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Aim To introduce dental hygienists ( DHs) in the UK to the principles of research through a practice-based product evaluation programme. Methods The programme consisted of an initial training and orientation day with presentations on evidence-based practice, research methods and the structure of research papers. The programme and its aims were explained in detail, and participants were briefed on the methods to be used. Participants then recruited seven to ten patients from their practices (offices), carried out a baseline assessment of: plaque, gingival health, calculus and staining at anterior teeth, and gave the patients a questionnaire asking about their teeth and then provided a 3-month supply of a test toothpaste. About 10 weeks later, a follow-up assessment of the same variables was performed and the questionnaire was repeated. A second training day followed during which the DHs provided feedback of their experiences and received training in literature searching and critical appraisal of literature including interpretation of results. Results Sixty-five DHs attended the first training day; 31 were able to recruit sufficient patients and attend the second training day. The DHs recruited 168 patients who received baseline and follow-up assessments. All the variables improved overall. Feedback from the DHs was very positive, and patients expressed delight with the care they had received. Conclusions Qualitative feedback for participating DHs suggests the programme met its aim and could be used in the future as a mechanism for helping DHs who want to increase their understanding of research methodology. [ABSTRACT FROM AUTHOR]

The continuing global increase in the prevalence of overweight and obesity, particularly amongst children, attracts widespread public and political attention. Obesity is a complex condition, with multi‐faceted determinants, and prevention strategies require consideration of dietary and lifestyle patterns alongside a range of environmental factors. Reduction in intake of sugar‐sweetened beverages and foods is advised around the world as part of healthier dietary patterns to help reduce energy intakes, obesity risk and obesity‐related disorders. Current intakes indicate that this is challenging and will likely require a concerted approach with a broad range of interventions including fiscal measures. In recent years, after some notable success with salt and trans fats, there has been considerable focus on food reformulation to support the reduction in population intakes of free sugars from manufactured foods, often without need for consumer behaviour change. In some products, particularly sugar‐sweetened beverages, reformulation is relatively easy and has been widely achieved, as the sweetness of sugars can be replaced with low‐calorie sweeteners. However, other products, in which sugar delivers a variety of functional properties, are more challenging to reformulate to maintain consumer acceptance and achieve a reduction in energy, alongside sugar, content. This paper will look at current definitions and recommendations for free (or added) sugars, as well as key dietary sources and trends in intakes, and explore various strategies to promote population reductions in intake of sugars for public health, including the opportunities and challenges presented by reformulation using low‐calorie sweeteners. Ultimately strategies to promote sugar reduction, including reformulation, should adopt a holistic approach that considers wider dietary recommendations. [ABSTRACT FROM AUTHOR]

Accessible summary: Children with learning disabilities often have problems with their eyesight.We tested the eyes of nine children and checked whether they needed glasses or bigger print.We found that when they got what they needed to see better, their behaviour improved.This is important because children with learning disabilities need to be able to see as well as anyone else. Background: Children with identified special educational needs are at higher risk than other children of having visual needs that are not adequately met. This paper evaluates the impact of addressing the visual needs of these children on behaviour and academic achievements in a number of case studies. Method: Nine children (4–11 years of age, from four classrooms), who attended a special school in a medium‐sized town in the UK, took part in the case studies reported here. The children were part of the Special Education Eyecare (SEE) Project. Six of the children were selected because they had unmet visual needs at baseline and required bespoke interventions to meet these needs; the other three children were selected because their visual needs had been met prior to the study and no further adjustments were needed. Repeated direct observations were conducted to assess the impact of the intervention on the children's behaviour in the classroom. The observer was "blind" with regard to the visual needs of the participants. Parents and teachers completed the Strength and Difficulties Questionnaire (SDQ) for each child, before and after the intervention. School files were analysed to assess effects on academic achievement. Findings: Subsequent to the implementation of bespoke visual adjustments, for example prescription of spectacles or changed seating in classroom, significant and sustained changes were observed with regard to the children's behaviour (i.e., increased engagement with peers and/or teachers and decreased off‐task behaviour). Strength and Difficulties Questionnaire scores showed improvements regarding total difficulties, emotional difficulties, hyperactivity and prosocial (kind and helpful) behaviour. Due to highly variable data in school files, the effects on academic achievement were inconclusive. Discussion: The case studies reported here explored changes in behaviour of children with identified special educational needs after their visual needs were met. Findings show a positive overall effect on the behaviour of these children. [ABSTRACT FROM AUTHOR]

SHIFT has been one of the largest RCTs in the field of systemic family therapy in the UK. The study took place over five years, including three major centres with fifteen Trusts and twenty‐five family therapists who worked with a manualized treatment in CAMHS with adolescents who self‐harmed. While the results are not available at the time of this publication, this paper will briefly describe the pre‐ existing factors which were helpful in developing a successful bid, clinical and managerial elements of ‘real world research’ of complex psychological processes and the construction of the manualized systemic family therapy. It also offers examples of some of the unanticipated events in the life of such a large trial. Practitioner Points: Large trials develop from small studies and clinicians are urged to look for opportunities for research partnershipsInvestment in time for consideration of difficult issues as they arise is essential for effective trial managementThe balance between research rigour and ‘real life’ practice is an inevitable area of tension and requires consideration of both immediate and outcome consequences 尝试和痛苦 – 一种随机对照试验对比下的把干预当作惯常和在实施过程中出现的重要事件上的反思的家庭治疗 人工家庭治疗 摘要: SHIFT目前是英国家庭治疗领域最大的随机对照试验之一。本研究历时5年, 囊括了三个主要的中心在内的15个信托, 25位曾在CAMHS对自残青少年进行人工治疗的家庭治疗师。因为在发表这篇文章的时候, 结果还没有出来, 本文将简短地描述1）有助发展成功bid的已经存在的因素, 2）临床以及管理方面的复杂心理过程的”真实情况研究”元素, 3）以及人工系统家庭治理的建构。本文还提供了生活在这样一种大的的尝试下的一些意想不到事件的例子。 对实践者有用的几点建议: 大的尝试发展自小的研究, 临床工作者急需寻找研究合作者的机会困难事件需要及时解决, 不然就会对有效尝试管理产生重要影响研究活力和”真实生活”实践的平衡是一种不可避免的引起紧张的领域, 这需要对当下和结果的同时考虑 关键词：实证实践, 研究, 儿童和青少年精神健康, 培训 [ABSTRACT FROM AUTHOR]

Background: CBT is an effective treatment for depression, but access varies across the United Kingdom. Online CBT increases access. The INTERACT platform was designed to support patient engagement in CBT, enabling therapists to deliver high‐intensity CBT via typed instant messaging and allowing patients and therapists access to an integrated online library of resources during and between sessions. Methods: The INTERACT trial aimed to evaluate this integrated approach to delivering CBT for primary care patients with depression. A nested qualitative study was conducted within the trial. Interviews were conducted with 20 patients who received the intervention, 9 therapists who delivered it and 3 therapist supervisors. Data were analysed using thematic analysis. Results: The combination of receiving support from a therapist and having access to integrated online CBT resources enabled patients to better manage their depression. Platform benefits included the opportunity to review transcripts to clarify how to complete homework tasks and track progress in managing their depression. The typing process allowed reflection and a focused discussion. However, less could be covered than during an in‐person session, which reduced therapists' expectations around goal setting. Patients who did not complete therapy struggled with the typing and found the CBT approach too demanding. Conclusion: Findings highlight the importance of establishing patient and therapist goals and expectations about what can be achieved in CBT mediated by typing. Some patients are comfortable communicating via typing and are motivated to utilise online resources in between sessions. Exploring the benefits and challenges of typed CBT with patients will enable them to make an informed choice about referral for this novel approach to therapy. Patient or Public Contribution: Patients, service users and members of the public were involved in the study design and management. Substantial pilot work gathered stakeholder feedback and informed the design of the intervention, before undertaking the RCT. Coauthor P.L. is a service user representative co‐applicant and member of the management group responsible for developing the intervention and the trial. Two PPI members sit on the Independent Steering Committee. PPI members provided valuable feedback on the study resources and documents. [ABSTRACT FROM AUTHOR]

Vocal fold nodules present the voice clinic team with a number of clinical dilemmas which are not as simple as previously thought. The definition, aetiology, prevalence and diagnosis are all poorly understood. Furthermore, treatment evidence for both behavioural and surgical approaches is weak. This paper reviews the published evidence pertaining to all of these aspects. Specific areas of uncertainty that remain include poorly defined nomenclature, the natural history of paediatric vocal nodules, the establishment of criteria to measure successful treatment, optimal configuration of speech therapy regimens and the rationale for surgical intervention. The authors suggest the development of evidence‐based guidelines for UK practice. [ABSTRACT FROM AUTHOR]

