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Background: Chronic pain after breast cancer surgery affects up to 60% of patients. Evidence supports the fact that pain outwith the surgical site is a significant issue. This systematic review and meta-analysis sought to evaluate the prevalence of non-surgical site pain (NSSP) in women after breast cancer surgery at 6 months post-operatively. Methods: Adult women with a confirmed breast cancer diagnosis who had undergone breast cancer surgery were identified. The outcome pursued was pain outwith the surgical site measured on either NRS/VRS or VAS rating scale. CENTRAL, Embase, PubMed, MEDLINE, CINAHL, PsycInfo, Web of Science, and Scopus were searched to identify studies that examined NSSP after breast cancer surgery at 6 months. Data were gathered via pre-piloted Excel forms and analysed both quantitively and qualitatively. Meta-analysis was carried out using a random-effects model to assess risk difference with 95% confidence interval (CI). Results: A total of sixteen studies were identified for inclusion. Eleven studies failed to provide sufficient data and consequently were analysed qualitatively. Five studies were adequate for quantitative analysis, including a total of 995 patients. Meta-analysis identified a risk difference of 18% (95% CI: 5–31%) between patients who had breast cancer surgery and a reference, however, this is low-quality evidence. Conclusion: This review has highlighted that breast cancer surgery increases the risk of pain outwith the surgical site postoperatively. It was additionally identified that NSSP data are often gathered in research yet rarely presented in results or highlighted as a primary outcome. As the quality of evidence was low, research specifying NSSP as a primary outcome is required to provide more certainty. [ABSTRACT FROM AUTHOR]

AbstractPurpose:To report any differences in the visual acuity (VA) recording method used in peer-reviewed ophthalmology clinical studies over the past decade. Methods:We reviewed the method of assessing and reporting VA in 160 clinical studies from 2 UK and 2 US peer-reviewed journals, published in 1994 and 2004. Results:The method used to assess VA was specified in 62.5 of UK-published and 60 of US-published papers. In the results sections of the UK publications the VA measurements presented were Snellen acuity (n = 58), logMAR acuity (n = 20) and symbol acuity (n = 1). Similarly in the US publications the VA was recorded in the results section using Snellen acuity (n = 60) and logMAR acuity (n = 14). Overall 10 of the authors appeared to convert Snellen acuity measurements to logMAR format. Five studies (3) chose to express Snellen-type acuities in decimal form, a method which can easily lead to confusion given the increased use of logMAR scoring systems. Conclusion:The authors recommend that to ensure comparable visual results between studies and different study populations it would be useful if clinical scientists worked to standardized VA testing protocols and reported results in a manner consistent with the way in which they are measured.Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Public health approaches to communication disability challenge the profession of speech-language pathology (SLP) to reconsider both frames of reference for practice and models of education. This paper reviews the impetus for public health approaches to communication disability and considers how public health is, and could be, incorporated into SLP education, both now and in the future. The paper describes tensions between clinical services, which have become increasingly specialized, and public health approaches that offer a broader view of communication disability and communication disability prevention. It presents a discussion of these tensions and asserts that public health approaches to communication are themselves a specialist field, requiring specific knowledge and skills. The authors suggest the use of the term 'communication disability public health' to refer to this type of work and offer a preliminary definition in order to advance discussion. Examples from three countries are provided of how some SLP degree programmes are integrating public health into the SLP curriculum. Alternative models of training for communication disability public health that may be relevant in the future in different contexts and countries are presented, prompting the SLP profession to consider whether communication disability public health is a field of practice for speech-language pathologists or whether it has broader workforce implications. The paper concludes with some suggestions for the future which may advance thinking, research and practice in communication disability public health. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objective: The Viking Speech Scale (VSS) reliably classifies the speech performance of children with cerebral palsy. This paper aims to establish the construct validity of the VSS by testing the extent to which percentage intelligibility in single word speech and connected speech predicts VSS rating. Patients and Methods: This is a secondary analysis of two sets of anonymised data collected for previous research. The full data set comprised 79 children with cerebral palsy from the US (n = 43) and the UK (n = 36): (43 boys, 36 girls); mean age 7.2 years (SD 3.3). Single word intelligibility was measured using the TOCS+ words for US children and Children's Speech Intelligibility Measure for the UK children. Connected speech intelligibility was measured from a subset of repeated sentences in TOCS+ for US children and picture description for the UK children. We used ordinal logistic regression to examine prediction of VSS rating by percentage single word and connected speech intelligibility scores in both samples. Results: Percentage single word intelligibility and connected speech intelligibility predicted VSS rating in univariate and multivariate regression models for both the US and UK samples. Conclusion: Intelligibility predicts VSS for both single words and connected speech, establishing the construct validity of VSS. [ABSTRACT FROM AUTHOR]

Background: The substantial increase in the complexity of breast cancer care in the last few decades has resulted in significant improvements in survival rates and also in the quality of life of breast cancer survivors. However, across Europe there are variations in outcomes and access to the latest techniques. Whilst much of this variance is due to differences in health economies between European member states, training variation may also play a part. Training in breast cancer surgery varies greatly across Europe, not only in its basal discipline (general surgery, gynaecology or plastic surgery) but also in the length of training and whether there is any requirement for specialist training. Several countries have been leading the way in training breast specialist surgeons (the USA, the UK, Australia and New Zealand) with dedicated 1- or 2-year fellowships either within or in addition to standard training. Access to such training is limited and consequently many women in Europe are still treated by generalists, potentially denying them access to the best care. This paper reviews the issues surrounding training provision in breast surgery and some of the challenges which need to be addressed to improve the current situation. Summary: Breast surgery training in Europe is of variable quality and duration, which may result in variations in the quality of care received by patients with breast cancer. Specialist training standards are urgently required which should be adopted by all European member states. Excellent models are available in the USA, the UK and Australia and New Zealand on which to base this training. Key Messages: The quality of training in breast surgery needs to be upgraded and harmonised across Europe. [ABSTRACT FROM AUTHOR]

Background: Alzheimer's disease (AD) with its high burden on disability is known as one of the critical public health issues worldwide. Hence, providing comprehensive care and effective symptomatic treatment are becoming a challenge for many healthcare systems. Quality of life (QOL) has been identified as an important indicator to develop holistic care for people living with AD since it reflects treatment response, the progression of AD, and activities of daily living. This study aimed to identify research trends and landscapes as well as important factors in QOL studies in the field of AD. Summary: English research was extracted from the online database Web of Science to analyze research publications' growth rate and content on AD and QOL. VOSviewer was used to visualize the correlations between terms in titles and abstracts. Research topics were created using Latent Dirichlet Allocation of abstracts' content and disciplines. Major landscapes in the QOL assessment included care and treatment for AD in epidemiological studies and clinical trials. Besides, most studies were conducted in high-income countries, such as the USA or the United Kingdom. Findings of our study also identified a lack of contextualized factors and research gaps in terms of QOL among individuals with AD. Key Messages: Further studies should be conducted taking an effort to assess QOL among demented patients as well as advancing knowledge, attitude, and practice among family caregivers. [ABSTRACT FROM AUTHOR]

