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Background: Interventions promoting social activity may reduce behavioural psychological symptoms and improve quality of life in people living with dementia. This study aimed to identify social benefits for participants living with dementia in the context of Promoting Activity, Independence and Stability in Early Dementia (PrAISED), an exercise intervention programme promoting physical activity and independence in participants living with dementia in England. Methods: This was a multi-method realist evaluation undertaking secondary analysis of data collected during the PrAISED process evaluation, including qualitative interviews with participants with dementia, caregivers and therapists, personal notes of researchers, and video recordings of therapy sessions. The study consisted of four phases: (1) Setting operational definition of social outcomes in PrAISED; (2) Developing Context, Mechanisms, Outcome (CMO) configurations; (3) Testing and refining CMOs; and (4) Synthesising definitive CMOs into a middle range theory. Results: Two CMOs were identified. (1) When therapists were able to make therapy sessions engaging and had the caregivers' support, the participants experienced therapy sessions as an opportunity to achieve goals in areas they were interested in. They also found the sessions enjoyable. This all led to the participants being highly engaged in their social interactions with the therapists. (2) When the participants realised that they were gaining benefits and progress through the PrAISED intervention, such as increased balance, this boosted their confidence in physical ability. It might also reduce caregivers' risk-aversion/gatekeeping attitude, which in turn would lead to participants' increased participation in social activities. Conclusion: The PrAISED intervention supported social participation in participants living with dementia. Under certain circumstances, home-based therapy interventions can be beneficial for social health (regardless of physical health gains). Given the limitations of currently available outcome measures to assess social participation, qualitative methods should be used to explore social health outcomes. [ABSTRACT FROM AUTHOR]

Background: General practice has one of the most diverse medical training programmes in terms of sex and ethnic background. However, this diversity of race and ethnicity is not reflected in academic GP careers, with just 17% (n = 81/473) of academic GPs being from racially minoritised groups, according to the Medical Schools Council. Aim: To determine whether GP academic clinical fellow (ACF) trainees from racially minoritised backgrounds are proportionally represented, compared with the non-academic training programme, using the annual GP ACF conference as a proxy. Design & setting: A retrospective analysis of conference programmes from national academic GP training conferences from 2018–2023 and demographic data obtained from Health Education England (HEE). Method: Using conference programmes and online searches, demographic information on conference speakers was obtained and a freedom of information request was made to HEE for the demographics of GP ACFs for corresponding years. This was compared with demographic data of GP trainees and academics. Results: On average, there were 40 speakers each year at the conference. White females (average 20.2 speakers each year) were the most well represented group, followed by White males (average 12.5), Asian females (average 3.3), Asian males (average 1.8), Black males (average 0.7), and Black females (average 0.3). HEE data from 2022 revealed that 27 (71.1%) of the 38 (excluding five who did not state their ethnicity) ACFs were White British. Conclusion: GP academia should be more representative of the non-academic GP training scheme. Work needs to be done to understand and overcome the structural barriers to recruiting from racially minoritised groups. [ABSTRACT FROM AUTHOR]

Introduction: In 2021, the UK Royal College of Anaesthetists published an updated curriculum which outlines specific peripheral nerve blocks in which all anesthetists must achieve competency during their training. Little is known about which nerve blocks anesthetists in the UK can perform, nor which techniques they use to perform them. Methods: We conducted a survey of anesthetists in North West England to discover their experience in anesthesia, which nerve blocks they can perform, and which techniques they use to perform them. Results: Overall, 195 responses were received. Seventy‐nine respondents (44%) preferred to perform nerve blocks on anesthetized patients, 70 (40%) preferred to perform nerve blocks with the patient awake with no sedation. One hundred and thirty‐seven (85%) respondents used ultrasound only to localize nerves when performing a block. Among consultant respondents, 21 (19%) were unable to perform any upper limb block, and 48 (44%) were unable to perform any block of the thorax, both are a required competency of trainees under the 2021 curriculum. Discussion: Trainees may struggle to achieve the required competencies of the new curriculum given many consultants are also unable to perform them. A structured placement in regional anesthetic training in each stage of training could help improve the acquisition of skills and knowledge among trainees. Further studies are needed to assess the ability of anesthetists nationwide in regional anesthesia. [ABSTRACT FROM AUTHOR]