Current policy in UK health services emphasizes that, where possible, people with intellectual disabilities should access the same services as people without intellectual disabilities. One of the barriers to this is the confidence of clinicians and therapists. In this paper, we report on the development of a scale to describe the confidence of therapists in working with people with intellectual disabilities (the Therapy Confidence Scale-Intellectual Disabilities [TCS-ID]). One-hundred and eighty-one therapists who provided talking therapies but who did not work primarily with people with intellectual disabilities completed the scale; 43 people completed the scale twice for test-retest reliability purposes. One-hundred and seven people also completed a scale of general therapy self-efficacy. The TCS-ID has a single factor structure accounting for 62% of the variance, Cronbach's alpha for the scale is 0.93 and test-retest reliability is 0.83. There are significant differences in confidence based upon participants experience in working with people with intellectual disabilities and their therapeutic orientation, and there is a significant association between the TCS-ID and the General Therapy Self-efficacy Scale. Sixty clinicians working in mainstream mental health services received training on adapting their therapeutic approaches to meet the needs of people with intellectual disabilities. The TCS-ID was used pre-training and post-training and demonstrated a significant increase in confidence for all group. We suggest that the scale has good psychometric properties and can be used to develop an understanding of the impact of training for mainstream therapist in working with people with intellectual disabilities. Copyright © 2014 John Wiley & Sons, Ltd. Key Practitioner Message There is increasing emphasis on people with intellectual disabilities receiving services from mainstream mental health services., There is no research describing the experiences and outcomes of people with intellectual disabilities receiving mainstream talking therapy services., The confidence that clinicians have in working with people with intellectual disabilities may be a barrier to them receiving mainstream services., The Therapy Confidence Scale-Intellectual Disabilities is a psychometrically sound scale for measuring the confidence of therapists in working with people with intellectual disabilities and is a useful outcome measure for training clinicians to work with people with intellectual disabilities. [ABSTRACT FROM AUTHOR]

Accessible Summary: Lots of people with intellectual disabilities in the UK are given medication to manage their behaviours and the NHS wants this to stop. In Cornwall, we wanted to see how often we give medication to people instead of other health care such as communication or occupational assessments etc. We found that around half the people we work with because of their behaviours get medication to manage their feelings and many do not get other assessments. We want to change this in Cornwall and stop over medicating people by learning from this study. Abstract: Background: The use of psychotropic medication to manage challenging behaviours of people with intellectual disabilities is a contentious issue which NHS England has now focused on. This paper looks to evaluate this within the multidisciplinary context. Method: Records of clients (n = 106) open to a Community Intellectual Disabilities team for care relating to challenging behaviours were examined. Those recommended psychotropic medications in the absence of a mental health diagnosis were scrutinised for supporting MDT assessments. Results: Over half the clients with challenging behaviours were being prescribed psychotropic medications and many of those had very few MDT assessments to inform care. Conclusions: This study demonstrates the extent psychotropics are used in the absence of MDT informed support for people with intellectual disabilities and behaviours that challenge. A vision to simply withdraw such medication might be simplistic. Local MDT plans are in development to systematically reduce reliance on this type of restrictive practice. [ABSTRACT FROM AUTHOR]

The progressive nature of Type 2 diabetes necessitates treatment intensification over time in order to maintain glycaemic control, with many patients ultimately requiring insulin therapy. While insulin has unlimited potential efficacy, its initiation is often delayed and improvements in glycaemic control are typically accompanied by weight gain and an increased risk of hypoglycaemia, particularly as HbA1c approaches and falls below target levels. This may account for the sub-optimal control often achieved after insulin initiation. Combining insulin with antihyperglycaemic therapies that have a low risk of hypoglycaemia and are weight-neutral or result in weight loss is a therapeutic strategy with the potential to improve Type 2 diabetes management. Although the effects differ with each individual class of therapy, clinical trials have shown that adding a glucagon-like peptide-1 receptor agonist, dipeptidyl peptidase-4 inhibitor or sodium-glucose co-transporter-2 inhibitor to insulin regimens can offer a significant reduction in HbA1c without substantially increasing hypoglycaemia risk, or weight. The evidence and merit of each approach are reviewed in this paper. Once-daily co-formulations of a basal insulin and a glucagon-like peptide-1 receptor agonist have been developed (insulin degludec/liraglutide) or are under development (lixisenatide/insulin glargine). Insulin degludec/liraglutide phase III trials and a lixisenatide/insulin glargine phase II trial have shown robust HbA1c reductions, with weight loss and a low risk of hypoglycaemia. With insulin degludec/liraglutide now approved in Europe, an important consideration will be the types of patients who may benefit most from a fixed-ratio combination; this is discussed in the present review, and we also take a look toward future developments in the field. [ABSTRACT FROM AUTHOR]

A repeated dose of an oral triptan has been shown in randomized controlled trials (RCTs) to be ineffective as a treatment for no or partial response 2 hours after initial dosing but effective as treatment for headache recurrence. In the official prescription information in the United States, the United Kingdom, and Denmark repeated dosing of all seven oral triptans are recommended for headache recurrence but some triptans are also recommended for no or partial response, a use of a triptan deemed to be not beneficial in European and Canadian migraine guidelines. In summary, not all recommendations are based on evidence from RCTs. In addition, some recommendations are ambiguous and patients need clearer instructions. An example of such a clear British instruction in a patient leaflet instruction is presented at the end of the paper. [ABSTRACT FROM AUTHOR]

Joint hypermobility syndrome (JHS) is a heritable disorder associated with excessive joint range of motion and pain in the absence of inflammatory joint disease. It is a relatively common cause of musculoskeletal pain but is generally understood to be under-recognized and poorly managed in clinical practice. The present study therefore aimed to identify how JHS is diagnosed, managed and assessed in routine physiotherapy practice. A survey tool was developed from similar physiotherapy surveys of musculoskeletal practice, a review of the literature, and consultation with researchers and clinicians. Paper copies of the final survey were sent to 201 randomly selected secondary care organizations across the UK and an electronic version was advertised through physiotherapy professional networks. A total of 66 responses (80% women) were received from physiotherapists, with a wide range of clinical experience. Only 32% of respondents reported that they had received formal training in JHS management. The Brighton diagnostic criteria for JHS were not often used (only 31% of respondents). The stated aims of physiotherapy and the specific interventions employed seem well matched, with a focus on advice, education, exercise and self-management. Although pain relief was not reported as a high priority in terms of treatment aims, pain was most often assessed as an outcome, suggesting a mismatch between what clinicians aim to achieve and what they measure. The results suggest that reported management strategies are broadly appropriate to long-term musculoskeletal conditions but additional training specific to JHS may be required, particularly in diagnosis and assessment. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Mindfulness-based interventions have been shown to be effective in the treatment of a range of health and psychological disorders in adults and young people without intellectual disabilities ( ID). Clinical studies are emerging reporting on the efficacy of mindfulness-based interventions as a stand-alone treatment for common clinical disorders in adults with ID. Method This paper aims to evaluate the efficacy of an innovative structured mindfulness-based cognitive therapy ( MBCT) group programme adapted for adults with ID with a diagnosis of either recurrent depression, anxiety or both clinical conditions and a history of deliberate self-harm behaviour. Two groups ran consecutively consisting of a total of fifteen participants and seven carers. All participants were recorded as having either a borderline, mild, or moderate ID. The group programme ran over a period of 9 weeks with a follow-up session at 6 weeks post group intervention. Outcome measures included the Hospital Anxiety and Depression Scale and two sub-scales from the Self- Compassion Scale administered at baseline, post therapy and at 6-week follow-up. Results The evaluation showed that participants reported an improvement in their experience of depression, anxiety, self-compassion and compassion for others. The most significant impact was in the reduced levels of anxiety reported. Improvements across all outcomes were maintained at 6-week follow-up. Conclusion The results of the evaluation suggest that people with intellectual disabilities benefit from a structured MBCT group intervention and the results are maintained at 6-week follow-up. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the editor discusses various reports within the issue on topics including the diabetes in childhood, aspects of diabetes epidemiology, and the management of diabetic ketoacidosis among adolescents and young adults.

A review of the article "National guidance contributes to the high incidence of inpatient hypoglycaemia" by N. Levy is presented.