Pseudohallucinations are poorly understood, with clinicians continuing to rely on historical contributions to inform their views. There have been a number of recent attempts to develop a phenomenologically adequate theory of psychotic symptoms, yet the reciprocal dependence between the structure of such theories and the understanding of pseudohallucinations remains unexploited. This paper seeks to progress the debate about the nature of pseudohallucinations whilst simultaneously providing implicit support for a new two-factor theory of psychotic symptoms by relating the important historical contributions by Hare and Jaspers to the contemporary debate about the aetiology of psychotic symptoms. It will be argued that the focus of Hare and Jaspers on abnormal experience and vivid imagination have their respective analogues in recent theories of psychotic symptoms. It will be suggested, however, that an adequate theory requires a contribution from both processes and that this suggests that there are two types of pseudohallucinations. The paper implies that the concept of pseudohallucination is central to relating aetiological to phenomenological considerations and concludes by drawing out some of the implications of the proposals for understanding pseudohallucinations involving insight and complex psychotic symptoms. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction: School-based exercise interventions targeted at reducing obesity are often successful in the short term, but they are resource-heavy and do not always lead to long-lasting behaviour changes. This study investigated the effect of reducing sedentary time, rather than increasing exercise, on physical activity (PA) behaviours and obesity in primary school children. Methods: Thirty UK state primary schools participated in this cluster-controlled intervention study (IDACI score = 0.15 ± 0.07, free school meals = 26 ± 9%). Twenty-six intervention and 4 control schools (intervention = 3,529, control = 308 children) completed the Physical Activity Questionnaire for Children (PAQ-C) in terms 1 and 3. Three intervention and 3 control schools (intervention = 219, control = 152 children) also measured waist-to-height ratio (WTHR). The Active Movement Intervention is a school-based programme which integrates non-sedentary behaviours such as standing and walking in the classroom. Data were analysed via ANCOVAs and multiple linear regressions. Results: WTHR was reduced by 8% in the intervention group only (F(2, 285) = 11.387, p < 0.001), and sport participation increased by 10% in the intervention group only (F(1, 232) = 6.982, p = 0.008). Other PAQ-C measures increased significantly in the intervention group, but there was no group*time interaction. Changes in PAQ-C did not predict reductions in WTHR. Instead, the amount of change in WTHR was predicted by intervention group and by baseline WTHR of the pupil, where children with higher baseline WTHR showed greater reductions (F(2, 365) = 77.21, p < 0.001, R2 = 0.30). Socio-economic status (SES), age, or gender did not mediate any of the changes in the PAQ-C or WTHR. Conclusion: Reducing sedentary behaviours during school time can be an effective obesity reduction strategy for primary school children who are overweight. The lack of demographic effects suggests that this method can be effective regardless of the school's SES, pupil age, or gender. [ABSTRACT FROM AUTHOR]

Background/Aims: To examine the validity of Addenbrooke's Cognitive Examination III (ACE-III) in detecting early dementia in UK memory clinic patients aged 75-85 years. Methods: The ACE-III was administered to 59 patients prior to diagnosis. The extent to which scores predicted the membership of the dementia or no-dementia group was explored using receiver operating characteristic curve analysis and other parameters of diagnostic performance. Thirty-three participants (55.9%) were diagnosed with dementia (Alzheimer's disease = 56.3%, Alzheimer's disease with cerebrovascular disease = 31.3%, and vascular dementia = 12.5%). Results: The optimal cut-off for detecting dementia was 81/100 (scores <81 indicating dementia with a sensitivity of 0.79, a specificity of 0.96, and a positive predictive value of 0.96), with superiority over published cut-offs (88/100 and 82/100) at medium and lower prevalence rates. The number of years of full-time education had a significant positive relationship to total ACE-III scores (r = 0.697, p < 0.001) for the no-dementia group. Exploratory analysis indicated that optimal cut-offs were different for higher versus lower education groups. Conclusions: The ACE-III has excellent accuracy for the detection of dementia in day-to-day clinical practice. Lower cut-offs than those specified in the index paper, and the consideration of the patients' years of full-time education may be necessary for optimal diagnostic performance. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction: Observational studies have shown that obesity is a risk factor for various autoimmune diseases. However, the causal relationship between obesity and autoimmune diseases is unclear. Mendelian randomization (MR) was used to investigate the causal effects of obesity on 15 autoimmune diseases. Methods: MR analysis employed instrumental variables, specifically single-nucleotide polymorphisms associated with obesity measures such as body mass index (BMI), waist circumference, hip circumference, and waist-to-hip ratio. The study utilized UK Biobank and FinnGen data to estimate the causal relationship between obesity and autoimmune diseases. Results: Genetically predicted BMI was associated with risk for five autoimmune diseases. The odds ratio per 1-SD increase in genetically predicted BMI, the OR was 1.28 (95% CI, 1.18–1.09; p < 0.001) for asthma, 1.37 (95% CI, 1.24–1.51; p < 0.001) for hypothyroidism, 1.52 (95% CI, 1.27–1.83; p < 0.001) for psoriasis, 1.22 (95% CI, 1.06–1.40; p = 0.005) for rheumatoid arthritis, and 1.55 (95% CI, 1.32–1.83; p < 0.001) for type 1 diabetes. However, after adjusting for genetic susceptibility to drinking and smoking, the correlation between BMI and rheumatoid arthritis was not statistically significant. Genetically predicted waist circumference, hip circumference, and waist and hip circumference were associated with 6, 6, and 1 autoimmune disease, respectively. Conclusion: This study suggests that obesity may be associated with an increased risk of several autoimmune diseases, such as asthma, hypothyroidism, psoriasis, rheumatoid arthritis, and type 1 diabetes. [ABSTRACT FROM AUTHOR]

Background: The British Association for Paediatric Nephrology Registry was established to analyse data related to renal replacement therapy (RRT) for children. The registry receives data from the 13 paediatric nephrology centres in the UK. Aim: To provide centre specific data so that individual centres can reflect on the contribution that their data makes to the national picture and to determine the extent to which their patient parameters meet nationally agreed audit standards for the management of children with established renal failure. Method: Data returns have been a mixture of electronic and paper returns. Data were analysed to calculate summary statistics and where applicable the percentage achieving an audit standard. The standards used were those set out by the Renal Association and the National Institute for Health and Clinical Excellence. Results: Anthropometric data confirmed that children receiving RRT are short compared to healthy peers. Amongst patients with a height z-score of <2SD between 2000 and 2010, 27% were receiving growth hormone if they were on dialysis compared to 10% if they had a functioning transplant. Blood pressure was higher in children receiving RRT than in healthy children with wide inter-centre variation. The percentage of patients achieving the treatment standards for haemoglobin and ferritin has gradually increased over the last decade, more noticeably in dialysis patients. Analysis by age showed that the proportion of children with a haemoglobin below the standard was greatest for the under 5 years age group irrespective of RRT modality. The control of renal bone disease remained challenging. Conclusions: Optimizing growth in children on RRT remains challenging and the control of bone biochemistry in children on dialysis is imperfect. However there is some room for optimism as this year's data shows an improving trend in the control of anaemia and systolic blood pressure. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Various models of intervention for caregivers of patients with dementia have been described. There has been little direct comparison of cultural differences between countries and the effect any differences may exert on the outcome of caregiver interventions. Aims: The aims of the three-country study (USA, Australia and the UK) were to assess whether caregiver interventions can still be successful when anti-dementia drugs are provided to patients, and whether a caregiver intervention can be successfully implemented using the same methods in three different English-speaking countries. In this paper, the cultural differences and similarities between the three countries are examined. Method: Randomised, controlled trial involving 158 patients and their caregivers (divided equally across three centres, New York, Sydney and Manchester) with all the patients receiving donepezil and the caregivers randomised to a caregiver intervention or treatment as usual. Results: There were few differences between countries in the main outcome measures, and no differences between the treatment-as-usual group and the intervention, but interesting cultural nuances were observed between groups. Despite these differences, the caregiver intervention was associated with positive results on caregiver depression across all the countries. Conclusions: This first multinational carer intervention study has emphasised the similarities between the three countries whilst highlighting crucial differences which may be important when planning cross-cultural studies in the future. The positive results achieved on caregiver depression were replicated across the three centres. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The British Association for Paediatric Nephrology Registry was established thirteen years ago to analyse data related to renal replacement therapy for children. The registry receives data from the 13 paediatric nephrology centres in the UK. In 2008 the registry was relocated to the UK Renal Registry (UKRR). Aim: To provide centre specific data so that individual centres can reflect on the contribution that their data makes to the national picture and to determine the extent to which their patient parameters meet nationally agreed audit standards for the management of children with established renal failure. Method: Data were submitted to the UKRR for analysis electronically via renal IT systems from 5 centres and on paper-based returns from the remaining centres. Data were analysed to calculate summary statistics and where applicable the percentage achieving an audit standard. The standards used were those set out by the Renal Association and the National Institute for Health and Clinical Excellence. Results: Data were received from all but one centre. Anthropometric data confirmed that children with ERF in the UK are short compared with their peers with no change in recent trends. In the UK as a whole, the control of blood pressure, anaemia and bone biochemistry is suboptimal, but for some parameters these appear to be better in the 2008 cohort than in the 1999–2008 cohort. Conclusions: Key features of this report are the provision of centre specific data and comparison of data to audit standards. It is hoped that this information will provide a basis for discussion and a stimulus to improve the care of children with ERF. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