Introduction: Women are on average diagnosed with diabetes mellitus at later age than men but have higher mortality. As the diagnosis of diabetes mellitus is primarily based on HbA1c, the use of a non-specific reference range and cut point for diabetes mellitus that does not account for gender differences in diabetes could potentially lead to underdiagnosis of diabetes mellitus in women and missed opportunities for intervention. We investigated whether a contributing factor to the later diagnosis in women may be a difference in distribution of HbA1c in premenopausal women versus men of the same age by comparing HbA1c values in men and women across multiple sites in the UK. Methods: We analysed the HbA1c levels of 146,907 individuals who underwent single testing only and had HbA1c ≤ 50 mmol/mol between 2012 and 2019 in one laboratory (cohort 1). This was replicated in six laboratories with 938,678 individuals tested between 2019 and 2021 (cohort 2). Results: In cohort 1, women < 50 years old had an HbA1c distribution markedly lower than that in men by a mean of 1.6 mmol/mol (p < 0.0001), while the difference in the distribution of HbA1c for individuals aged ≥ 50 years was less pronounced (mean difference 0.9 mmol/mol, p < 0.0001). For individuals under the age of 50, HbA1c in women lagged by up to 10 years compared to men. Similar findings were found in cohort 2. We estimated an additional 17% (n = 34,953) of undiagnosed women aged < 50 years in England and Wales could be reclassified to have diabetes mellitus, which may contribute to up to 64% of the difference in mortality rates between men/women with diabetes mellitus aged 16–50 years. Conclusion: The HbA1c cut point for diagnosis of diabetes mellitus may need to be re-evaluated in women under the age of 50 years. Early identification of diabetes mellitus in women has the potential to improve women's health outcomes in the longer term. [ABSTRACT FROM AUTHOR]

Background: Older housebound people are an under-researched group for whom achieving good primary health care can be resource intensive. Aims: To describe the characteristics and healthcare use of older (≥65 years) housebound people; explore clinician views on delivery of care to housebound people; and assess the feasibility of using a new network of healthcare professionals to deliver high quality research. Design & setting: Retrospective observational study of electronic GP records and clinician survey in England. Method: Clinical members of a new UK research network called the Primary care Academic CollaboraTive (PACT) will collect the data. For part A, around 20 GP practices will be recruited and clinicians will identify 20 housebound and 20 non-housebound people, matched by age and gender (around 400 total in each group). Anonymised data will be collected on characteristics (age, gender, ethnicity, deprivation decile), long-term conditions, prescribed medicines, quality of healthcare (via Quality Outcomes Framework targets), and continuity of care. Reports with benchmarked practice-level data will be provided to practices to identify areas for quality improvement and to enhance engagement. For part B, 2-4 clinicians will be recruited from around 50 practices in England (̴150 clinicians) to complete a survey about delivery of healthcare for housebound people. For part C, data will be collected to assess the feasibility of using the PACT network to deliver primary care research. Conclusion: Older housebound people are a neglected group both in terms of research and clinical care. Understanding the characteristics and use of primary healthcare of housebound people will help identify how to improve their care. [ABSTRACT FROM AUTHOR]