Axon degeneration accounts for the poor clinical outcome in Guillain‐Barré syndrome (GBS), yet no treatments target this key pathogenic stage. Animal models demonstrate anti‐ganglioside antibodies (AGAb) induce axolemmal complement pore formation through which calcium flux activates the intra‐axonal calcium‐dependent proteases, calpains. We previously showed protection of axonal components using soluble calpain inhibitors in ex vivo GBS mouse models, and herein, we assess the potential of axonally‐restricted calpain inhibition as a neuroprotective therapy operating in vivo. Using transgenic mice that over‐express the endogenous human calpain inhibitor calpastatin (hCAST) neuronally, we assessed distal motor nerve integrity in our established GBS models. We induced immune‐mediated injury with monoclonal AGAb plus a source of human complement. The calpain substrates neurofilament and AnkyrinG, nerve structural proteins, were assessed by immunolabelling and in the case of neurofilament, by single‐molecule arrays (Simoa). As the distal intramuscular portion of the phrenic nerve is prominently targeted in our in vivo model, respiratory function was assessed by whole‐body plethysmography as the functional output in the acute and extended models. hCAST expression protects distal nerve structural integrity both ex and in vivo, as shown by attenuation of neurofilament breakdown by immunolabelling and Simoa. In an extended in vivo model, while mice still initially undergo respiratory distress owing to acute conduction failure, the recovery phase was accelerated by hCAST expression. Axonal calpain inhibition can protect the axonal integrity of the nerve in an in vivo GBS paradigm and hasten recovery. These studies reinforce the strong justification for developing further animal and human clinical studies using exogenous calpain inhibitors. [ABSTRACT FROM AUTHOR]

Background: Significant progress has been made in reducing inappropriate transfusion of blood products. However, there is also a need to monitor for their underutilization in patients who would benefit from transfusion. This study aimed to develop a method to monitor for undertransfusion and conduct a preliminary examination of whether it is a problem in modern clinical practice.Study Design and Methods: All patients with a hemoglobin (Hb) concentration below 6 g/dL or platelet (PLT) count of fewer than 10 × 10(9) /L were identified during a 1-month period in an academic medical center in the United Kingdom. Patients who were transfused within 72 hours of the low reading were excluded from further analysis. For all other patients, records were examined against predefined criteria to ascertain whether the reason for nonadministration of transfusion was justified.Results: During the study period there were 63 eligible Hb readings and 130 eligible PLT counts in 93 patients. Of these, 36 patients were not transfused within 72 hours of the low reading. The majority of nonadministration (n = 28) was justified by either an additional Hb or an additional PLT count on repeat sampling being above the transfusion threshold or the transfusion being medically inappropriate. No documentation was found to indicate that any cases of nonadministration of blood were unjustified.Conclusion: This study did not find that patients with low Hb readings or PLT counts were inappropriately undertransfused. However, systems similar to those described in this study should be developed to monitor for inappropriate undertransfusion as well as continuing efforts to monitor for and reduce inappropriate overtransfusion. [ABSTRACT FROM AUTHOR]

Human prion diseases (HPDs) are progressive and fatal neurodegenerative diseases caused by abnormal prion protein (PrPSc). They can be sporadic, genetic or acquired. Sporadic HPDs include sporadic Creutzfeldt–Jakob disease (CJD) and sporadic fatal insomnia. Genetic HPDs include genetic CJD, Gerstman–Sträussler–Scheinker disease and fatal familial insomnia. Acquired HPDs include Kuru, variant CJD and iatrogenic CJD. The World Health Organization clinical diagnostic criteria for HPDs include clinical findings, cerebrospinal fluid protein markers and electroencephalography, and the UK and European clinical diagnostic criteria include a combination of clinical findings, 14‐3‐3 protein in the cerebrospinal fluid, magnetic resonance imaging diffusion‐weighted imaging and electroencephalography. Recently, the development and clinical application of real‐time quaking‐induced conversion has allowed pre‐mortem diagnosis of sporadic CJD. The real‐time quaking‐induced conversion assay allows detection of >1 fg of PrPSc in diluted CJD brain homogenate, as well as a variety of biological tissues and cerebrospinal fluid. However, the real‐time quaking‐induced conversion assay does not provide prognostic data and has lower diagnostic accuracy for some rarer, atypical prion diseases. Furthermore, recent advancements in laboratory testing and magnetic resonance imaging diffusion‐weighted imaging have shown improved diagnostic accuracy for prion diseases. Clinical trials of prion disease treatments have recently begun in many countries. The therapeutic window consists mainly of the early stage of disease, and few clinical studies have examined the role of biomarkers at this stage. Therefore, biomarkers, imaging and clinical symptoms might be extremely important for the diagnosis of prion diseases. Clinical trials of prion disease treatments have recently begun in many countries. The therapeutic window mainly consists of the early stage of disease, and few clinical studies have examined the role of biomarkers at this stage. Therefore, biomarkers, imaging and clinical symptoms might be extremely important for the diagnosis of prion diseases. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to determine the differences and potential mechanistic rationale for observed adverse drug reactions (ADRs) between four approved PARP inhibitors (PARPi). Methods: The Medicines and Healthcare products Regulatory Authority (MHRA) Yellow Card drug analysis profiles and NHS secondary care medicines database enabled the identification of suspected ADRs associated with the PARPi in the UK from launch to 2020. The polypharmacology of the PARPi were data‐mined from several public data sources. Results: The overall ADRs per 100 000 Rx identified across the four PARPi are statistically significant (χ2 test, P <.001). Rucaparib has the greatest relative suspected ADRs, which can be explained by its least clean kinome and physicochemical properties. The suspected gastrointestinal ADRs of rucaparib and niraparib can be ascribed to their kinase polypharmacology. Suspected blood and lymphatic system ADRs of PARPi can be linked to their high volume of distribution (Vd). The thrombocytopenia rate of niraparib > rucaparib > olaparib tracked with the Vd trend. Hypertension is only associated with niraparib and could be explained by the therapeutically achievable inhibition of DYRK1A and/or transporters. Arrhythmia cases are potentially linked to the structural features of hERG ion‐channel inhibition found in rucaparib and niraparib. Enhanced psychiatric/nervous disorders associated with niraparib can be interpreted from the diverse neurotransporter off‐targets reported. Conclusions: Despite their similar mode of action, the differential polypharmacology of PARP inhibitors influences their ADR profile. [ABSTRACT FROM AUTHOR]

We present findings from a longitudinal ethnographic study of infertile couples seeking treatment following initial GP referral to specialist fertility services. Repeated observations and interviews were undertaken with the same 14 heterosexual participants over an 18‐month period. Heterosexual, non‐donor couples comprise the majority of fertility clinic patients; however, research interest in this group has dwindled over time as IVF cycles have increased. In the United Kingdom, IVF is presented as a logical response to involuntary childlessness, and as an entirely predictable, and linear, course of action. The market is well‐developed and often patients' first experience of privatised health care in the NHS. Our couples were challenged by this, and while they felt expected to move on to IVF, some wished to explore other options. While IVF is ubiquitous, the discomfort and challenge around fertility treatments remain; experiences are prolonged and characterised by recursive narratives and expressions of disequilibrium, which are rarely acknowledged and reflected in ongoing clinic‐patient interactions. Our findings develop understanding of the process of 'mazing' (Image ‐ The Journal of Nursing Scholarship, 1989, 21, 220), the pursuit of parenthood, by showing that the routine and normative status of IVF, at least in the current health care context, is at odds with the lived experiences of individuals. [ABSTRACT FROM AUTHOR]

Background: There is currently little evidence exploring menopausal status, age at last menstrual period (LMP) and management of menopause among women living with HIV aged 45–60 years in England. Methods: Socio‐demographic, lifestyle and clinical data were collected through a self‐completed cross‐sectional survey. Longitudinal CD4 count and viral load data were available from linkage to clinical records, if consent was provided. Women were categorised as pre‐, peri‐ or post‐menopausal. Factors associated with menopausal stage were examined using ordinal logistic regression adjusting for age. Age at LMP was estimated using Kaplan–Meier survival analysis. Results: The 847 women had a median age of 49 [interquartile range (IQR): 47–52] years. Most were of black ethnicity (81.3%), were born outside the UK (85.0%) and had completed secondary education (88.7%); 177 (20.4%), 373 (43.0%) and 297 (34.2%) were pre‐, peri‐ or post‐menopausal, respectively. After adjusting for age, associations of menopausal status with non‐cohabiting relationship [adjusted odds ratio = 0.63 (95% confidence interval: 0.43–0.91)], baseline viral load ≥ 100 000 copies/mL [2.67 (1.20–5.94)] and unemployment [1.34 (0.97–1.84)] remained significant. Median (IQR) age at LMP was 54 (51–55) years in the group. In total, 27.9% (233/836) of women reported severe menopausal symptoms; 45.6% of those with somatic symptoms had heard of hormone replacement therapy and 8.7% had used it. Only 5.6% of women with urogenital symptoms had used topical oestrogen. Conclusions: Our findings highlight the importance of educating both women and their healthcare providers about menopausal symptoms and management options. [ABSTRACT FROM AUTHOR]

