natural de los acuíferos. Dicha gestión del recurso no convencional obstaculiza la recuperación de las masas de agua naturales del entorno. Finalmente, en la investigación se evalúa la implementación de una medida directa de la gestión de la demanda. Se analiza la puesta en marcha de sistemas descentralizados de aprovechamiento de aguas pluviales y de reutilización de aguas grises tratadas, para usos no potables, en edificios a escala municipal. Los resultados confirman distintos valores de disminución de la demanda de agua potable en función del uso y de la tipología del edificio. En conclusión, la Directiva Marco del Agua debe adaptarse a la especificidad hídrica de cada territorio y, por otro lado, es importante dar continuidad a la senda inversionista iniciada asegurando el balance adecuado entre las políticas de la oferta y la demanda. Además, el sector del agua debe apostar por la mejora del conocimiento, el fomento de las nuevas tecnologías y la inserción de los recursos digitales disponibles. En definitiva, en las Islas Baleares a pesar de registrarse periodos de escasez, hasta la fecha se ha garantizado la seguridad hídrica. Ahora bien, es necesario que tanto la planificación territorial como el crecimiento económico se ajusten a la cantidad de recurso disponible. El manejo del agua ha de ser capaz de optimizar el nivel de extracción de las reservas hídricas naturales, priorizando el uso complementario con recurso no convencional, anticipándose a la sobreexplotación y procurando lograr un buen estado en las masas de agua. La tesis integra tres artículos científicos publicados. En cada publicación se analizan cuestiones particulares con el fin de dar respuesta al objetivo principal de la investigación.[CA] El maneig sostenible de l'aigua ha esdevingut una prioritat a tot el món, particularment en aquells territoris que pateixen escassetat. Al litoral mediterrani, la proliferació del turisme i el desenvolupament urbanístic, juntament amb la resta d'activitats econòmiques han contribuït a la sobreexplotació dels recursos hídrics naturals. Les Illes Balears no estan exemptes d'aquesta problemàtica. L'increment de la població flotant ha ocasionat que la màxima demanda es produïsca a l'època estival, coincident amb el període de menor recàrrega natural. Davant d'aquest escenari és bàsic fixar accions directes que afavorisquen la recuperació i la conservació de l'aigua. Encara més, a l'actual context de canvi climàtic. La investigació aborda punts fonamentals de la governança de l'aigua analitzant el marc normatiu, econòmic i social. El seu objectiu principal és establir el diagnòstic actual dels recursos hídrics a les Illes Balears i aportar mesures per avançar cap a un bon estat ecològic, químic i quantitatiu de les masses d'aigua. Per això, la tesi dona resposta als següents objectius específics: -Analitzar els mecanismes de la legislació vigent i la viabilitat dels objectius plantejats d'inici a la Directiva Marc de l'Aigua. En segon lloc, reflexionar sobre els seus èxits i mancances i, finalment, determinar els reptes futurs als quals s'enfronta. -Valorar el maneig i l'estat de les masses d'aigua a la Demarcació Hidrogràfica de les Illes Balears. -Avaluar els resultats de la implementació d'una acció concreta de gestió de la demanda. Els resultats obtinguts mostren que les aspiracions inicials de la Directiva Marc de l'Aigua no s'han complert i el seu progrés ha estat lent. Tot i això, s'han produït grans esforços entre cicles de planificació i la qualitat de les masses d'aigua ha millorat des de la seua posada en vigor. En segon lloc, es conclou que l'ús d'indicadors causa-efecte s'erigeix com un instrument vàlid d'ajuda a la planificació i l'administració de l'aigua. Els resultats del treball manifesten que, a les estacions dessalinitzadores d'aigua marina de Palma i Eivissa es redueix la producció de dessalades als anys amb una major recàrrega natural dels aqüífers. Aquesta gestió del recurs no convencional obstaculitza la recuperació de les masses d'aigua naturals de l'entorn. Finalment, a la investigació s'avalua la implementació d'una mesura directa de la gestió de la demanda. S'analitza la posada en marxa de sistemes descentralitzats d'aprofitament d'aigües pluvials i de reutilització d'aigües grises tractades per a usos no potables, en edificis a escala municipal. Els resultats confirmen diferents valors de disminució de la demanda d'aigua potable en funció de l'ús i de la tipologia de l'edifici. En conclusió, la Directiva Marc de l'Aigua s'ha d'adaptar a l'especificitat hídrica de cada territori i, per altra banda, és important donar continuïtat al camí inversor iniciat assegurant el balanç adequat entre les polítiques de l'oferta i la demanda. A més, el sector de l'aigua ha d'apostar per la millora del coneixement, el foment de les noves tecnologies i la inserció dels recursos digitals disponibles. En definitiva, a les Illes Balears tot i registrar-se períodes d'escassetat, fins ara s'ha garantit la seguretat hídrica. Ara bé, cal que tant la planificació territorial com el creixement econòmic s'ajusten a la quantitat de recurs disponible. El maneig de l'aigua ha de ser capaç d'optimitzar el nivell d'extracció de les reserves hídriques naturals, prioritzant l'ús complementari amb recurs no convencional, anticipant-se a la sobreexplotació i procurant aconseguir un bon estat a les masses d'aigua. La tesi integra tres articles científics publicats. A cada publicació s'analitzen qüestions particulars per tal de donar resposta a l'objectiu principal de la investigació.[EN] The sustainable management of water has become a priority throughout the world, particularly in those territories that suffer from scarcity. On the Mediterranean coast, the proliferation of tourism and urban development, along with other economic activities have contributed to the overexploitation of natural water resources. The Balearic Islands are not exempt from this problem. The increase in the floating population has caused the maximum demand to occur in the summer season, coinciding with the period of least natural recharge. Faced with this scenario, it is essential to establish direct actions that favor the recovery and conservation of water. Even more so, in the current context of climate change. The research addresses fundamental points of water governance by analyzing the regulatory, economic and social framework. Its main objective is to establish the current diagnosis of water resources in the Balearic Islands and provide measures to move towards a good ecological, chemical and quantitative status of the water bodies. To do this, this thesis responds to the following specific objectives: -Analyze the mechanisms of current legislation and the feasibility of the objectives set forth in the Water Framework Directive. Secondly, reflect on its achievements and shortcomings and, finally, determine the future challenges faces. -Assess the management and status of the water bodies in the Hydrographic Demarcation of the Balearic Islands. -Evaluate the results of the implementation of a specific action to manage the demand. The results obtained show that the initial aspirations of the Water Framework Directive have not been fulfilled and its progress has been slow. However, there have been great efforts between planning cycles and the quality of the water bodies has improved since their implementation. Secondly, it is concluded that the use of cause-effect indicators stands as a valid tool to help planning and water management. The results of the work show that, in the seawater desalination plants of Palma and Ibiza, there is a reduction in the production of desalinated water in the years with a greater natural recharge of the aquifers. Said non-conventional resource management hinders the recovery of the natural water bodies of the environment. Finally, the research evaluates the implementation of a direct measure of demand management. The implementation of decentralized systems for the use of rainwater and the reuse of treated gray water, for non-potable uses, in buildings at the municipal level is analysed. The results confirm different values of decrease in the demand for drinking water depending on the use and the type of building. In conclusion, the Water Framework Directive must be adapted to the water specificity of each territory and, on the other hand, it is important to continue the investor path started, ensuring the proper balance between supply and demand policies. In addition, the water sector must commit to improving knowledge, promoting new technologies and inserting the digital resources available. In short, in the Balearic Islands, despite registering periods of scarcity, to date water security has been guaranteed. However, it is necessary that both territorial planning and economic growth adjust to the amount of available resources. Water management must be capable of optimizing the level of extraction from natural water reserves, prioritizing complementary use with unconventional resources, anticipating overexploitation and trying to achieve a good status in the water bodies. The thesis integrates three published scientific articles. In each publication, particular issues are analyzed in order to answer the main objective of the research.Navarro Sousa, S. (2024). Mecanismos de las políticas públicas para la gestión sostenible del agua: hacia un modelo eficiente en las Islas Baleares [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/203170Compendi