Introduction: Head and neck cancer (HNC) is the eighth most common cancer in the United Kingdom. Survival rates improve when the cancer is diagnosed at an early stage, highlighting a key need to identify at‐risk patients. This study aimed to explore opportunistic HNC identification and referral by community pharmacists (CPs) using a symptom‐based risk assessment calculator, from the perspective of patients with a diagnosis of HNC. Methods: Purposive sampling was used to recruit patients from the HNC pathway in three large teaching hospitals in Northern England. Qualitative methodology was used to collect data through an iterative series of semistructured telephone interviews. Framework analysis was utilised to identify key themes. Results: Four main themes were constructed through the analytic process: (1) HNC presentation and seeking help; (2) the role of the CP; (3) public perception of HNC and (4) the role of a symptom‐based risk calculator. Participants agreed that CPs could play a role in the identification and referral of suspected HNCs, but there were concerns about access as patients frequently only encounter the medicine counter assistant when they visit the pharmacy. HNC symptoms are frequently attributed to common or minor conditions initially and therefore considered not urgent, leading to delays in seeking help. While there is public promotion for some cancers, there is little known about HNC. Early presentation of HNC can be quite variable, therefore raising awareness would help. The use of a symptom‐based risk calculator was considered beneficial if it enabled earlier referral and diagnosis. Participants suggested that it would also be useful if the public were made aware of it and could self‐assess their symptoms. Conclusion: In principle, CPs could play a role in the identification and referral of HNC, but there was uncertainty as to how the intervention would work. Future research is needed to develop an intervention that would facilitate earlier identification and referral of HNC while not disrupting CP work and that would promote HNC and the risk calculator more widely. Patient or Public Contribution: Patient and public involvement and engagement (PPIE) was integrated throughout the project. Initially, the proposal was discussed during a Cancer Head and Neck Group Experience (CHANGE) PPIE meeting. CHANGE was set up to support HNC research in 2018. The group is composed of seven members (four female, three male) with an age range of 50–71 years, who were diagnosed at Sunderland Royal Hospital. A patient representative from the University of Sunderland PPIE group and a trustee of the Northern HNC Charity were recruited as co‐applicants. They attended project management group meetings and reviewed patient‐facing documentation. [ABSTRACT FROM AUTHOR]

Pharmacists have a contribution to make in improving optimising medication use for people on antipsychotic medication. The rates of prescribing antipsychotics have increased in England with an 18% rise from 2015 to 2020. People on antipsychotic medication are not treated as equal partners in conversations about their medications. This can leave people to make decisions about their antipsychotic medications without input from their prescribers which can have significant consequences for individuals. Involving people in the decision-making process, as experts on their own condition, has the potential to improve treatment outcomes. The evidence suggests that involving pharmacists in supporting people with serious mental illnesses will lead to improved clinical outcomes. Key areas for pharmacist involvement are providing information, education and counselling on antipsychotic medication and the side effects and reducing polypharmacy especially when antipsychotics are prescribed off license. [ABSTRACT FROM AUTHOR]

Introduction: Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. Methods: In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. Results: In April 2020, monthly requests dropped to 7.9–18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7–86.9% of 2019 levels. During April–June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4–63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April–June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April–June 2020; trend test p < 0.001) and two subsequent periods (July–September and October–December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. Conclusion: Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59–86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality. [ABSTRACT FROM AUTHOR]

Background: The Promoting Activity, Independence and Stability in Early Dementia (PrAISED) intervention is a programme of physical activity and exercise designed to maintain participation in activities of daily living, mobility, and quality of life for people living with dementia. During the COVID-19 pandemic first national lockdown in England, the PrAISED physiotherapists, occupational therapists, and rehabilitation support workers adapted to delivering the intervention remotely via telephone or video conferencing. Objective: The aim of this study was to explore therapists' experience of delivering the PrAISED intervention during the COVID-19 pandemic and derive implications for clinical practice. Methods: Qualitative semi-structured interviews were conducted with 16 therapists using purposive sampling. Thematic analysis was used to analyze the transcripts. Results: Therapists reported a change in the relationship between themselves, the person with dementia and the caregiver, with an increased reliance on the caregiver and a loss of autonomy for the person living with dementia. There was concern that this would increase the burden on the caregiver. The therapists reported using creativity to adapt to different modes of delivery. They felt their sessions were mostly focused on providing social and emotional support, and that assessing, progressing, and tailoring the intervention was difficult. Conclusion: It is possible to deliver some elements of a physical intervention using remote delivery, but a dual modal approach including remote and face-to-face delivery would optimize treatment efficacy. Educational support would be required to enable people living with dementia and their caregivers to overcome barriers relating to digital literacy. [ABSTRACT FROM AUTHOR]