Objectives: To characterise and document the progression of idiopathic renal haematuria in a large cohort of medically managed UK dogs. Materials and Methods: Retrospective study of 41 client‐owned dogs with confirmed (n=14), or suspected (n=27) idiopathic renal haematuria from 4 UK‐based referral centres. Clinical findings and outcomes of dogs (2001 to 2018) were determined from the review of medical records and telephone follow‐up. Results: Median survival time from diagnosis was long [1482 (152 to 1825) days] irrespective of treatment and clinical response. Only 1 case was euthanased due to idiopathic renal haematuria, and anaemia or azotaemia occurred infrequently. In total, 25 dogs received angiotensin‐converting enzyme‐inhibitor or angiotensin receptor blocker therapy, of which 23 received benazepril [0.44 (0.19 to 0.82) mg/kg/24 hours], two received enalapril (0.40 and 0.78 mg/kg/24 hours) and one received telmisartan (1 mg/kg/24 hours). In cases with follow‐up urinalyses, complete resolution of haematuria was documented in eight of 19 (42%) dogs following angiotensin‐converting enzyme‐inhibitor/angiotensin receptor blocker treatment, with partial improvement in five of 19 (26%) and no improvement in six of 19 (31%). Conversely, of the two untreated dogs where outcome was available, one had partial improvement and the other had no improvement. Clinical Significance: In this study, idiopathic renal haematuria was associated with a good prognosis and low complication rate. Resolution or improvement in haematuria occurred in both angiotensin‐converting enzyme‐inhibitor/angiotensin receptor blocker‐treated and untreated dogs, indicating that further studies are required to evaluate the effectiveness and safety of these interventions. [ABSTRACT FROM AUTHOR]

Background: In the UK, there is increasing pressure on ear, nose and throat (ENT) clinicians and departments, which is anticipated to amplify in the coming months and years due to the coronavirus disease 2019 pandemic and other workforce pressures. In the context of a national drive to advance practice of Allied Health Professionals to address some key challenges facing the National Health Service, we explored whether UK speech and language therapists (SLTs) felt it is possible to utilize and extend their existing skills to patients on the urgent 2-week wait (2ww) ENT pathway. Aims: To explore SLTs' views of extending their role to work with patients referred on the ENT 2ww pathway. Methods&Procedures: Two separate focus groupswere conducted using nominal group technique to generate and rank benefits and challenges of the proposed extension of role. Participants were invited to take part through Clinical Excellence Networks relevant to head and neck cancer and voice sub-specialties. Participants were competent in performing nasendscopy in at least a highly specialist role in voice or head and neck subspecialties. Outcomes & Results: Nine SLTs from England, Wales and Northern Ireland attended two focus groups. All were employed in band 8 roles in head and neck and/or voice. Eight were competent to Royal College of Speech and Language Therapists' scoping level 3. Important benefits of the proposed novel service delivery model were generated and ranked by participants, with both groups identifying improved quality and efficiency of service for patients among the most important. Disadvantages were then generated and ranked across the two groups with potential for misdiagnosis ranked as the most important by both. Conclusions & Implications: Participants responded that extending the SLT role into assessment of 2ww patients would provide benefits for quality of care, healthcare efficiency and the SLT workforce. The identified disadvantages require addressing if the proposed SLT-led model of service delivery is piloted in the UK. These include practical matters such as referral and prescribing rights, alongside wider implications such as support, governance, indemnity, acknowledgement and remuneration for the extended role. Nationally agreed competencies and training for the role are required if this model is to be successful. [ABSTRACT FROM AUTHOR]

Aim: To describe variation in the initial management of children presenting to Emergency Departments (ED) with coins lodged in the oesophagus. To determine the usage of hand-held metal detectors (HHMDs) in EDs, including their role in clinical decision-making, and training in their use.Methods: Online multicentre cross-sectional survey of EDs in the UK and Ireland, with results described using descriptive statistics.Results: Fifty-five (90%) of 61 sites responded. The two main strategies described for lodged oesophageal coins were endoscopic removal or observation with reassessment, dependent on location. For coins in the proximal third of the oesophagus 43/55 (78.2%) referred for endoscopic removal, 6/55 (10.9%) observed and the remaining 10.9% used a variety of methods, including: Foley catheter removal with fluoroscopy, blind Foley catheter removal, referral to paediatric surgery/ENT. Thirty (55%) of 55 used HHMDs, 21/30 (70%) had guidelines for their use, and 3/30 (10%) provided formal training. Twenty (67%) of 30 used the xiphisternum as the anatomical cut-off for assuming safe passage of metallic foreign bodies (FB) beyond the lower oesophageal sphincter.Conclusions: There is considerable variation in the management of oesophageal coins in children, though two dominant strategies were identified. As endoscopy is significantly more invasive than observation, future research should aim to determine whether either is more effective and safer in children. There is a clear division in departmental adoption of HHMDs. However, in those sites using HHMDs there was little formal training in their use, and there are large variations in techniques and their role in clinical decision-making. [ABSTRACT FROM AUTHOR]

Background: Parkinson's disease (PD) is a chronic progressive neurological disorder with a high psychosocial and economic burden. As part of the European Brain Council (EBC)‐led Value of Treatment project, this study aimed to capture the economic benefit of timely, adequate, and adherence to PD treatment. Methods: The EBC Value of Treatment Initiative combined different stakeholders to identify unmet needs in the patients' journey according to Rotterdam methodology. The economic evaluation focused on three major topics identified as major gaps: start of treatment; best treatment for advanced disease; and adherence to treatment. Two separate healthcare systems (Germany and the UK) were chosen. Cost‐effectiveness was determined by using decision‐analytical modelling approaches. Effectiveness was expressed as quality‐adjusted life‐years (QALYs) gained and incremental cost‐effectiveness ratio (ICER). Results: Treatment intervention in PD was found to be cost‐effective regardless of the initial health state of the patient receiving the treatment. Cost savings were between ‐€1000 and −€5400 with 0.10 QALY gain and ‐€1800 and ‐€7600 with 0.10 QALY gain for Germany and the UK, respectively. Treatment remains cost‐effective within the National Institute for Health and Care Excellence thresholds. Availability of adequate treatment to more patients was also found to be cost‐effective, with an ICER of €15,000–€32,600 across country settings. Achieving the target adherence to treatment would generate cost‐savings of €239,000–€576,000 (Germany) and €917,000–€2,980.000 (UK) for every 1,000 patients treated adequately. Conclusions: The analyses confirmed that timely, adequate, and adherence to PD treatment will not only improve care of the patients but is also cost‐effective across healthcare systems. Further studies with a distinct identification of gaps in care are necessary to develop better and affordable care. [ABSTRACT FROM AUTHOR]

Over the last quarter century, non‐medical prescribing in the UK has grown significantly; eight non‐medical professional groups now have authority to prescribe a wide range of medicines, suggesting it could be a potent driver of pharmaceuticalisation. In this article, we present data from a case study of physiotherapists' prescribing practices. UK physiotherapists have had legal rights to prescribe medicines since 2005, but relatively little is known about the contribution they make to expanding patient access to medicines. We approached our study through a lens of governmentality to capture the mentalities and micro‐practices governing physiotherapist non‐medical prescribing. Ethnographic methods were used to gather data from an outpatient orthopaedic service in an NHS Trust in England employing physiotherapist prescribers. From the data, we identified a grid of intelligibility – an organising framework formulated by powerful discourses and technologies of government through which physiotherapist prescribing was acted into being. A primary effect of this grid was the constitution of new physiotherapist subjectivities, mostly as non‐prescribers of medicines contrary to policy intentions, underpinned by a familiar and enduring template of medical professionalism. [ABSTRACT FROM AUTHOR]