Ahorro hídrico y análisis económico del aprovechamiento del agua de lluvia y reutilización de aguas grises en edificios: estimación en una población del Levante mallorquín (España)

The Balearic Islands are characterized by large fluctuations in precipitation between winter and summer. The increase in demand by the tourism sector at the time of least recharge causes pressure on the natural water resource. In this context, it is important to establish alternatives that reduce extraction in aquifers, favouring the sustainability of the urban water cycle. Therefore, the objective of the research is to determine the water savings involved in the reuse, for non-drinking water uses, of rainwater and recycled grey water in the buildings of Son Servera (Spain). To do this, initially a geospatial analysis has been carried out and the methodology of the UNE-EN 16941-1 and 2 standards has been applied. Secondly, the economic profitability of these systems has been assessed. The results confirm different reductions in drinking water extraction depending on the use and type of building. Likewise, the single-family houses evaluated do not produce the payback on the investment, unlike in the multi-family houses and hotels. When the municipality has a supply of desalinated water, this strategy would reduce its production, particularly, in those periods of groundwater scarcity.Las Islas Baleares se caracterizan por tener grandes fluctuaciones de precipitación entre el invierno y el verano. El incremento de la demanda por el turismo en la época de menor recarga origina presión sobre el recurso hídrico natural. En esta contextualización es importante establecer alternativas que reduzcan la extracción en los acuíferos, favoreciendo la sostenibilidad del ciclo urbano del agua. Por tanto, el objetivo de la investigación es determinar el ahorro de agua que supone la reutilización, para usos no potables, del agua de lluvia y las grises recicladas en los edificios de Son Servera (España). Para ello, inicialmente se ha realizado un análisis geoespacial y aplicado la metodología de las normas UNE-EN 16941-1 y 2. En segundo lugar se ha valorado la rentabilidad económica de estos sistemas. Los resultados confirman diferentes reducciones de la extracción de agua potable en función del uso y la tipología del edificio. Así mismo, en las unifamiliares evaluadas no se produce la recuperación de la inversión, al contrario que en las plurifamiliares y hoteles. Cuando el municipio cuente con el suministro de agua desalada, esta estrategia reduciría su producción y, en particular, en aquellos periodos de escasez de recurso hídrico subterráneo