Previous research has demonstrated a graded relationship between the number of Adverse Childhood Experiences reported (an ACE score) and child outcomes. However, ACE scores lack specificity and ignore the patterning of adversities, which are informative for interventions. The aim of the present study was to explore the clustering of ACEs and whether this clustering differs by gender or is predicted by poverty. Data on 8,572 participants of the Avon Longitudinal Study of Parents and Children (ALSPAC) were used. ALSPAC is a regionally representative prenatal cohort of children born between 1991 and 1992 in the Avon region of South-West England. ACEs included parental divorce, death of a close family member, interparental violence, parental mental health problems, parental alcohol misuse, parental drug use, parental convictions, and sexual, emotional, and physical abuse, between birth and 19 years. Latent class analysis was used to derive ACE clusters and associations between poverty, gender, and the derived classes tested using multinomial logistic regression. Five latent classes were identified: "Low ACEs" (55%), "Parental separation and mother's mental health problems" (18%), "Parental mental health problems, convictions and separation" (15%), "Abuse and mental health problems" (6%), and "Poly adversity" (6%). Death of a close family member and sexual abuse did not cluster with other adversities. The clustering did not differ by gender. Poverty was strongly related to both individual ACEs and clusters. These findings demonstrate that ACEs cluster in specific patterns and that poverty is strongly related to this. Therefore, reducing child poverty might be one strategy for reducing ACEs. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Chief Medical Officer for England recommending that young people remaining alcohol free until 18 years of age. Topics include highest levels of drinking among adolescents and the North East England being one of the highest levels of adolescent alcohol consumption in the UK; and exploring the relationship between alcohol use during adolescence and negative consequences in adulthood.

Low-carbon hydrogen can assist in addressing the global crisis of climate change by significantly decarbonizing a range of heavy-emitting sectors. In the United Kingdom, hydrogen technologies are at the forefront of the net zero-emission roadmaps of many industrial clusters. However, with impending timeframes linked to emission targets and other decarbonization objectives, it is increasingly important to understand how to accelerate such transitions to hydrogen. There is, to date, a notable gap in the academic literature concerning the acceleration of sustainability transitions. Using the case of the hydrogen agenda in England's North West region, we explore how the transition to hydrogen can be accelerated and thus begin to contribute toward filling this omission. In doing so, we use data collected through semi-structured interviews and from the public domain to unpack and develop upon an existing framework that emerged from the European Commission funded-project Accelerating and Rescaling Transitions to Sustainability (ARTS). The framework comprises five acceleration mechanisms which local sustainability transition initiatives have adopted. This analysis generates novel findings in relation to why actors in the region have faced difficulties in instrumentalizing as well as the mechanism's overall importance in acceleration. We use these challenges to inform several recommendations which policy makers could adopt to accelerate the North West's, and wider UK's, transition to hydrogen. [ABSTRACT FROM AUTHOR]

This Arts and Medicine feature reviews journalist Polly Morland's A Fortunate Woman, a 2022 follow-up to John Berger's classic 1967 A Fortunate Man, detailing changes over 50 years in the rewards and challenges of primary care practice in small-town rural general practice in northern England. [ABSTRACT FROM AUTHOR]