Background: Primary progressive aphasia (PPA) describes a heterogeneous group of language‐led dementias. People with this type of dementia are increasingly being referred to speech and language therapy (SLT) services. Yet, there is a paucity of research evidence focusing on PPA interventions and little is known about SLT practice in terms of assessment and provision of intervention. Aims: To survey the practices of SLTs in the areas of assessment and intervention for people with PPA. Methods & Procedures: A 37‐item, pilot‐tested survey was distributed electronically through the Royal College of Speech and Language Therapists (RCSLT), Clinical Excellence Networks (CENs) and social media networks. Survey items included questions on care pathways, assessment and intervention approaches, and future planning. Analysis was conducted using descriptive statistics and thematic analysis. Outcomes & Results: A total of 105 SLTs completed the survey. Respondents reported more frequently using formal assessment tools designed for stroke‐related aphasia than for dementia. Informal interviews were reportedly always used during assessment by almost 80% of respondents. Respondents were significantly more likely to use communication partner training than impairment‐focused interventions. Goal attainment was the most commonly used outcome measure. Respondents provided 88 goal examples, which fell into six themes: communication aid; conversation; functional communication; impairment focused; specific strategy; and communication partner. Additionally, respondents reported addressing areas such as future deterioration in communication and cognition, decision‐making and mental capacity, and driving. Ten (9.4%) respondents reported the existence of a care pathway for people with PPA within their service. Conclusions & Implications: This survey highlights the range of current PPA assessment and intervention practices in use by the respondents. Communication partner training is commonly used by the surveyed SLTs, despite the lack of research evidence examining its effectiveness for PPA. There is a need to develop evidence‐based care pathways for people with PPA in order to advocate for further commissioning of clinical services. [ABSTRACT FROM AUTHOR]

Key content: Approximately 21 000 women in the UK were diagnosed with a gynaecological malignancy in 2015; although most of these malignancies occurred in postmenopausal women, 30–40% present in premenopausal or perimenopausal women.Management typically involves surgery and/or chemotherapy and/or radiotherapy, which in younger women may result in an induced menopause.Many women struggle with both the immediate symptoms and the long‐term consequences of estrogen deficiency, all of which are debilitating and compromise the quality and quantity of life, in addition to the cancer diagnosis and treatment.These patients represent a complex group and most units in the UK do not have easy access to menopause specialists.Gynaecologists may be reluctant to prescribe hormone replacement therapy (HRT) to these women; clinicians involved in the care of these women must appreciate when HRT is and is not contraindicated. Learning objectives: To understand the safety of HRT in women who have undergone treatment for endometrial, ovarian, cervical, vulval or vaginal malignancies, with particular emphasis on the type, stage and grade of cancer.To establish an evidence‐based approach to the management of menopausal symptoms using HRT in women who have previously been treated for a gynaecological malignancy.To appreciate the role of non‐hormonal alternatives to HRT in these women. Ethical issues: How to balance the known benefits of HRT against the potential risks, when evidence is limited in women who have undergone treatment for a gynaecological malignancy. [ABSTRACT FROM AUTHOR]

Aims: To investigate medical students' perspectives on the influence of their undergraduate course and the UK prescribing safety assessment (PSA) on the acquisition of practical prescribing skills. Methods: An online questionnaire comprising multiple choice and open‐ended questions was available to UK medical students in years 3, 4 and 5. Descriptive statistics and thematic analysis were completed. Results: In total, 1023 medical students from 25 UK medical schools responded: 22% (3rd year), 37% (4th year) and 41% (final year). A minority of medical students believed that their medical course prepared them sufficiently for practical prescribing (36.4%, n = 372, 95% confidence interval [CI] = 32–41%), 52.6%, of students thought that practical prescribing should be introduced into the curriculum earlier (n = 538, CI = 48–57%), and 73.7% reported that a more consistent approach to the teaching and learning of practical prescribing might be beneficial (n = 754, CI = 71–77%). An awareness of the national PSA was high (86.5%, n = 885), particularly amongst final year students (98.3%, n = 413, CI = 97–100%); 67.4% of all students (n = 690, CI = 64–71%) and 72.1% (n = 303) of final year students perceived that the PSA will improve or had improved their practical prescribing skills. Conclusions: The majority of medical students perceive that their undergraduate course does not adequately prepare them for practical prescribing. Many believe that there is some merit in introducing practical prescribing teaching earlier in the curriculum and medical schools adopting a more consistent approach. Among medical students, the PSA is thought to have a positive influence on prescribing skills learning. These data might be useful in developing a programme of study dedicated to practical prescribing. [ABSTRACT FROM AUTHOR]

In people with Type 2 diabetes, cardiovascular disease is a leading cause of morbidity and mortality. Thus, as well as controlling glucose, reducing the risk of cardiovascular events is a key goal. The results of cardiovascular outcome trials have led to updates for many national and international guidelines. England, Wales and Northern Ireland remain exceptions, with the most recent update to the National Institute for Health and Care Excellence (NICE) guidelines published in 2015. We reviewed current national and international guidelines and recommendations on the management of people with Type 2 diabetes. This article shares our consensus on clinical recommendations for the use of sodium‐glucose co‐transporter 2 inhibitors (SGLT‐2is) and glucagon‐like peptide 1 receptor agonists (GLP‐1RAs) in people with Type 2 diabetes and established or at very high risk of cardiovascular disease in the UK. We also consider cost‐effectiveness for these therapies. We recommend considering each person's cardiovascular risk and using diabetes therapies with proven cardiovascular benefits when appropriate to improve long‐term outcomes and cost‐effectiveness. What's new?: Following positive cardiovascular outcome trial results, many national and international guidelines on the management of people with Type 2 diabetes have been updated for those also at high risk of cardiovascular disease. However, not all countries have updated their guidelines, notably England, Wales and Northern Ireland.This review shares a consensus on clinical recommendations for use of glucagon‐like peptide 1 receptor agonists and sodium–glucose co‐transporter 2 inhibitors in people with Type 2 diabetes.Although some countries have not yet updated their guidelines, we recommend consideration of each person's cardiovascular risk when selecting their diabetes therapy, to improve long‐term outcomes and cost‐effectiveness. [ABSTRACT FROM AUTHOR]

Background: Health‐related quality of life (HRQOL) may improve as an additional benefit of the growth hormone treatment (GHT) in children with short stature, but this effect has not been conclusively proven. Objectives: To explore the direct effect of GHT on HRQOL in children starting GHT due to isolated or multiple GH deficiency (IGHD), acquired GH deficiency (AGHD) and Turner syndrome (TS), in comparison with untreated short stature controls in 18 UK centres. Methods: We used recognized measures of HRQOL, the PedsQL, the Strengths and Difficulties Questionnaire and Youth Life Optimism Test scales to investigate the effect of GHT at 0, 6 and 12 months in children and adolescents 6‐16 years with IGHD (n = 73) and AGHD (n = 45), and 22 girls with TS. 49 children with non‐GHD short stature served as the controls. Results: Children rated their HRQOL better than their parents. Those with IGHD and TS rated their overall HRQOL lower than the controls at baseline, psychosocial scores significantly lower in IGHD. After 12 months, the control and TS groups scored higher than UK norms. Those with AGHD had lowest HRQOL scores at all time points, due to poorer physical functioning. The controls showed the greatest improvement in the strength and difficulties scale. All measures evaluated, whether from child, parent or teacher showed an equal improvement over the year of GHT with no discernible direct treatment effect, despite reduced numbers in some patient groups. Conclusions: Children with short stature resulting from GHD have lower functioning than controls but HRQOL appears to improve with GHT, most likely on account of greater attention and as a result of the retest phenomenon. We were not able to demonstrate an absolute and independent effect of GHT in itself. HRQOL should not be used as a primary measure, as in adults, to determine whether children should receive GHT. [ABSTRACT FROM AUTHOR]

Aim: Colorectal cancer (CRC) is diagnosed in approximately 45 000 people annually in the UK, and it is estimated that Lynch syndrome (LS) accounts for 3.1% of these cases. In February 2017, National Institute for Health and Care Excellence (NICE guideline DG27 recommended universal testing of new cases of CRC for mismatch repair (MMR) status. The aim of this study was to implement universal testing for LS in CRC patients in a secondary care setting. Method: We prospectively collected data on consecutive newly diagnosed CRC patients at our centre from November 2016 to August 2018, including evidence of MMR status determined by immunohistochemistry. We recorded clinicopathological data including age at diagnosis, stage, tumour site, reported histological findings and MMR tumour status. Statistical analysis was performed using the chi‐square test and the two‐tailed t‐test for binary and continuous variables, respectively. Results: A cohort of 203 consecutive patients were diagnosed with CRC during this period. Universal MMR testing was performed for the 198 CRC patients in whom a diagnosis of adenocarcinoma was confirmed, with colonoscopic biopsy used as the source material in 68.6% of cases. Twenty‐three CRCs (11.6%) were MMR deficient (dMMR). Most dMMR CRCs (21/23) were early stage tumours (Dukes A or B, P = 0.002). In 39 Dukes B CRCs in patients under 70 years of age, the result of MMR testing influenced decision‐making about personalized treatment with 5‐fluorouracil based chemotherapy. Conclusion: Our results demonstrate that universal testing of all new cases of CRC for features suggestive of LS is feasible and effective in the UK. Our data also indicate the importance of genetic testing and personalized oncological care. [ABSTRACT FROM AUTHOR]