Use of cause-effect indicators for the diagnosis of water sustainability in the Balearic Islands (Spain)

[EN] In the Balearic Islands, the expansion of the tourism sector and the urban growth have meant a transformation of the uses of water increasing the extractions and the average provisioning in the urban supply. This study aims to establish in its Hydrographic Demarcation a comparative diagnosis of the use of the resource with sustainability in the management. For the analysis, a set of cause-effect indicators is applied following the framework of reference Drivers - PressuresState- Impact and Response (DPSIR). One of the limitations detected is the difficulty in collecting data given the large number of continental water exploitation systems in the Demarcation. The socioeconomic results evaluated indicate the big bet for an economy of the service sector, which has meant a coastal population increase and the progressive abandonment of the agricultural sector. In all the islands, although at different percentage levels, there has been detected overexploitation, salinisation and contamination of some of their groundwater body masses. The current model of development, in order to avoid risks of the resource and guarantee autonomy and security in the supply, requires mid-scale adaptations from an approach of progress towards integration and moderation in growth, obeying the environmental objectives proposed by the Water Framework Directive (WFD) in the foreseen terms.[ES] En las Islas Baleares, la expansión del turismo y el crecimiento urbanístico ha supuesto una transformación de los usos del agua incrementando las extracciones y las dotaciones medias urbanas. Este estudio pretende establecer en su Demarcación Hidrográfica un diagnóstico comparativo del uso del recurso con la sostenibilidad en el manejo. Para el análisis, se aplican un conjunto de indicadores causa-efecto siguiendo el marco de referencia Fuerzas Motrices-PresionesEstado-Impactos-Respuestas (FPEIR). Una de las limitaciones detectadas es la dificultad en la recogida de datos dado el gran número de sistemas de explotación de aguas continentales de la Demarcación. Los resultados socioeconómicos evaluados indican la gran apuesta por una economía del sector servicios, que ha supuesto un aumento demográfico litoral y el abandono progresivo del 2 sector agrícola. En todas las islas, aunque a niveles porcentuales distintos, se ha detectado sobreexplotación, salinización y contaminación de algunas de sus masas de agua. El actual modelo de desarrollo, para evitar riesgos sobre el recurso y garantizar la autonomía y seguridad en el abastecimiento, requiere adaptaciones medioplacistas desde un planteamiento de avance hacia la integración y la moderación en el crecimiento cumpliendo con los objetivos medioambientales propuestos por la Directiva Marco del Agua (DMA) en los plazos previstos.El presente trabajo ha sido posible gracias a un Convenio de Colaboración entre la Universitat Politècnica de València y la Universitat de les Illes Balears dentro de un programa individual de intercambio de doctorado del primer autor, en cuya tesis se integrará dicho trabajo. Los autores agradecen a las/os revisoras/es de este artículo sus observaciones y recomendaciones.Navarro-Sousa, S.; Estruch-Guitart, V.; García, C. (2020). Uso de indicadores causa-efecto para el diagnóstico de la sostenibilidad hídrica en las Islas Baleares (España). Boletín de la Asociación de Geógrafos Españoles. 85:1-48. https://doi.org/10.21138/bage.2833S1488

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Clonal chromosomal mosaicism and loss of chromosome Y in elderly men increase vulnerability for SARS-CoV-2

The pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) had an estimated overall case fatality ratio of 1.38% (pre-vaccination), being 53% higher in males and increasing exponentially with age. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, we found 133 cases (1.42%) with detectable clonal mosaicism for chromosome alterations (mCA) and 226 males (5.08%) with acquired loss of chromosome Y (LOY). Individuals with clonal mosaic events (mCA and/or LOY) showed a 54% increase in the risk of COVID-19 lethality. LOY is associated with transcriptomic biomarkers of immune dysfunction, pro-coagulation activity and cardiovascular risk. Interferon-induced genes involved in the initial immune response to SARS-CoV-2 are also down-regulated in LOY. Thus, mCA and LOY underlie at least part of the sex-biased severity and mortality of COVID-19 in aging patients. Given its potential therapeutic and prognostic relevance, evaluation of clonal mosaicism should be implemented as biomarker of COVID-19 severity in elderly people. Among 9578 individuals diagnosed with COVID-19 in the SCOURGE study, individuals with clonal mosaic events (clonal mosaicism for chromosome alterations and/or loss of chromosome Y) showed an increased risk of COVID-19 lethality