Background: The prevalence of obesity has increased in the United Kingdom, and reliably measuring the impact on quality of life and the total healthcare cost from obesity is key to informing the cost-effectiveness of interventions that target obesity, and determining healthcare funding. Current methods for estimating cost-effectiveness of interventions for obesity may be subject to confounding and reverse causation. The aim of this study is to apply a new approach using mendelian randomisation for estimating the cost-effectiveness of interventions that target body mass index (BMI), which may be less affected by confounding and reverse causation than previous approaches.Methods and Findings: We estimated health-related quality-adjusted life years (QALYs) and both primary and secondary healthcare costs for 310,913 men and women of white British ancestry aged between 39 and 72 years in UK Biobank between recruitment (2006 to 2010) and 31 March 2017. We then estimated the causal effect of differences in BMI on QALYs and total healthcare costs using mendelian randomisation. For this, we used instrumental variable regression with a polygenic risk score (PRS) for BMI, derived using a genome-wide association study (GWAS) of BMI, with age, sex, recruitment centre, and 40 genetic principal components as covariables to estimate the effect of a unit increase in BMI on QALYs and total healthcare costs. Finally, we used simulations to estimate the likely effect on BMI of policy relevant interventions for BMI, then used the mendelian randomisation estimates to estimate the cost-effectiveness of these interventions. A unit increase in BMI decreased QALYs by 0.65% of a QALY (95% confidence interval [CI]: 0.49% to 0.81%) per year and increased annual total healthcare costs by £42.23 (95% CI: £32.95 to £51.51) per person. When considering only health conditions usually considered in previous cost-effectiveness modelling studies (cancer, cardiovascular disease, cerebrovascular disease, and type 2 diabetes), we estimated that a unit increase in BMI decreased QALYs by only 0.16% of a QALY (95% CI: 0.10% to 0.22%) per year. We estimated that both laparoscopic bariatric surgery among individuals with BMI greater than 35 kg/m2, and restricting volume promotions for high fat, salt, and sugar products, would increase QALYs and decrease total healthcare costs, with net monetary benefits (at £20,000 per QALY) of £13,936 (95% CI: £8,112 to £20,658) per person over 20 years, and £546 million (95% CI: £435 million to £671 million) in total per year, respectively. The main limitations of this approach are that mendelian randomisation relies on assumptions that cannot be proven, including the absence of directional pleiotropy, and that genotypes are independent of confounders.Conclusions: Mendelian randomisation can be used to estimate the impact of interventions on quality of life and healthcare costs. We observed that the effect of increasing BMI on health-related quality of life is much larger when accounting for 240 chronic health conditions, compared with only a limited selection. This means that previous cost-effectiveness studies have likely underestimated the effect of BMI on quality of life and, therefore, the potential cost-effectiveness of interventions to reduce BMI. [ABSTRACT FROM AUTHOR]

Insufficient young doctors choose careers in general practice – this may relate to cultural, personal and educational influences during medical school. University of East Anglia (UEA) medical school historically produces more GPs than most but no previous studies have aimed to quantify factors which may be leading to this. This study's aim was to improve understanding of the attitudes of students towards general practice (GP) at UEA. A questionnaire study compared views of three different years of students. GP was the most popular choice for male and female students, with women expressing higher levels of commitment. Students saw GP as intellectually stimulating and making key contributions to the NHS. The main reason for the choice of GP was interest in the speciality, with positive influences attributed to contact with GPs and general practice as a setting during their course. These results suggest course design and presence of GP faculty in core teaching have crucial influences on career choices. GP can be a popular career choice, but the perceptions which lead to that choice are course-and experience – dependent. Reforms towards community-based learning and the involvement of GPs in training are crucial levers for change if workforce needs are to be achieved. [ABSTRACT FROM AUTHOR]