Introduction: Patient–physician shared decision‐making (SDM) has become increasingly seen as having a positive effect on management of chronic diseases. However, little is known of the factors that encourage SDM or how effective it may be at improving health outcomes or how cost‐effective it is. Aim: To investigate the uses and applications of patient physician–SDM in the management of haemophilia and the influence of healthcare systems in the United States and the United Kingdom. Methods: This was a qualitative study based on interviews with treatment experts in the United States and United Kingdom. A grounded theory approach was used to analyse the data from the transcribed interviews and themes that emerged as related to the decision influencers. Twelve physicians from each country were interviewed by the author. Results: Treatment guidelines were viewed as having only limited applicability because of the lack of universal best options in haemophilia. The US physicians in the sample appeared to be more influenced by patient preferences than physicians in the UK, who instead tended to follow policies and standards of care more closely. Physicians in both countries commented that many of their patents had become highly knowledgeable of their bleeding disorder. US physicians were sometimes limited by insurance company policies but also reported that they were often successful in appealing insurance decisions. Conclusion: The research suggests that there are different influences on decision‐making between healthcare systems; patients and overarching healthcare systems play a major role in how physicians treat haemophilia. [ABSTRACT FROM AUTHOR]

Background: The increasing incidence of diffuse large B-cell lymphoma (DLBCL) in ageing populations places a significant burden on healthcare systems. Co-morbidity, frailty, and reduced organ and physiological reserve contribute to treatment-related complications. The optimal dose intensity of R-CHOP to optimize outcome across different ages with variable frailty and comorbidity burden is unclear.Objectives and Methods: We examined the influence of intended (IDI) and relative (RDI) dose intensity of the combination of cyclophosphamide and doxorubicin, age and comorbidity on outcomes for DLBCL patients ≥70 years in a representative, consecutive cohort across eight UK centres (2009-2018). We determined predictors of survival using multivariable Cox regression, and predictors of recurrence before death using competing risks regression.Results: Porgression-free survival (PFS) and overall survival (OS) were significantly inferior in patients ≥80 vs. 70-79 years (P < 0.001). In contrast, 2-year cumulative relapse incidence, when accounting for non-relapse mortality as a competing risk, was no different between 70-79 vs. ≥80 years (P = 0.27) or comorbidity status (CIRS-G: 0-6 vs. >6) (P = 0.27). In 70-79 years, patients with an IDI ≥80% had a significantly improved PFS and OS (P < 0.001) compared to IDI < 80%. Conversely, in patients ≥80 years, there was no difference in PFS (P = 0.88) or OS (P = 0.75) according to IDI <80% vs. ≥80%. On multivariable analysis, when comparing by age, there was a significantly higher cumulative relapse rate for patients aged 70-79 years with an IDI <80% (vs. >80%) (P = 0.04) but not for patients ≥80 years comparing IDI (P = 0.32).Conclusion: 'R-mini-CHOP' provides adequate lymphoma-specific disease control and represents a reasonable treatment option in elderly patients ≥80 years aiming for cure. [ABSTRACT FROM AUTHOR]

Background: It is unclear on how children with compromised first permanent molars (cFPMs) are currently managed in the UK by either general dental practitioners (GDP) or specialists in paediatric dentistry (SPD). Aim: Explore the current attitudes to the management of compromised first permanent molars amongst UK general dental practitioners and specialists in paediatric dentistry. Design: Self‐completed online questionnaire including three clinical vignettes of 7, 9, and 15 years old with cFPM. All registered SPDs (n = 236), as of May 2017, 500 randomly selected GDPs from England, selected from a national performers list, and 52 Scottish GDPs, part of Scottish dental practice research network, were invited to complete the questionnaire. Results: About 71.6% (n = 53) of SPDs agreed that children with cFPM should be referred to a paediatric specialist for treatment planning, whereas the reverse for GDPs is true, as 86.8% (n = 138) believe they have a responsibility to treat these teeth. Responses to clinical vignettes suggest a slight preference amongst GDPs to restore cFPM, including root canal treatment, whereas SPDs have a slight preference towards extraction. Conclusion: Current pathways for cFPM, amongst UK general dental practitioners and specialists in paediatric dentistry, vary greatly between and within each professional group. [ABSTRACT FROM AUTHOR]

Aims: To assess the role played by carbohydrates, fat and proteins in the management of Type 2 diabetes. Background: Diabetes research tends to reflect the interests of academics or the pharmaceutical industry, rather than those of people living with Type 2 diabetes. The James Lind Alliance and Diabetes UK addressed this issue by defining the research priorities of people living with Type 2 diabetes. Three of the top 10 research priority questions focused on lifestyle. Methods: A narrative review was undertaken with a structured search strategy using three databases. Search terms included the three macronutrients and Type 2 diabetes. No restrictions were placed on macronutrient quantity or length of study follow‐up. Outcomes included changes in HbA1c, body weight, insulin sensitivity and cardiovascular risk. Results: There is no strong evidence that there is an optimal ratio of macronutrients for improving glycaemic control or reducing cardiovascular risk. Challenges included defining the independent effect of macronutrient manipulation and identifying the effects of macronutrients, independent of foods and dietary patterns. Extreme intakes of macronutrients may be associated with health risks. Conclusions: It is challenging to formulate food‐based guidelines from studies based on macronutrient manipulation. Structured education should be offered to support individuals in discovering their optimal, individual dietary approach. Recommendations for dietary guidelines should be expressed in terms of foods and not macronutrients. [ABSTRACT FROM AUTHOR]

Aim: To conduct an open‐label study to provide UK real‐world evidence regarding the use of insulin glargine 300 units/ml (U300) in people with Type 1 diabetes mellitus. Methods: People with Type 1 diabetes who had been prescribed U300 ≥6 months before data collection and had HbA1c levels recorded within 3 months prior to U300 (baseline) were included. The primary endpoint was change in HbA1c from baseline to month 6 after U300 initiation. Other endpoints included number of documented hypoglycaemic and diabetic ketoacidosis episodes, and change in daily basal insulin dose. Results: A total of 298 people with Type 1 diabetes were included [mean age 42.1 years, mean HbA1c 79 mmol/mol (9.4%)]. After U300 initiation, the mean reduction in HbA1c from baseline to month 6 was –4 mmol/mol (–0.4%; P<0.001; n=188). The total daily basal insulin dose at 6 months was 1.3 units higher than at the time of U300 initiation (P<0.001; n=275) but was not significantly different from the prior basal insulin dose. There was no clinically significant difference in weight between baseline and month 6 [mean difference +0.7 kg, 95% CI –0.1, 1.5; P=0.084; n=115). During the 6 months before and after U300 initiation, severe hypoglycaemic episodes were documented for 6/298 and 4/298 participants. Diabetic ketoacidosis episodes requiring Accident and Emergency department visits or hospitalization were documented for 4/298 and 6/298 participants, before and after U300 initiation, respectively. Conclusions: In people with Type 1 diabetes, a change in basal insulin to U300 was associated with clinically and statistically significant HbA1c improvements, without significant changes in basal insulin dose and weight. Documented severe hypoglycaemia episodes and diabetic ketoacidosis requiring Accident and Emergency department visits or hospitalization were low and similar before and after U300 initiation. What's new?: This descriptive, retrospective study provides real‐world data on the use of a second‐generation basal insulin, insulin glargine 300 units/ml (U300), in Type 1 diabetes across the UK.Overall, participants who switched to U300 demonstrated improvements in HbA1c without significant changes in basal insulin dose and weight from baseline.The number of participants with documented severe hypoglycaemia and ketoacidosis requiring Accident and Emergency department visits or hospitalization was low and similar prior to and after U300 initiation.Results from this real‐world study show that observations made in randomized controlled trials translate to people with Type 1 diabetes treated with U300 in clinical practice in the UK. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the Editor discusses an article in the journal which deals with cognitive behaviour therapy for pediatric dental patients who suffer from anxiety, and it mentions the Children Experiencing Dental Anxiety Collaboration on Research and Education group.