There has been considerable debate about the effectiveness of drug treatment in reducing offending and drug use, with limited support for the effectiveness of the UK Drug Intervention Programme to reduce offending through diversion into treatment. The current paper examines drug users diverted into treatment in one UK city to assess their treatment engagement and criminal thinking styles. There is an association between higher criminal thinking and both poorer engagement in treatment and worse client functioning. The key implication is that to address offending-prone behaviour as a determinant of ongoing drug use, it is essential that criminal thinking styles are addressed. Copyright © 2009 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: The femoral region (‘groin’) appears to be increasingly commonly used by injecting drug users in the UK. With the advent of Britain’s first supervised prescribed injectable opioid treatment clinic, unprecedented decisions and judgements were required about the safe supervision of this practice, or whether to permit this behaviour on site at all. This paper reports the reasons for, and outcome of, development of a clinical policy on injecting into the deep femoral vein (groin injecting). Method: A small in-depth audit of the complications of femoral injecting was undertaken in a supervised injecting clinic. Results: All femoral injectors had had either local site-related medical complications or other health problems which could potentially be worsened by ongoing injection. This finding along with the personal and professional issues raised by staff for supervision of femoral injecting led to a revised policy focussing on achieving a shift towards lower-risk peripheral venous and intramuscular sites. Conclusion: While the clinic staff’s training may be more compatible with professional duties of care by encouraging cessation of femoral injecting, this does not tell us what advice harm reduction workers in the field should offer groin injectors. More research is needed into this high-risk, controversial injecting practice. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This paper outlines the principles of palliative care (PC) provision for sick children at home, in the UK. The differences between home and hospital with regard to the illness and availability and type of services and equipment are discussed. The need to plan for the availability of appropriate professional staff, equipment, medication, information and the procedure when the child dies is discussed. Successful PC at home is possible for most children, if plans are made for all potential eventualities. These principles of PC may be helpful in delivering PC at home in other countries. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

This paper takes an international perspective on the marketing of alcohol to young people by examining case studies of the marketing of alcohol in the UK and Poland. It is suggested that marketing is a powerful mechanism for attracting young consumers. The alcohol industry is an innovative industry able to use a wide variety of marketing tools to achieve success in the market-place. It is important to recognise that the marketing activities of the industry are becoming increasingly transnational and that policy response has to be equally transnational. [ABSTRACT FROM AUTHOR]

Introduction: Time spent on screen-based sedentary activities is significantly associated with dementia risk, however, whether the associations vary by family history (FHx) of dementia is currently unknown. We aimed to examine independent associations of two prevalent types of screen-based sedentary activities (television [TV] viewing and computer use) with dementia and assess the modifying effect of FHx. Methods: We included 415,048 individuals free of dementia from the UK Biobank. Associations of TV viewing, computer use, and FHx with dementia risk were determined using Cox regression models. We estimated both multiplicative- and additive-scale interactions between TV viewing and computer use and FHx. Results: During a median follow-up of 12.6 years, 5,549 participants developed dementia. After adjusting for potential confounding factors, we observed that moderate (2–3 h/day; hazard ratio [HR] 1.13, 95% confidence interval 0.03–1.23) and high (>3 h/day; 1.33, 1.21–1.46) TV viewing was associated with a higher dementia risk, compared with low (0–1 h/day) TV viewing. Using restricted cubic spline models, the relationship of TV viewing with dementia was nonlinear (relative to 0 h/day; p for nonlinear = 0.005). We found that >3 h/day of TV viewing was associated with a 42% (1.42, 1.18–1.71) higher dementia risk in participants with FHx while a 30% (1.30, 1.17–1.45) in those without FHx. For computer use, both low (0 h/day; 1.41, 1.33–1.50) and high (>2 h/day; 1.17, 1.05–1.29) computer use were associated with elevated dementia risk, compared with moderate (1–2 h/day) computer use. We observed a J-shaped relationship with dementia (relative to 2 h/day; p for nonlinear <0.001). Compared with 1–2 h/day of computer use, the HRs of dementia were 1.46 (1.29–1.65) and 1.10 (0.90–1.36) for 0 h/day and >2 h/day of computer use in participants with FHx, respectively, while the corresponding HRs were 1.40 (1.30–1.50) and 1.19 (1.06–1.33) in those without FHx. We observed a positive additive interaction (RERI 0.29, 0.06–0.53) between computer use and FHx, while little evidence of interaction between TV viewing and FHx. Conclusions: The time spent on TV viewing and computer use were independent risk factors for dementia, and the adverse effects of computer use and FHx were additive. Our findings point to new behavioral targets for intervention on preventing an early onset of dementia, especially for those with FHx. [ABSTRACT FROM AUTHOR]

Introduction Falls have major implications for quality-of-life, independence and cost to health services. Strength and balance training has been found to be effective in reducing the rate/risk of falls, as long as there is adequate fidelity to the evidence-based programme. The aims of this study were to: (1) assess the feasibility of using the 'Motivate Me' and 'My Activity Programme' intervention to support falls rehabilitation when delivered in practice (2) assess study design and trial procedures for the evaluation of the intervention. Methods A two-arm, pragmatic feasibility randomised controlled trial was conducted with five health service providers in the UK. Patients aged 50+ years eligible for a falls rehabilitation exercise programme from community services were recruited and received either: (1) standard service with a smartphone for outcome measurement only or (2) standard service plus the 'Motivate Me' and 'My Activity Programme' apps. The primary outcome was feasibility of the intervention, study design and procedures (including recruitment rate, adherence and drop-out). Outcome measures include balance, function, falls, strength, fear of falling, health related quality of life, resource use and adherence, measured at baseline, three and six month post-randomisation. Blinded assessors collected the outcome measures. Results 24 patients were randomised to control group, 26 to intervention group, mean age 77.6 (Range 62 to 92) years. We recruited 37.5% of eligible participants across the five clinical sites. 77% in the intervention group completed their full exercise programme (including the use of the app). Response rate for outcome measures at six months were 77%-80% across outcome measures, but this was effected by the COVID19 pandemic. There was a mean 2.6 ± 1.9 point difference between groups in change in BERG balance score from baseline to three months and mean 4.4 ± 2.7 point difference from baseline to six months in favour of the intervention group. Less falls (1.8 ± 2.8 vs 9.1 ± 32.6) and less injurious falls (0.1 ± 0.5 vs 0.4 ± 0.6) in the intervention group and higher adherence scores at three (17.7 ± 6.8 vs 13.1 ± 6.5) and six months (15.3 ± 7.8 vs 14.9 ± 7.8). There were no related adverse events. Health professionals and patients had few technical issues with the apps. Conclusions The motivational apps and trial procedures were feasible for health professionals and patients. There are positive indications from outcome measures in the feasibility trial and key criteria for progression to full trial were met. [ABSTRACT FROM AUTHOR]