Background: Experiencing multiple adverse childhood experiences (ACEs) is a risk factor for many adverse outcomes. We explore associations of ACEs with educational attainment and adolescent health and the role of family and socioeconomic factors in these associations.Methods and Findings: Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective cohort of children born in southwest England in 1991-1992, we assess associations of ACEs between birth and 16 years (sexual, physical, or emotional abuse; emotional neglect; parental substance abuse; parental mental illness or suicide attempt; violence between parents; parental separation; bullying; and parental criminal conviction, with data collected on multiple occasions between birth and age 16) with educational attainment at 16 years (n = 9,959) and health at age 17 years (depression, obesity, harmful alcohol use, smoking, and illicit drug use; n = 4,917). We explore the extent to which associations are robust to adjustment for family and socioeconomic factors (home ownership, mother and partner's highest educational qualification, household social class, parity, child's ethnicity, mother's age, mother's marital status, mother's depression score at 18 and 32 weeks gestation, and mother's partner's depression score at 18 weeks gestation) and whether associations differ according to socioeconomic factors, and we estimate the proportion of adverse educational and health outcomes attributable to ACEs or family or socioeconomic measures. Among the 9,959 participants (49.5% female) included in analysis of educational outcomes, 84% reported at least one ACE, 24% reported 4 or more ACEs, and 54.5% received 5 or more General Certificates of Secondary Education (GCSEs) at grade C or above, including English and Maths. Among the 4,917 participants (50.1% female) included in analysis of health outcomes, 7.3% were obese, 8.7% had depression, 19.5% reported smoking, 16.1% reported drug use, and 10.9% reported harmful alcohol use. There were associations of ACEs with lower educational attainment and higher risk of depression, drug use, and smoking. For example, odds ratios (ORs) for 4+ ACEs compared with no ACEs after adjustment for confounders were depression, 2.4 (1.6-3.8, p < 0.001); drug use, 3.1 (2.1-4.4, p < 0.001); and smoking, 2.3 (1.7-3.1, p < 0.001). Associations with educational attainment attenuated after adjustment but remained strong; for example, the OR after adjustment for confounders for low educational attainment comparing 4+ ACEs with no ACEs was 2.0 (1.7-2.4, p < 0.001). Associations with depression, drug use, and smoking were not altered by adjustment. Associations of ACEs with harmful alcohol use and obesity were weak. For example, ORs for 4+ ACEs compared with no ACEs after adjustment for confounders were harmful alcohol use, 1.4 (0.9-2.0, p = 0.10) and obesity, 1.4 (0.9-2.2, p = 0.13) We found no evidence that socioeconomic factors modified the associations of ACEs with educational or health outcomes. Population attributable fractions (PAFs) for the adverse educational and health outcomes range from 5%-15% for 4+ ACEs and 1%-19% for low maternal education. Using data from multiple questionnaires across a long period of time enabled us to capture a detailed picture of the cohort members' experience of ACEs; however, a limitation of our study is that this resulted in a high proportion of missing data, and our analyses assume data are missing at random.Conclusions: This study demonstrates associations between ACEs and lower educational attainment and higher risks of depression, drug use, and smoking that remain after adjustment for family and socioeconomic factors. The low PAFs for both ACEs and socioeconomic factors imply that interventions that focus solely on ACEs or solely on socioeconomic deprivation, whilst beneficial, would miss most cases of adverse educational and health outcomes. This interpretation suggests that intervention strategies should target a wide range of relevant factors, including ACEs, socioeconomic deprivation, parental substance use, and mental health. [ABSTRACT FROM AUTHOR]

Background: Patient and public involvement (PPI) is a requirement for UK health and social care research funding. Evidence for how best to implement PPI in research programmes, such as National Institute for Health Research (NIHR) Collaborations for Applied Health Research and Care (CLAHRCs), remains limited. This paper reports findings from an action research (AR) project called IMPRESS, which aims to strengthen PPI within CLAHRC East of England (EoE). IMPRESS combines AR with Normalisation Process Theory (NPT) to explore PPI within diverse case study projects, identifying actions to implement, test and refine to further embed PPI. Methods: We purposively selected CLAHRC EoE case study projects for in-depth analysis of PPI using NPT. Data were generated from project PPI documentation, semi-structured qualitative interviews with researchers and PPI contributors and focus groups. Transcripts and documents were subjected to abductive thematic analysis and triangulation within case. Systematic across case comparison of themes was undertaken with findings and implications refined through stakeholder consultation. Results: We interviewed 24 researchers and 13 PPI contributors and analysed 28 documents from 10 case studies. Three focus groups were held: two with researchers (n = 4 and n = 6) and one with PPI contributors (n = 5). Findings detail to what extent projects made sense of PPI, bought in to PPI, operationalised PPI and appraised it, thus identifying barriers and enablers to fully embedded PPI. Conclusion: Combining NPT with AR allows us to assess the embeddedness of PPI within projects and programme, to inform specific local action and report broader conceptual lessons for PPI knowledge and practice informing the development of an action framework for embedding PPI in research programmes. To embed PPI within similar programmes teams, professionals, disciplines and institutions should be recognised as variably networked into existing PPI support. Further focus and research is needed on sharing PPI learning and supporting innovation in PPI. [ABSTRACT FROM AUTHOR]