The article presents papers about diabetes management. Topics mentioned include the best timing of injections of prandial insulin for the management of type 1 diabetes to match the supply of carbohydrate from the gastrointestinal tract and the correct levels of glucose for the treatment of hypoglycemia.

This article aims to document the growth in extracellular vesicle (EV) research. Here, we report the growth in EV-related studies, patents, and grants as well as emerging companies with major intent on exosomes. Four different databases were utilized for electronic searches of published literature: two general databases - Scopus/Elsevier and Web of Science (WoS), as well as two specialized US government databases - the USA Patent and Trademark Office and National Institutes of Health (NIH) of the Department of Health and Human Services. The applied combination of key words was carefully chosen to cover the most commonly used terms in titles of publications, patents and grants dealing with conceptual areas of EVs. Within the time frame from 1 January 2000 to 31 December 2016, limited to articles published in English, we identified output using search strategies based upon Scopus/Elsevier and WoS, patent filings and NIH Federal Reports of funded grants. Consistently, USA and UK universities are the most frequent among the top 15 affiliations/organizations of the authors of the identified records. There is clear evidence of upward streaming of EV-related publications. By documenting the growth of the EV field, we hope to encourage a roster of independent authorities skilled to provide peer review of manuscripts, evaluation of grant applications, support of foundation initiatives and corporate long-term planning. It is important to encourage EV research to further identify biomarkers in diseases and allow for the development of adequate diagnostic tools that could distinguish disease subpopulations and enable personalized treatment of patients. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The aims of the present study was to examine the associations between the severity of pain and anxiety in a community population reporting joint pain, and to investigate the management of joint pain in the presence of comorbid anxiety. Methods: A population survey was carried out of people aged ≥45 years, registered with eight general practices in Cheshire, Shropshire and Staffordshire, UK. Respondents were asked to report pain intensity in their hands, hips, knees and feet (on a numerical rating scale), anxiety symptoms (Generalized Anxiety Disorder seven‐item [GAD‐7] scale) and guideline‐recommended treatments used to manage pain. Clinical anxiety was defined by a GAD‐7 score of 10 or more. Results: A total of 11,222 respondents with joint pain were included in the analysis, with 1,802 (16.1%) reporting clinical anxiety. Respondents reporting more severe pain were more likely to report clinical anxiety (severe versus mild pain, odds ratio [OR] 5.36, 95% confidence interval [CI] 4.56 to 6.31). The number of pain sites was also positively associated with clinical anxiety (four versus one site; OR 3.64, 95% CI 3.09 to 4.30). Those with clinical anxiety were less likely to undertake general fitness exercises (OR 0.60, 95% CI 0.52 to 0.70), but more likely to diet (OR 1.43, 95% CI 1.21 to 1.69), use walking aids (OR 1.53, 95% CI 1.32 to 1.77) and assistive devices (OR 1.24, 95% CI 1.04 to 1.49), and more likely to use opioids (OR 1.34, 95% CI 1.18 to1.52). Conclusions: Anxiety is common among patients presenting to primary care with joint pain. Patients with anxiety are likely to manage their joint pain differently to those without. Case‐finding to identify and treat anxiety would be appropriate in this population, with caution about opioid prescribing and consideration of exercise as an intervention. [ABSTRACT FROM AUTHOR]

The aim of this study is to explore recreational ketamine users' experiences of ketamine bladder syndrome (KBS) and related health care provision issues. KBS is an emerging condition caused by chronic, recreational ketamine use, which can result in extensive, irreparable damage to the bladder and urinary tract. However, little is yet known about how patients are personally affected by the condition, their help seeking behaviour or experiences of related health care services. A qualitative study, informed by Heideggerian hermeneutics was undertaken. Twelve participants affected by KBS were purposively recruited into the study from an National Health Service (NHS) continence service and a drug support agency in South Wales, UK. Data were collected through recorded, semi‐structured interviews and analysed using a three‐step approach. Participants were predominantly younger, poly‐drug users and typically developed KBS following prolonged, habitual ketamine use. The effects of KBS were considerable and included incontinence, haematuria, profound abdominal pain and embarrassment and were exacerbated by delays in help seeking, disjointed medical care and on‐going ketamine use, which was integral to the self‐management of KBS pain. KBS has significant impact on those affected and can result in extensive, irreversible damage to the bladder and urinary tract. The condition, and its management, is further compounded by chronic poly‐drug use, chaotic lifestyles and a range of complex, related co‐morbidities, which require a collaborative, multi‐disciplinary approach. Anderson's behavioural model of health services use provides an appropriate framework for better understanding help seeking/avoidance behaviour in this cohort, which can help inform clinical practice. [ABSTRACT FROM AUTHOR]

Background: Cognitive behavioural therapy (CBT) is commonly used to treat cancer patients with psychological disorders such as depression. There has been little qualitative research exploring the experience of therapists delivering CBT to patients with advanced cancer and long‐term health conditions generally. Therapists' views may help identify difficulties in delivering therapy and how these may be overcome. The aim of this study was to inform practice by qualitatively exploring the experiences of therapists delivering CBT to patients with advanced cancer. Design: Sixteen semi‐structured interviews were conducted with therapists from Increasing Access to Psychological Therapy (IAPT) services in London, UK, who had delivered CBT to patients enrolled on the CanTalk trial. Interviews were recorded, transcribed, and analysed using framework analysis. Results: Therapists reported positive experiences when working with the target population. Flexibility, adaptability, and a consideration of individual needs were identified as important when delivering CBT, but the rigidity of IAPT policies and demand for services were perceived as problematic. Although therapists reported adequate training, specialist supervision was desired when delivering therapy to this complex population. Conclusion: IAPT therapists can deliver CBT to advanced cancer patients, given therapists positive experiences evident in the present study. However, it was concluded that additional service and modifications of therapy may be needed before positive outcomes for both therapists and patients can be achieved. [ABSTRACT FROM AUTHOR]

The systematic review and network meta‐analysis of the efficacy of 21 antidepressants by Andrea Cipriani and colleagues has been hailed as a major contribution to the body of evidence that supports the use of these drugs in managing major depressive disorder. This article summarises the review's findings and their implications for practice. [ABSTRACT FROM AUTHOR]

Abstract: Aims: To investigate whether smokers prescribed varenicline had lower risks of serious ill‐health during the 4 years following treatment compared with those prescribed nicotine replacement therapy (NRT). Design: Observational cohort study of electronic medical records. Setting: A total of 370 UK general practices sampled from the Clinical Practice Research Datalink. Participants: A total of 126 718 patients aged 18 and over who were issued smoking cessation prescriptions between 1 September 2006 and 31 March 2014. Measurements: Our primary outcome was all‐cause mortality within 2 years of first prescription as indicated by linked Office of National Statistics data. Our secondary outcomes were cause‐specific mortality, all‐cause, cause‐specific hospitalization, primary care diagnosis of myocardial infarction or chronic obstructive pulmonary disease (COPD), body mass index and attendance rate to primary care within 2 years of first prescription. Risk differences and 95% confidence intervals were estimated by multivariable adjusted regression and propensity score matched regression. We used instrumental variable analysis to overcome residual confounding. Findings: People prescribed varenicline were healthier at baseline than those prescribed NRT in almost all characteristics, highlighting the potential for residual confounding. Our instrumental variable analysis results found that people prescribed varenicline had a similar risk of mortality at 2 years [risk difference per 100 patients treated = 0.67, 95% confidence interval (CI) = ‐0.11 to 1.46)] to those prescribed NRT, and there were similar rates of all‐cause hospitalization, incident primary‐care diagnoses of myocardial infarction and COPD. People prescribed varenicline subsequently attended primary care less frequently. Conclusions: Smokers prescribed varenicline in primary care in the United Kingdom do not appear to be less likely to die, be hospitalized or experience a myocardial infarction or chronic obstructive pulmonary disease during the following 2 years compared with smokers prescribed nicotine replacement therapy, but they gain more weight and attend primary care less frequently. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Naloxone is an opioid antagonist used for emergency resuscitation following opioid overdose. Prisoners with a history of heroin use by injection have a high risk of drug-related death in the first weeks after prison-release. The N-ALIVE trial was planned as a large prison-based randomised controlled trial (RCT) to test the effectiveness of naloxone-on-release in the prevention of fatal opiate overdoses soon after release. The N-ALIVE pilot trial was conducted to test the main trial's assumptions on recruitment of prisons and prisoners, and the logistics for ensuring that participants received their N-ALIVE pack on release.Design and Methods: Adult prisoners who had ever injected heroin, were incarcerated for ≥7 days and were expected to be released within 3 months were eligible. Participants were randomised to receive, on liberation, a pack containing a single 'rescue' injection of naloxone or a control pack with no naloxone syringe. The trial was double-blind prior to prison-release.Results: We randomised 1685 prisoners (842 naloxone; 843 control) across 16 prisons in England. We stopped randomisation on 8 December 2014 because only one-third of administrations of naloxone-on-release were to the randomised ex-prisoner; two-thirds were to others whom we were not tracing.Discussion and Conclusions: Prevention RCTs are seldom conducted within prisons; we demonstrated the feasibility of conducting a multi-prison RCT to prevent fatality from opioid overdose in the outside community. We terminated the N-ALIVE trial due to the infeasibility of individualised randomisation to naloxone-on-release. Large RCTs are feasible within prisons. [ABSTRACT FROM AUTHOR]