Introduction: Significant variation exists in the prevalence of home haemodialysis (HHD) among UK renal centres. Our centre has a HHD prevalence of 2%, and we aimed to study how many patients who chose HHD as their preferred mode of renal replacement therapy (RRT) went on to receive this treatment and the barriers to starting this treatment. Methods: A retrospective single-centre analysis of electronic medical records for all patients who chose HHD at the time of RRT education was performed, and data were collected on patient demographics, comorbidity, frailty, RRT events, and barriers to HHD. Results: 116 patients chose HHD as their preferred mode of RRT between 2006 and 2018. Of these patients, 93 required RRT, but only 28 patients ever received HHD. No statistical difference was identified between those patients who only received unit haemodialysis (UHD) and those who went onto receive HHD with respect to age, gender, comorbidity, frailty, and socioeconomic deprivation. Patient choice, change in clinical condition, transplantation, home environment, vascular access problems, and training delays were identified as reasons patients did not start HHD. No documented reason could be found in 9 patients with a breakdown of communication between clinics and peripheral dialysis units attributed as a significant contributor in some of these patients. Of the 26 patients who started HHD after UHD, 19 did so within 1 year of starting UHD. Conclusion: Most patients who choose HHD do not receive HHD. Many patients never start HHD because of potentially reversible barriers including inadequate communication among clinicians about patient choices, patients changing their minds once in a dialysis unit, and inadequate timely training support. [ABSTRACT FROM AUTHOR]

Introduction: Peritoneal dialysis (PD) remains underutilised in the West. The proportion of patients in the UK starting renal replacement therapy (RRT) with PD fell from 7.2% in 2011 to 6.0% in 2016. At our centre, 8.4% of dialysis patients received PD in April 2014. Evidence suggests that home dialysis improves patient clinical outcomes; therefore, a target was agreed to achieve 25% of dialysis patients receiving PD by 2018. Methods: A rapid improvement process was introduced, as a quality improvement tool, to increase and sustain the PD programme. With multidisciplinary team support for PD growth, a nephrologist was trained to insert PD catheters. Nurses were trained to provide patients with balanced pre-dialysis information and discuss alternative dialysis modalities with haemodialysis (HD) patients. The "Acceptance, Choice and Empowerment" project raised awareness of home therapy choices, using a peer educator model specifically for ethnic minority patients. Lean methodologies were used to ensure continuous quality improvement. Results: PD uptake increased from 37 to 84 patients, giving a PD penetration increase from 8.4% to 19.1% between April 2014 and March 2018. Catheter insertions increased from 94 at the end of QI Period 1 to 185 at the end of QI Period 2, representing a 97% increase, with the medical/surgical split remaining stable. Peritonitis rates remained stable, and PD drop off to HD reduced from 52% to 41% during the same period. Conclusions: By implementing a rapid improvement process and embedding a quality improvement programme, the number of incidents and prevalent PD patients increased and was sustained. [ABSTRACT FROM AUTHOR]

Introduction: Adults with overweight and obesity are vulnerable to weight gain and mental health deterioration during the COVID-19 pandemic. We developed a web-based, guided self-help intervention based on Acceptance and Commitment Therapy (ACT) that aims to support adults with overweight and obesity to prevent weight gain by helping them to manage their eating behaviours, be more physically active, and protect their emotional wellbeing ("SWiM-C"). SWiM-C is a guided self-help programme using non-specialist guides to enhance scalability and population reach while minimizing cost. This study evaluated the effect of SWiM-C on bodyweight, eating behaviour, physical activity, and mental wellbeing in adults with overweight and obesity over 4 months during the COVID-19 pandemic in the UK. Methods: We randomized adults (BMI ≥25 kg/m2) to SWiM-C or to a wait-list standard advice group. Participants completed outcome assessments online at baseline and 4 months. The primary outcome was self-measured weight; secondary outcomes were eating behaviour, physical activity, experiential avoidance/psychological flexibility, depression, anxiety, stress, and wellbeing. We estimated differences between study groups in change in outcomes from baseline to 4 months using linear regression, adjusted for outcome at baseline and the randomization stratifiers (BMI, sex). The trial was pre-registered (ISRCTN12107048). Results: 486 participants were assessed for eligibility; 388 participants were randomized (196 standard advice, 192 SWiM-C), and 324 were analysed. The adjusted difference in weight between SWiM-C and standard advice was −0.60 kg (−1.67 to 0.47, p = 0.27). SWiM-C led to improvements in uncontrolled eating (−3.61 [−5.94 to −1.28]), cognitive restraint (5.28 [2.81–7.75]), experiential avoidance (−3.39 [−5.55 to −1.23]), and wellbeing (0.13 [0.07–0.18]). Conclusions: SWiM-C improved several psychological determinants of successful weight management and had a protective effect on wellbeing during the pandemic. However, differences in weight and some other outcomes were compatible with no effect of the intervention, suggesting further refinement of the intervention is needed. [ABSTRACT FROM AUTHOR]

Introduction: Body mass index (BMI) is often elevated at type 2 diabetes (T2D) diagnosis. Using latent class trajectory modelling (LCTM) of BMI, we examined whether weight loss after diagnosis influenced cancer incidence and all-cause mortality. Methods: From 1995 to 2010, we identified 7,708 patients with T2D from the Salford Integrated Record database (UK) and linked to the cancer registry for information on obesity-related cancer (ORC), non-ORC; and all-cause mortality. Repeated BMIs were used to construct sex-specific latent class trajectories. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression models. Results: Four sex-specific BMI classes were identified; stable-overweight, stable-obese, obese-slightly-decreasing, and obese-steeply-decreasing; comprising 41%, 45%, 13%, and 1% of women, and 45%, 37%, 17%, and 1% of men, respectively. In women, the stable-obese class had similar ORC risks as the obese-slightly-decreasing class, whereas the stable-overweight class had lower risks. In men, the obese-slightly-decreasing class had higher risks of ORC (HR = 1.86, 95% CI: 1.05–3.32) than the stable-obese class, while the stable-overweight class had similar risks No associations were observed for non-ORC. Compared to the stable-obese class, women (HR = 1.60, 95% CI: 0.99–2.58) and men (HR = 2.37, 95% CI: 1.66–3.39) in the obese-slightly-decreasing class had elevated mortality. No associations were observed for the stable-overweight classes. Conclusion: Patients who lost weight after T2D diagnosis had higher risks for ORC (in men) and higher all-cause mortality (both genders) than patients with stable obesity. [ABSTRACT FROM AUTHOR]

Introduction: To highlight the importance of the need for new treatment modalities, this study aimed to characterise the experience of patients with postinfectious olfactory dysfunction (PIOD) in terms of the treatment they received. Methods: An online survey was hosted by the Norwich Clinical Trials Unit on the secure REDCap server. Members of the charity Fifth Sense (the UK charity that represents and supports people affected by smell and taste disorders) were invited to participate. Results: There were 149 respondents, of whom 127 had identified themselves as having (or had) PIOD. The age range of respondents to the survey was 28–85 years, with a mean of 58 ± 12 years, with the duration of their disorder <5 years in 63% of cases. Respondents reported experiencing variable treatment with oral and/or intranasal steroids given typically (28%), often with no benefit, but with 50% receiving no treatment whatsoever; only 3% reported undertaking olfactory training. Over two-thirds of patients experience parosmia and, up to 5 years from the onset of the problem, were still actively seeking a solution. Conclusion: There appears to be a need to encourage greater use of guidelines for olfactory disorders amongst medical practitioners and also to develop more effective treatments for patients with PIOD, where there is clearly an unmet need. [ABSTRACT FROM AUTHOR]

Introduction: We examined the impact of the coronavirus disease 2019 (COVID-19) pandemic on our regional stroke thrombectomy service in the UK. Methods: This was a single-center health service evaluation. We began testing for COVID-19 on 3 March and introduced a modified "COVID Stroke Thrombectomy Pathway" on 18 March. We analyzed the clinical, procedural and outcome data for 61 consecutive stroke thrombectomy patients between 1 January and 30 April. We compared the data for January and February ("pre-COVID," n = 33) versus March and April ("during COVID," n = 28). Results: Patient demographics were similar between the 2 groups (mean age 71 ± 12.8 years, 39% female). During the COVID-19 pandemic, (a) total stroke admissions fell by 17% but the thrombectomy rate was maintained at 20% of ischemic strokes; (b) successful recanalization rate was maintained at 81%; (c) early neurological outcomes (neurological improvement following thrombectomy and inpatient mortality) were not significantly different; (d) use of general anesthesia fell significantly from 85 to 32% as intended; and (e) time intervals from onset to arrival, groin puncture, and recanalization were not significantly different, whereas internal delays for external referrals significantly improved for door-to-groin puncture (48 [interquartile range (IQR) 39-57] vs. 33 [IQR 27-44] minutes, p = 0.013) and door-to-recanalization (82.5 [IQR 61-110] vs. 60 [IQR 55-70] minutes, p = 0.018). Conclusion: The COVID-19 pandemic has had a negative impact on the stroke admission numbers but not stroke thrombectomy rate, successful recanalization rate, or early neurological outcome. Internal delays actually improved during the COVID-19 pandemic. Further studies should examine the effects of the COVID-19 pandemic on longer term outcome. [ABSTRACT FROM AUTHOR]