Objectives To explore how embedded patient and public involvement is within mainstream health research following two decades of policy-driven work to underpin health research with patient and public involvement in England. Methods Realist evaluation using Normalization Process Theory as a programme theory to understand what enabled patient and public involvement to be embedded as normal practice. Data were collected through a national scoping and survey, and qualitative methods to track patient and public involvement processes and impact over time within 22 nationally funded research projects. Results In research studies that were able to create reciprocal working relationships and to embed patient and public involvement this was contingent on: the purpose of patient and public involvement being clear; public contributors reflecting research end-beneficiaries; researchers understanding the value of patient and public involvement; patient and public involvement opportunities being provided throughout the research and ongoing evaluation of patient and public involvement. Key contested areas included: whether to measure patient and public involvement impact; seeking public contributors to maintain a balance between being research-aware and an outsider standpoint seen as ‘authentically’ lay; scaling-up patient and public involvement embedded within a research infrastructure rather than risk token presence and whether patient and public involvement can have a place within basic science. Conclusions While patient and public involvement can be well-integrated within all types of research, policy makers should take account of tensions that must be navigated in balancing moral and methodological imperatives. [ABSTRACT FROM AUTHOR]

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Background: Body mass index (BMI) rebound refers to the beginning of the second rise in BMI during childhood. Accurate estimation of an individual's timing of BMI rebound is important because it is associated with health outcomes in later life.Methods: We estimated BMI trajectories for 6545 children from the Avon Longitudinal Study of Parents and Children. We used a novel Bayesian two-phase piecewise linear mixed model where the "change point" was an individual-level random effect corresponding to the individual-specific timing of BMI rebound. The model's individual-level random effects (intercept, prechange slope, postchange slope, change point) were multivariate normally distributed with an unstructured variance-covariance matrix, thereby, allowing for correlation between all random effects.Results: Average age at BMI rebound (mean change point) was 6.5 (95% credible interval: 6.4 to 6.6) years. The standard deviation of the individual-specific timing of BMI rebound (random effects) was 2.0 years for females and 1.6 years for males. Correlation between the prechange slope and change point was 0.57, suggesting that faster rates of decline in BMI prior to rebound were associated with rebound occurring at an earlier age. Simulations showed that estimates from the model were less biased than those from models, assuming a common change point for all individuals or a nonlinear trajectory based on fractional polynomials.Conclusions: Our model flexibly estimated the individual-specific timing of BMI rebound, while retaining parameters that are meaningful and easy to interpret. It is applicable in any situation where one wishes to estimate a change-point process which varies between individuals. [ABSTRACT FROM AUTHOR]

Background: Cerebral small vessel disease is a common cause of vascular cognitive impairment in older people, with no licensed treatment. Cerebral blood flow is reduced in small vessel disease. Tadalafil is a widely prescribed phosphodiesterase-5 inhibitor that increases blood flow in other vascular territories. The aim of this trial is to test the hypothesis that tadalafil increases cerebral blood flow in older people with small vessel disease.Methods/design: Perfusion by Arterial Spin labelling following Single dose Tadalafil In Small vessel disease (PASTIS) is a phase II randomised double-blind crossover trial. In two visits, 7-30 days apart, participants undergo arterial spin labelling to measure cerebral blood flow and a battery of cognitive tests, pre- and post-dosing with oral tadalafil (20 mg) or placebo.Sample Size: 54 participants are required to detect a 15% increase in cerebral blood flow in subcortical white matter (p < 0.05, 90% power). Primary outcomes are cerebral blood flow in subcortical white matter and deep grey nuclei. Secondary outcomes are cortical grey matter cerebral blood flow and performance on cognitive tests (reaction time, information processing speed, digit span forwards and backwards, semantic fluency).Discussion: Recruitment started on 4th September 2015 and 36 participants have completed to date (19th April 2017). No serious adverse events have occurred. All participants have been recruited from one centre, St George's University Hospitals NHS Foundation Trust.Trial Registration: European Union Clinical Trials Register: EudraCT number 2015-001235-20 . Registered on 13 May 2015. [ABSTRACT FROM AUTHOR]