Cabbage and fermented vegetables : From death rate heterogeneity in countries to candidates for mitigation strategies of severe COVID-19

Large differences in COVID-19 death rates exist between countries and between regions of the same country. Some very low death rate countries such as Eastern Asia, Central Europe, or the Balkans have a common feature of eating large quantities of fermented foods. Although biases exist when examining ecological studies, fermented vegetables or cabbage have been associated with low death rates in European countries. SARS-CoV-2 binds to its receptor, the angiotensin-converting enzyme 2 (ACE2). As a result of SARS-CoV-2 binding, ACE2 downregulation enhances the angiotensin II receptor type 1 (AT(1)R) axis associated with oxidative stress. This leads to insulin resistance as well as lung and endothelial damage, two severe outcomes of COVID-19. The nuclear factor (erythroid-derived 2)-like 2 (Nrf2) is the most potent antioxidant in humans and can block in particular the AT(1)R axis. Cabbage contains precursors of sulforaphane, the most active natural activator of Nrf2. Fermented vegetables contain many lactobacilli, which are also potent Nrf2 activators. Three examples are: kimchi in Korea, westernized foods, and the slum paradox. It is proposed that fermented cabbage is a proof-of-concept of dietary manipulations that may enhance Nrf2-associated antioxidant effects, helpful in mitigating COVID-19 severity.Peer reviewe

Nrf2-interacting nutrients and COVID-19 : time for research to develop adaptation strategies

There are large between- and within-country variations in COVID-19 death rates. Some very low death rate settings such as Eastern Asia, Central Europe, the Balkans and Africa have a common feature of eating large quantities of fermented foods whose intake is associated with the activation of the Nrf2 (Nuclear factor (erythroid-derived 2)-like 2) anti-oxidant transcription factor. There are many Nrf2-interacting nutrients (berberine, curcumin, epigallocatechin gallate, genistein, quercetin, resveratrol, sulforaphane) that all act similarly to reduce insulin resistance, endothelial damage, lung injury and cytokine storm. They also act on the same mechanisms (mTOR: Mammalian target of rapamycin, PPAR gamma:Peroxisome proliferator-activated receptor, NF kappa B: Nuclear factor kappa B, ERK: Extracellular signal-regulated kinases and eIF2 alpha:Elongation initiation factor 2 alpha). They may as a result be important in mitigating the severity of COVID-19, acting through the endoplasmic reticulum stress or ACE-Angiotensin-II-AT(1)R axis (AT(1)R) pathway. Many Nrf2-interacting nutrients are also interacting with TRPA1 and/or TRPV1. Interestingly, geographical areas with very low COVID-19 mortality are those with the lowest prevalence of obesity (Sub-Saharan Africa and Asia). It is tempting to propose that Nrf2-interacting foods and nutrients can re-balance insulin resistance and have a significant effect on COVID-19 severity. It is therefore possible that the intake of these foods may restore an optimal natural balance for the Nrf2 pathway and may be of interest in the mitigation of COVID-19 severity

Search for dark matter produced in association with bottom or top quarks in √s = 13 TeV pp collisions with the ATLAS detector

A search for weakly interacting massive particle dark matter produced in association with bottom or top quarks is presented. Final states containing third-generation quarks and miss- ing transverse momentum are considered. The analysis uses 36.1 fb−1 of proton–proton collision data recorded by the ATLAS experiment at √s = 13 TeV in 2015 and 2016. No significant excess of events above the estimated backgrounds is observed. The results are in- terpreted in the framework of simplified models of spin-0 dark-matter mediators. For colour- neutral spin-0 mediators produced in association with top quarks and decaying into a pair of dark-matter particles, mediator masses below 50 GeV are excluded assuming a dark-matter candidate mass of 1 GeV and unitary couplings. For scalar and pseudoscalar mediators produced in association with bottom quarks, the search sets limits on the production cross- section of 300 times the predicted rate for mediators with masses between 10 and 50 GeV and assuming a dark-matter mass of 1 GeV and unitary coupling. Constraints on colour- charged scalar simplified models are also presented. Assuming a dark-matter particle mass of 35 GeV, mediator particles with mass below 1.1 TeV are excluded for couplings yielding a dark-matter relic density consistent with measurements

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research