Introduction: Complex cases of multiple allergies can be particularly difficult to diagnose using standard methods such as skin prick tests and assessment of a patient's allergic history. Multiplex allergy testing may improve outcomes for allergy patients by avoiding misdiagnosis and providing reassurance. The ImmunoCAP Immuno Solid-Phase Allergen Chip (ISAC) 112 is a CE-marked, molecular, multiplex, allergy test that can test for IgE antibodies to 112 components from 51 allergen sources. However, its clinical utility is unknown and is difficult to estimate due to the complexity of the diagnostic pathway in which it is used. Objective: To assess how the ImmunoCAP ISAC 112 is currently being used in UK practice. The patient populations in which it may have the most benefit were examined, and the sequence of other tests implemented alongside ISAC was determined. Methods: A retrospective audit of 100 patient cases from 2 UK tertiary allergy clinics was performed. Fifty paediatric and fifty adult cases were selected for audit. The indications for ordering an ISAC test, the other tests used alongside ISAC, and changes in management actioned by the ISAC test were investigated. Results: 73.6% of paediatric and 78% of adult patients referred for an ISAC test were suspected to have multiple sensitizations. The sequence of testing varied greatly between cases, but 70% of adult and 98% of paediatric patients had at least one other investigation prior to an ISAC test. In most cases, ISAC testing confirmed clinical suspicion. Conclusions: A prospective research study is necessary to further investigate the clinical utility and cost-effectiveness of the ISAC. A UK national registry would be of great benefit but will require a large resource base. [ABSTRACT FROM AUTHOR]

Background: Independent peer review of healthcare services can complement existing internal-, institutional-, and national-level regulatory mechanisms aimed at improving quality of healthcare. However, this has not been reported for paediatric endocrinology services in the UK. We aimed to test feasibility and acceptability through a first cycle of a national peer review of paediatric endocrine services. Methods: Tertiary centres in paediatric endocrinology across the UK were assessed against 54 quality standards, developed by the British Society for Paediatric Endocrinology and Diabetes (BSPED) in five domains of healthcare by a team comprising paediatric endocrinologists and specialist nurses. The evaluation was supported by a self-assessment. A post-peer-review questionnaire was used as feedback. Results: All 22 centres in the UK underwent independent peer review between 2011 and 2017. Each served a median population of 2.6 million (range 1–8 million) and offered 1,872 (range 779–6,738) outpatient consultations annually. A total of 43 (range 30–49) standards were met in combined evaluation of all centres. Variance of adherence for essential standards ranged from 52 to 97% at individual centres with 90% adherence demonstrated by 32% of centres. Post-review feedback showed 20/22 (95%) validating the utility of the peer review. Conclusions: The BSPED peer review of all UK centres providing paediatric endocrine services is shown to be feasible and provides a quality benchmark for replication by national services. [ABSTRACT FROM AUTHOR]

Background: Although several risk factors are associated with multiple sclerosis (MS) in adulthood, evidence for risk factors acting from birth to adolescence is scarce. Methods: We conceived a 2-step study design, where signals from an Environment-Wide Association Study are prioritized for follow-up in a Mendelian Randomization study (MR-EWAS), to examine the association of early-life factors with risk of MS. The EWAS was conducted in UK Biobank, where we agnostically selected all the available risk factors acting from the perinatal period until the adolescence, including perinatal factors, anthropometric characteristics during childhood, male and female sexual factors, and skin phenotypic characteristics. We prioritized statistically significant risk factors to perform a 2-sample MR study using publicly available summary-level genetic data. We also calculated the power of the 2-step MR-EWAS approach under several scenarios and compared it against a 1-step hypothesis-free MR approach to detect risk factors of MS. Results: In the EWAS, an increase per 1 year in age at menarche was associated with a lower risk of MS (OR = 0.93; 95% CI: 0.90–0.96) and a plumper than average body size at the age of 10 was associated with a higher risk of MS (OR = 1.42; 95% CI: 1.24–1.61). Individuals getting very tanned or moderately tanned were at higher risk of MS compared with individuals that never tan or get mildly to occasionally tanned (OR = 0.86; 95% CI: 0.79–0.94). The MR analysis supported the association of age at menarche and childhood body mass index (BMI) without presence of pleiotropic effects. In the multivariable MR analysis, the association of age at menarche was not statistically significant after adjusting for childhood BMI. The MR analysis for ease of tanning did not reveal a statistically significant association. In multiple scenarios, the power of MR-EWAS approach was larger than the power of a hypothesis-free MR approach. Conclusions: We introduced the MR-EWAS, a 2-step approach that is more powerful compared with the hypothesis-free MR approach under certain scenarios, to test potential causal signals. Our comprehensive assessment of early-life risk factors of MS highlighted a potential causal role of early menarche and elevated childhood BMI for risk of MS. [ABSTRACT FROM AUTHOR]

Background: Current practice in the UK is to plot premature infant anthropometric measurements on Neonatal and Infant Close Monitoring (NICM) reference charts. These charts have several known limitations. The INTERGROWTH-21st Project has recently produced international ante- and postnatal growth standards. Exact knowledge of growth centiles allows clinicians to accurately assess infant nutritional requirements. Objective: To compare target centile measurements between INTERGROWTH-21st and UK NICM growth charts for premature infants. Method: Anthropometric measurements (weight and head circumference) of a convenience sample of neonates born between 24 and 32 weeks of gestation were analysed retrospectively. Measurements were collected across three time points and plotted on both the NICM and INTERGROWTH-21st growth charts. The respective centiles were compared and analysed by paired-sample t test, Wilcoxon rank test analysis, and multilevel mixed-effect linear regression models. Results: Centiles for weight and head circumference measurements of 96 infants plotted on INTERGROWTH-21st charts were significantly greater than their corresponding UK charts at all three time points. For weight, the average difference between the two charts varied from 9.1 to 16.4 centiles. The difference between the two charts was greater for female than male infants by up to 6.9 centiles (95% CI 10.1–3.8). Conclusion: Existing UK NICM reference charts are significantly different to the growth standards of INTERGROWTH-21st. The choice of which growth chart to adopt in the UK could have important consequences on premature infants' future adult health and therefore requires further prospective observational studies with larger data sets including length measurements and more comprehensive population characteristics. [ABSTRACT FROM AUTHOR]