Abstract: Background: This study is a qualitative analysis of clients’ experiences of a new avatar based counselling intervention, based on the ‘ProReal’ software ( www.proreal.world). The intervention was piloted in eight secondary schools in the UK in 2016. Aims: Twenty‐nine participants (53% of the full sample) were interviewed about their use of the software, experience of the intervention, process of change and views about its helpfulness. Materials and Methods: Interviews were semi‐structured and were analysed using thematic analysis. Results: The analysis shows that the intervention was potentially attractive to these clients, particularly those enthusiastic about digital software and clients who found visual communication helpful. The software provided additional opportunities for clients to communicate their inner worlds to the counsellor and supported the development of insight. Male clients, in particular, commented on its helpfulness. Discussion: There is an indication that digital imagery supported the process of change in counselling and the development of meaning bridges: both internally and with the counsellor (Stiles, 2011; Stiles et al., 1990). However, the software could be experienced as an obstacle when clients wanted to talk about specific problems or ‘vent’ their feelings. All clients who reported that they did not find the software helpful were female. There were a number of suggestions about developing the software to increase opportunities for expression as well as appropriateness for clients from different minority ethnic backgrounds. Conclusion: Use of digital software in counselling has a potential to enhance communication and support a process of change, particularly with male clients, those who find visual communication helpful, and clients enthusiastic about digital technology. Further research is needed to develop the intervention and compare it to the use of other creative media in counselling. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Counselling for Depression (CfD) is a person‐centred experiential therapy developed for implementation in the Improving Access to Psychological Therapies (IAPT) programme. Training in this model has been available across England since 2011. This study aims to investigate counselling practitioners’ experiences of learning the CfD model and implementing CfD in practice settings. Method: Participants were recruited by an email sent to the British Association for Counselling and Psychotherapy's (BACP) CfD Practice Research Network (PRN). Of the 53 CfD practitioners belonging to BACP's CfD PRN, 18 participated in this mixed‐methods piece of research. All 18 participants completed an online questionnaire, and one hour follow‐up semi‐structured interviews were conducted with six of the participants. Results: Descriptive analyses from the online questionnaire indicated a positive experience of CfD training, with practitioners indicating a positive impact on sense of self, practice and skill set. Although a degree of challenge was encountered when training in the CfD model, thematic analysis from the six semi‐structured interviews revealed factors contributing to the positives and challenges experienced on the course. Themes also revealed a predominately negative experience of CfD in practice and service settings, although this was service dependent. Conclusions and implications for practice: The findings can inform future recruitment of trainees to CfD training programmes and the training programme itself. They can also be used to achieve greater congruence between training in CfD and the delivery of the model. Future research may need to focus on the service level factors influencing practitioners’ experiences, and whether this experience is specific to the CfD modality in IAPT. [ABSTRACT FROM AUTHOR]

Abstract: Background: The speech intelligibility of children with dysarthria and cerebral palsy has been observed to increase following therapy focusing on respiration and phonation. Aims: To determine if speech intelligibility change following intervention is associated with change in acoustic measures of voice. Methods & Procedures: We recorded 16 young people with cerebral palsy and dysarthria (nine girls; mean age 14 years, SD = 2; nine spastic type, two dyskinetic, four mixed; one Worster–Drought) producing speech in two conditions (single words, connected speech) twice before and twice after therapy focusing on respiration, phonation and rate. In both single‐word and connected speech we measured vocal intensity (root mean square—RMS), period‐to‐period variability (Shimmer APQ, Jitter RAP and PPQ) and harmonics‐to‐noise ratio (HNR). In connected speech we also measured mean fundamental frequency, utterance duration in seconds and speech and articulation rate (syllables/s with and without pauses respectively). All acoustic measures were made using Praat. Intelligibility was calculated in previous research. Outcomes & Results: In single words statistically significant but very small reductions were observed in period‐to‐period variability following therapy: Shimmer APQ –0.15 (95% CI = –0.21 to –0.09); Jitter RAP –0.08 (95% CI = –0.14 to –0.01); Jitter PPQ –0.08 (95% CI = –0.15 to –0.01). No changes in period‐to‐period perturbation across phrases in connected speech were detected. However, changes in connected speech were observed in phrase length, rate and intensity. Following therapy, mean utterance duration increased by 1.11 s (95% CI = 0.37–1.86) when measured with pauses and by 1.13 s (95% CI = 0.40–1.85) when measured without pauses. Articulation rate increased by 0.07 syllables/s (95% CI = 0.02–0.13); speech rate increased by 0.06 syllables/s (95% CI = < 0.01–0.12); and intensity increased by 0.03 Pascals (95% CI = 0.02–0.04). There was a gradual reduction in mean fundamental frequency across all time points (–11.85 Hz, 95% CI = –19.84 to –3.86). Only increases in the intensity of single words (0.37 Pascals, 95% CI = 0.10–0.65) and reductions in fundamental frequency (–0.11 Hz, 95% CI = –0.21 to –0.02) in connected speech were associated with gains in intelligibility. Conclusions & Implications: Mean reductions in impairment in vocal function following therapy observed were small and most are unlikely to be clinically significant. Changes in vocal control did not explain improved intelligibility. [ABSTRACT FROM AUTHOR]

Background: Nintedanib has been shown to slow disease progression in patients with idiopathic pulmonary fibrosis (IPF). It was approved by the National Institute for Health and Care Excellence (NICE) in January 2016 for IPF patients with a forced vital capacity (FVC) of 50-80% in the United Kingdom (UK). Aim: To report real world data about our early clinical experience using nintedanib in 187 patients with a multi-disciplinary (MDT) diagnosis of IPF in a manufacturer funded patient in need scheme (three UK centres) prior to NICE approval. Methods: All patients with a MDT diagnosis of IPF from December 2014 to January 2016 commenced on nintedanib were included. Demographic details, adverse events (AEs) and where available lung function results were retrospectively collected from clinical letters. Results: 187 patients (76% males) with a median age of 72 years (49-89) were treated with nintedanib. The average pre-treatment FVC was 81.1 ± 19.8% and diffusion capacity of the lungs for carbon monoxide was 43.9 ± 15% (n = 82). Fifty percent of patients started nintedanib because they were ineligible for pirfenidone due to an FVC > 80%. The median treatment course was 8 ± 4 months. The majority of patients experienced 1-3 AEs with nintedanib (52%, n = 97). The most frequent AEs were diarrhoea (50%), nausea (36%), reduced appetite (24%), tiredness (20%) and gastro-oesophageal reflux (18%). The majority of AEs resulted in no change in treatment (64%, n = 461). 21% (n = 150) of AEs resulted in a dose reduction and 13% (n = 94) necessitated discontinuation of treatment. 1 in 5 patients discontinued treatment either temporarily or on a permanent basis during the monitoring period. In a select cohort of patients, a statistically significant greater proportion of patients remained stable or improved and a lower proportion declined, as depicted by FVC changes of > 5% after nintedanib commencement (P < 0.05 using Chi squared test). Conclusions: Nintedanib is well tolerated and has an acceptable safety profile. Only 8% of those reporting diarrhoea discontinued treatment either on a temporary or permanent basis. There were no signals with respect to increased cardiovascular morbidity or major bleeding risk. This is in keeping with the INPULSIS clinical trial findings but in a real world cohort. [ABSTRACT FROM AUTHOR]