Objectives: To determine differences in body composition and glucose metabolism according to childhood growth outcomes in a population-based sample of children born small for gestational age (SGA). Methods: A single-centre study of 259 children born SGA identified through hospital records and contacted when aged 4–7 years. Questionnaire data on pre/perinatal history and growth parameters during childhood was collected from the parents, and in a subgroup of 150 children face-to-face assessments were performed, including anthropometric parameters, lean and fat mass, blood pressure, fasting glucose, and C-peptide. Results: Based on the questionnaires, few children had formal clinic follow-up of growth, but 7% of the cohort showed a height and weight of <–2SDS during childhood, and only 2 children met the criteria for growth hormone therapy. Out of the 150 children assessed at a mean age of 6.1 ± 0.8 years, 122 (81%) showed a catch-up growth in weight. Compared to those without weight catch-up, these children had a higher fat mass index (3.13 ± 1.36 vs. 2.56 ± 0.91 kg/m2, p = 0.04), trunk-to-limb fat mass ratio (0.63 ± 0.14 vs. 0.56 ± 0.08, p = 0.002), systolic blood pressure SDS (0.09 ± 0.71 vs. –0.32 ± 0.63, p = 0.008), fasting glucose (4.5 ± 0.5 vs. 4.3 ± 0.5 mmol/L, p = 0.03), and C-peptide (306 ± 116 vs. 256 ± 112 pmol/L, p = 0.08). Among children with weight catch-up growth, those with less height gain had a lower limb lean mass index (4.25 ± 0.48 vs. 4.48 ± 0.56 kg/m2, p = 0.02) and fat mass index (1.57 ± 0.59 vs. 1.83 ± 0.77 kg/m2, p = 0.04). Conclusions: Within this population-based sample of SGA children, catch-up growth in weight was associated with higher abdominal fat mass, blood pressure and glycemia; furthermore, in these children, less height gain was associated with reduced limb lean and fat mass. [ABSTRACT FROM AUTHOR]

Speech and language therapists often contribute to public awareness campaigns as well as supporting, teaching and promoting the facilitation of speech, language, communication, and safe swallowing with the general public and health and social care professionals. These are sometimes considered as public health interventions. It is important to consider the objectives, costs, and impact of this involvement in the same way as reviewing the evidence associated with the more personally targeted interventions with individuals or groups of clients with specific conditions. This opinion piece discusses speech and language therapy in the context of public health, clarifies the terminology, and proposes different approaches to demonstrate its influence associated with its objectives. The content has been informed by a Working Party of the Royal College of Speech and Language Therapists (2017–2018). [ABSTRACT FROM AUTHOR]

Background: Digital retinal imaging is the gold standard technique for diabetic retinopathy (DR) and diabetic macular oedema (DME) assessment during DR screening. Objectives: To evaluate the diagnostic accuracy of digital retinal fundus image (DRFI) analysis in detecting DME using three manual grading systems (MGS) and comparing it with optical coherence tomography (OCT) findings. Method: A total of 287 DRFI of 287 eyes were analysed. Non-stereoscopic 45° images were acquired using a Kowa VX-20 camera and were graded according to three MGS: Early Treatment Diabetic Retinopathy Study (ETDRS), International Clinical Diabetic Retinopathy (ICDR), and United Kingdom National Screening Committee (UKNSC). The two graders were masked to the patient's clinical DR status. DME characteristics were analysed using OCTs. Results: A very good agreement in detecting DME was found with Cohen's κ = 0.83 (ICDR vs. ETDRS), κ = 0.83 (ICDR vs. UKNSC), and κ = 0.82 (ETDRS vs. UKNSC). Sensitivity and specificity of DRFI analysis in DME assessment were 70.0 and 69.6% for UKNSC, 71.9 and 67.4% for ETDRS, and 70.9 and 65.2% for ICDR, respectively. Positive and negative predictive values were 91.7 and 32.7% for UKNSC, 91.4 and 33.3% for ETDRS, and 90.7 and 31.9% for ICDR, respectively. On OCT scans, micro-architectural damages of both inner and outer retinal layers and mean ganglion cell layer thickness showed a significant association with the presence of DME detected with DRFI analysis. Conclusions: Despite the low negative predictive value, the good specificity and sensitivity of DRFI in detecting DME make it a useful tool in a routine clinical setting, and its potential in diabetic eye screening is yet to be realized. [ABSTRACT FROM AUTHOR]

Background: The German guideline on long-term oxygen therapy (LTOT) was published in 2008 by the German Respiratory Society (DGP), while the British Thoracic Society (BTS) published their most recent guideline in 2015. Objectives: The aim of the present article was to highlight the major areas of consensus and disagreement in the recently published BTS and DGP guidelines on LTOT. Methods: The BTS and DGP guidelines were directly compared in terms of congruencies and differences. A critical appraisal was then performed and authors' suggestions were provided. Results: The 2 guidelines are almost congruent in 2 major areas, namely, (1) the indication criteria for LTOT in chronic obstructive pulmonary disease (COPD) patients at rest and (2) the recommended duration of LTOT over a 24-h period. However, 8 major areas in which the guidelines differ considerably were identified: (1) techniques for blood gas analysis; (2) timing of LTOT in stable patients; (3) LTOT in postexacerbation COPD patients; (4) ambulatory oxygen therapy; (5) nocturnal oxygen therapy; (6) titration of oxygen flow rates; (7) follow-up visits; and (8) LTOT for patients who still smoke. Furthermore, the BTS guideline is much more detailed, includes more references (161 vs. 71) and is more up to date than the DGP guideline. Conclusion: There are major differences between the 2 guidelines. Many of the aspects raised by the BTS guideline appear to be reasonable with regard to the current literature, clinical experience and prescription practices. However, an international consensus on LTOT is lacking. [ABSTRACT FROM AUTHOR]

Objectives: The combination of 5-fluorouracil (5-FU), irinotecan and oxaliplatin (FOLFIRINOX) is considered the first-line chemotherapy for fit patients with advanced pancreatic ductal adenocarcinoma (PDAC) but carries an unfavourable adverse event (AE) profile. We retrospectively evaluated the tolerability and efficacy of a modified FOLFIRINOX (mFOLFIRINOX) regimen: intravenous oxaliplatin 85 mg/m2, irinotecan 135 mg/m2, folinic acid 400 mg/m2 and 5-FU infusion 2,400 mg/m2 over 46 h, with routine subcutaneous filgrastim on a 14-day cycle. Methods: Records of 18 patients with advanced PDAC who received treatment with mFOLFIRINOX were reviewed. Imaging of measurable disease was assessed for response, and survival was measured from the date of commencing chemotherapy to disease progression and/or death. Results: Grade 3 or 4 AEs (n; %) included vomiting (5; 28), nausea (4; 22), diarrhoea (3; 17) and non-neutropaenic fever (3; 17). For patients with stage IV disease, 12/15 (80%) achieved at least stable disease as the best radiological response, with 7/15 (47%) objective responses. In this subgroup, median overall and progression-free survival were 9.3 months (95% CI 8.3-10.4) and 7.2 months (95% CI 4.7-9.6), respectively. Conclusion: Compared to full-dose FOLFIRINOX, our modified regimen resulted in lower haematological but only marginally improved non-haematological toxicity rates, with comparable efficacy outcomes. Prospective studies are required to validate these findings. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Estimations of life expectancies (LE) in health and ill health are important for planning future health care support. This study aimed at quantifying whether an increased LE is accompanied by an increase in the duration of life with dementia (DemLE) in Hong Kong SAR. Methods: Two parameters from a logistic model were used to fit the overall trend of the weighted prevalence of dementia. Abridged age- and sex-specific life tables and Sullivan's method were used to calculate dementia-free LE (DemFLE) for 1998 and 2013. Results: In 2013, among elderly individuals in Hong Kong aged 65 years, men had lived with dementia for 1.8 years and women for 3.6 years. These values are similar to those for subjects aged ≥85 years, while the proportion of DemLE was much greater at advanced ages. Elderly female individuals tend to experience a greater number of years with dementia than males. Conclusion: Our results indicate although LE has increased for all older age groups over time, the increase in DemFLE has not been greater than the gain in LE, suggesting an absolute expansion of the burden of dementia to the community between 1998 and 2013. The results suggest that more caregiving resources and manpower will be needed in the future as the population ages. © 2015 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Appreciation of the barriers and drivers affecting enrolment in randomised clinical trials (RCTs) is important for future trial design, communication and information provision. Methods: As part of an intervention to facilitate UK multidisciplinary team communication about RCTs, women with breast cancer who discussed trials with doctors or research nurses completed questionnaires examining i) clarity of trial information and ii) reasons for their trial decision. Results: 152 women completed the questionnaires; 113/152 (74%) consented to RCT enrolment. Patients' satisfaction with communication about the trial information was very good, irrespective of participation decisions. Acceptors' and decliners' responses to 9/16 statements concerning decisions about trial participation differed significantly. 'Wanting to help with doctor's research' influenced 100% acceptors compared to 57% of decliners (p < 0.001). Decliners were more likely to be 'worried about randomisation' (20 vs. 39%; p < 0.035) and to 'want doctor to choose treatment rather than be randomised' (31 vs. 53%; p < 0.031). Primary reason for trial acceptance was altruism; 'I feel that others with my illness will benefit from the results of the trial', 58/108 (54%). Conclusion: A majority of women accepted RCT entry citing altruistic motivations as the primary driver for participation. Trial design and setting (metastatic or adjuvant) had little impact on participation. © 2015 S. Karger GmbH, Freiburg [ABSTRACT FROM AUTHOR]

Background: This study assessed the views of patients undergoing breast surgery for breast cancer with a planned overnight stay, asking whether they would be happy to be discharged home on the same day of surgery. Methods: A structured questionnaire sent out in the 6 weeks following surgery was used to ascertain the patients' views. Results: The majority of patients undergoing mastectomy and axillary node clearance preferred an overnight stay, primarily for psychological reasons. Conclusions: Patients undergoing breast-conserving surgery were more prepared to go home on the day of surgery. [ABSTRACT FROM AUTHOR]

Background: Evidence-based medicine (EbM) is a vital part of reasonable and conclusive decision making for clinicians in daily clinical work. To analyze the knowledge and the attitude of surgeons towards EbM, a survey was performed in the UK and Germany. Methods: A web-based questionnaire was distributed via mailing lists from the Royal College of Surgeons of England (RCSE) and the Berufsverband Deutscher Chirurgen (BDC). Our primary aim was to get information about knowledge of EbM amongst German and British surgeons. Results: A total of 549 individuals opened the questionnaire, but only 198 questionnaires were complete and valid for analysis. In total, 40,000 recipients were approached via the mailing lists of the BDC and RCSE. The response rate was equally low in both countries. On a scale from 1 (unimportant) to 10 (very important), all participants rated EbM as very important for daily clinical decision making (7.3 ± 1.9) as well as for patients (7.8 ± 1.9) and the national health system (7.8 ± 1.9). On a scale from 1 (unimportant) to 5 (very important), systematic reviews (4.6 ± 0.6) and randomized controlled trials (4.6 ± 0.6) were identified as the highest levels of study designs to enhance evidence in medicine. British surgeons considered EbM to be more important in daily clinical work when compared to data from German surgeons (7.9 ± 1.6 vs. 6.7 ± 2.1, p < 0.001). Subgroup analysis showed different results in some categories; however, a pattern to explain the differences was not evident. Personal requirements expressed in a free text field emphasized the results and reflected concerns such as broad unwillingness and lack of interdisciplinary approaches for patients (n = 59: 25 in the UK and 34 in Germany). Conclusion: The overall results show that EbM is believed to be important by surgeons in the UK and Germany. However, perception of EbM in the respective health system (UK vs. Germany) may be different. Nonetheless, EbM is an important tool to navigate through daily clinical problems although a discrepancy between the knowledge of theoretical abstract terms and difficulties in implementing EbM in daily clinical work has been detected. The provision of infrastructure, courses and structured education as a permanent instrument will advance the knowledge, application and improvement of EbM in the future. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Data from individual collections, such as biobanks and cohort studies, are now being shared in order to create combined datasets which can be queried to ask complex scientific questions. But this sharing must be done with due regard for data protection principles. DataSHIELD is a new technology that queries nonaggregated, individual-level data in situ but returns query data in an anonymous format. This raises questions of the ability of DataSHIELD to adequately protect participant confidentiality. Methods: An ethico-legal analysis was conducted that examined each step of the DataSHIELD process from the perspective of UK case law, regulations, and guidance. Results: DataSHIELD reaches agreed UK standards of protection for the sharing of biomedical data. All direct processing of personal data is conducted within the protected environment of the contributing study; participating studies have scientific, ethics, and data access approvals in place prior to the analysis; studies are clear that their consents conform with this use of data, and participants are informed that anonymisation for further disclosure will take place. Conclusion: DataSHIELD can provide a flexible means of interrogating data while protecting the participants' confidentiality in accordance with applicable legislation and guidance. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: The objectives of this study were to estimate and cross-nationally compare the medical costs shared by payers and patients and the distributions of medical costs by cost category. Material and Methods: We estimated the medical costs covered from definitive diagnosis to completion of treatments of early-stage breast cancer and follow-up, assuming almost identical medical care provided in Japan, the UK, and Germany. The analysis was performed from the payer's perspective. Medical costs were calculated by multiplying the unit costs by the number of units consumed, based on assumption case scenarios. The medical costs incurred by payers or patients were estimated according to the cost-sharing and the cost-bearing systems in each country. Results: The total medical costs in Japan were much lower than those in the UK and Germany, and these differences were mainly caused by the low costs of surgery and radiotherapy in Japan. For the base-case scenario, the co-payment in Japan (€ 3,486) was found to be 6.4-fold higher than that in Germany (€ 548). The payers in the European countries paid 2.9-fold more than those in Japan (€ ∼25,000 vs. € 8,627). Conclusion: Our results will be useful for policy makers in considering how to share medical costs and how to allocate limited resources. © 2013 S. Karger GmbH, Freiburg [ABSTRACT FROM AUTHOR]

Introduction: National transplant registries routinely focus on centre-specific patient and graft survival rates following renal transplantation. However other outcomes such as graft function (as measured by eGFR), haemoglobin and blood pressure are also important quality of care indicators. Methods: Renal transplant activity, incident graft survival data and donor information were obtained from NHS Blood and Transplant. Laboratory and clinical variables and prevalent survival data were obtained from the UK Renal Registry. Data were analysed separately for prevalent and one year post-transplant patients. Results: The only increase in transplant activity in 2011 was the use of donors after circulatory death. The death-censored graft failure rate was similar to previous years at 2.2% and the transplant patient death rates remained stable at 2.3 per 100 patient years. There was centre variation in outcomes including eGFR and haemoglobin in prevalent and 1 year post-transplant patients. Analysis of prevalent transplants by chronic kidney disease stage showed 13.6% with an eGFR <30 ml/min/1.73 m2 and 1.7% with an eGFR <15 ml/min/1.73 m2. Of those with CKD stage 5T, 34% had haemoglobin concentrations <10.0 g/dl, 19.8% phosphate concentrations &ges;1.8 mmol/L and 7.1% adjusted calcium concentrations &ges;2.6 mmol/L. Infection (23%), malignancy (21%), and cardiac disease (16%) remained amongst the commonest causes of death in patients with a functioning renal transplant. Conclusion: Significant variations in clinical outcomes (unadjusted for patient-specific variables) amongst kidney transplant recipients continued to exist in the UK and may reflect differences in healthcare delivery between renal centres. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: Correct coding is essential for accurate reimbursement for clinical activity. Published data confirm that significant aberrations in coding occur, leading to considerable financial inaccuracies especially in interventional procedures such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Previous data reported a 15% coding error for EBUS-TBNA in a UK service. Objectives: We hypothesised that greater physician involvement with coders would reduce EBUS-TBNA coding errors and financial disparity. Methods: The study was done as a prospective cohort study in the tertiary EBUS-TBNA service in Bristol. 165 consecutive patients between October 2009 and March 2012 underwent EBUS-TBNA for evaluation of unexplained mediastinal adenopathy on computed tomography. The chief coder was prospectively electronically informed of all procedures and cross-checked on a prospective database and by Trust Informatics. Cost and coding analysis was performed using the 2010-2011 tariffs. Results: All 165 procedures (100%) were coded correctly as verified by Trust Informatics. This compares favourably with the 14.4% coding inaccuracy rate for EBUS-TBNA in a previous UK prospective cohort study [odds ratio 201.1 (1.1-357.5), p = 0.006]. Projected income loss was GBP 40,000 per year in the previous study, compared to a GBP 492,195 income here with no coding-attributable loss in revenue. Conclusions: Greater physician engagement with coders prevents coding errors and financial losses which can be significant especially in interventional specialties. The intervention can be as cheap, quick and simple as a prospective email to the coding team with cross-checks by Trust Informatics and against a procedural database. We suggest that all specialties should engage more with their coders using such a simple intervention to prevent revenue losses. Copyright © 2013 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction: National transplant registries routinely focus on centre-specific patient and graft survival rates following renal transplantation. However other outcomes such as graft function (as measured by eGFR), haemoglobin and blood pressure are also important quality of care indicators. Methods: Renal transplant activity, incident graft survival data and donor information were obtained from NHS Blood and Transplant. Laboratory and clinical variables and prevalent survival data were obtained from the UK Renal Registry. Data were analysed separately for prevalent and one year post-transplant patients. Results: The numbers of live and deceased kidney donors increased in 2010. The death-censored graft failure rate fell slightly to 2.4% and the transplant patient death rates remained stable at 2.5 per 100 patient years. There was centre variation in outcomes including eGFR and haemoglobin in prevalent and 1 year post-transplant patients. Analysis of prevalent transplants by chronic kidney disease stage showed 13.7% with an eGFR <30 ml/min/1.73 m2 and 1.5% with an eGFR <15ml/min/1.73 m2. Of those with CKD stage 5T, 36.1% had haemoglobin concentrations <10.5g/dl, 22.9% phosphate concentrations 51.8mmol/L and 6.2% adjusted calcium concentrations 52.6 mmol/L. Malignancy (23%) and infection (22%) remained the commonest two causes of death in prevalent transplant patients. Conclusion: Significant variations in clinical outcomes (unadjusted for patient-specific variables) amongst kidney transplant recipients continued to exist in the UK and may reflect differences in healthcare delivery between renal centres. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aims: To describe the demographics of the paediatric RRT population under the age of 16 years in the UK and to analyse changes in demography with time. Methods: Data were collected from all 13 paediatric renal centres within the UK. A series of cross-sectional and longitudinal analyses were performed to describe the demographics of prevalent paediatric RRT patients. Results: A total of 870 children and young people under 18 with ERF were receiving treatment at paediatric nephrology centres in 2010. At the census date, 76.7% had a functioning transplant, 14.3% were receiving peritoneal dialysis (PD) and 9.0% were receiving haemodialysis (HD). In patients aged <16 years the prevalence of ERF was 59.3 pmarp and the incidence 8.1 pmarp. Analysis of trends over the last 15 years shows that both incidence and prevalence are increasing with the most marked increases in children aged 12-16 years and in ethnic minority groups. A third of the patients have one or more reported comorbidities. At transfer to adult services, 84.9% of patients had a functioning renal transplant. Conclusions: The data provided in this report show increasing trends over 15 years in the incidence and prevalence of established renal failure. This is important for the planning of the provision of care for children needing renal replacement therapy. The inclusion this year of an analysis of the patients transferring to adult services may assist in developing care pathways for this vulnerable group. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

An appendix regarding the statement of purpose of the Great Britain Renal Registry as of August 2, 2012 is presented.

Background: Chronic kidney disease (CKD) prevalence and complications are known to be associated with deprivation, but there is limited understanding of the underlying reasons for inequalities. Aims: To evaluate the association of both individual and area level socioeconomic status (SES) with heavy proteinuria at presentation, progression of CKD, end-stage renal disease (ESRD) and death. Methods: A retrospective study of 918 CKD patients using integral multivariate logistic regression to adjust for known clinical and demographic explanatory variables. Results: During 3 years of median follow-up, 34% of the study population had progression of their CKD and of these, 32% experienced rapid progression. 23% presented with heavy proteinuria (urine protein:creatinine ratio ≥300 mg/mmol), 4% developed ESRD requiring renal replacement therapy and 10% died. Area level deprivation was independently associated with heavy proteinuria, progression and rapid progression of CKD. People living in the most deprived areas were more likely to develop ESRD. Unskilled professionals were more likely to experience a higher mortality rate. Conclusion: Area level SES is inversely associated with both heavy proteinuria on presentation and progression as well as rapid progression of CKD. In contrast, individual level SES, unskilled professionals found to have a marginally significant association with increased risk of mortality. People living in more deprived areas presenting with CKD are likely to be at increased risk of poor outcomes and may need more active management and earlier referral. Copyright © 2012 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Objectives: To assess the safety and clinical efficacy of Tm:YAG laser vaporesection of the prostate (ThuVaRP) at intermediate-term follow-up. Patients and Methods: We identified the first 60 consecutive patients who underwent ThuVaRP at our institute. Operative outcomes assessed were resection time, resection weight, drop in haemoglobin, transfusion rate, catheter time and complication rate. The International Prostate Symptom Score (IPSS) was documented at a mean follow-up period of 19 months postoperatively. Results: 45/60 patients underwent treatment due to lower urinary tract symptoms secondary to benign prostatic obstruction, 11/60 patients had a long-term catheter in situ for refractory urinary retention secondary to benign prostatic obstruction, and 4/60 patients had bladder outflow obstruction secondary to adenocarcinoma of the prostate. 1/60 patients developed urosepsis, 1/60 patients developed a urinary tract infection and 1/60 patients required 3-way catheterization and irrigation due to haematuria. No patients required a blood transfusion. The mean IPSS at a mean follow-up interval of 19 months (range 15-28 months) was 5.1 (range 1-23). Postoperative maximum flow rate improved from 7.9 to 17.1 ml/s, and post-micturition residual volume decreased from 254 to 86 ml. Conclusion: ThuVaRP is safe and appears to have durable efficacy at intermediate follow-up. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Introduction: The Memokath 051™ is a semipermanent inert metal alloy ureteric stent which can bridge strictures and, compared to double J stents, causes less bladder irritation and pain, is more resistant to external compression forces and may be more effective in patients with malignant ureteric obstruction. We present our experience with this novel stent in such cases. Methods: All suitable patients referred to us with malignancy-associated ureteric strictures over a 4-year period had ureteric Memokath 051™ stents inserted. Data on aetiology and position of the strictures as well as length of the Memokath stents used and their efficacy and complications were recorded prospectively. Results: 42 ureteric Memokath 051™ stents were inserted in 37 patients (mean age 64 years). 40.5% of strictures were related to gynaecological cancer, 21% to bowel cancer, 14% were post radiation, 14% occurred in prostate cancer patients and 9.5% were found in other cancers. The mean follow-up was 22 months (range 5-60 months). The main complications were stent migrations in 5, urinary tract infections in 3 and blockage of stent due to progressive transitional cell carcinoma of the ureter in 2 cases. Conclusion: Memokath 051™ ureteric stents are safe, effective and durable in the long-term treatment of malignant strictures. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: UK-born infants of South Asian ethnic origin are known to have lower birthweights than their White British counterparts. When plotted on currently used birthweight charts they can be misclassified as small for gestational age. Similarly, large for gestational age infants can be missed. This has important clinical implications in their management. Objective: To create birthweight centile charts for the UK-born South Asian infants to identify true small and large for gestational age infants. Methods: A retrospective cross-sectional analysis of infants born 1 January 2003 to 31 December 2006 was undertaken. The birthweights of the South Asian and White British infants were compared. The LMS method was used to construct centile charts for the South Asian infants. Results: 24,274 White British and 7,190South Asian infants were included in the analysis. Overall, the South Asian males were 9-15% lighter than the White British males and the South Asian females were 9-13% lighter than the White British females. At term, the median birthweight for South Asian males was 329 g lower than that for White British males and for South Asian females 295 g less than the White British females. Conclusion: There are significant differences in the birthweights of White British and UK-born South Asian infants. Hence the standard birthweight centile charts which were designed using the birthweight data of White British infants appear to misclassify a proportion of South Asian infants. Use of ethnic specific birthweight charts would allow better detection of truly growth-restricted and macrosomic South Asian infants. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]