In recent years, society has witnessed a proliferation of digital technologies facilitate new ways to monitor young people's health. This paper explores a group of English adolescent girls' understandings of 'health' promoted by health and fitness related technologies. Five focus group meetings with the same 8 girls, aged between 14 and 17, were conducted to explore their experiences of using health and fitness apps. The girls' understandings of the digitised body are examined through a Foucauldian lens, with particular attention to conceptualisations of bio-power and technologies of the self. The data reveal how the girls negotiated, and at times critiqued, the multiple health discourses that are manifest through digital health technologies and performative health culture. The results emphasise that individual-based applications (apps) remove the social and interactive elements of physical activity valued by the girls. This research highlights the possibilities digital technologies provide for health promotion, yet also illuminates the limitations of these technologies if used uncritically and inappropriately. [ABSTRACT FROM AUTHOR]

Aim To investigate whether an antenatal surveillance protocol including ultrasound and cardiotocograph monitoring reduces intrauterine death (IUD) in cases of gastroschisis. Secondary outcomes included neonatal death rate, mode of delivery and rate of intervention before planned time of delivery. Methods This was a retrospective observational study of all women with antenatally diagnosed gastroschisis who were managed according to the surveillance program between 2002 and 2015 in a tertiary fetal medicine and pediatric surgical center covering the Wessex region of England. We reviewed and analyzed data from the Wessex Antenatally Detected Anomalies (WANDA) database as well as prospectively managed maternity, ultrasound and neonatal databases over the given time period. Case notes were reviewed when delivery was expedited. Results The IUD rate was 2.2%, a 58% reduction since the introduction of the surveillance protocol. Delivery was expedited in 35.4% of cases, and in 86% of these, delivery was by cesarean section. In women being induced as planned at 38 weeks, the vaginal delivery rate was 88%, and for those in spontaneous labor before 38 weeks it was 75%. Conclusions An antenatal surveillance program appears to reduce the IUD in gastroschisis. In one-third of cases, delivery was indicated before the planned date of delivery. When expedited delivery was indicated, the chance of cesarean section was high. [ABSTRACT FROM AUTHOR]

People living with HIV are surviving longer on successful antiretroviral therapy and obesity rates are increasing. We sought to determine the prevalence of being overweight or obese in a regional population of people living with HIV and to explore the demographic and clinical characteristics associated with obesity or being overweight. Data on patients attending three Northeast England clinics were collected including body mass index and demographics. The prevalence of being overweight (body mass index ≥ 25 kg/m2) or obese (body mass index ≥ 30 kg/m2) was determined and compared with regional population data. Associations between being overweight or obese and demographic and other data were further explored using logistic regression models. In 560 patients studied (median age 45 years, 26% Black-African and 69% male), 65% were overweight/obese and 26% obese, which is similar to the local population. However, 83% and 48% of Black-African women were overweight/obese or obese, respectively, with 11% being morbidly obese (body mass index > 40 kg/m2). In the multivariate analyses, the only factors significantly associated with obesity were Black-African race (adjusted odds ratio 2.78, 95% confidence interval 1.60-4.85) and type 2 diabetes (adjusted odds ratio 4.23, 95% confidence interval 1.81-9.91). Levels of obesity and overweight in people living with HIV are now comparable to the levels in the local population of Northeast England; however, the prevalence is significantly higher in Black-African women. Given the additional risk factors for cardiovascular disease inherent in people living with HIV, better strategies to prevent, identify and manage obesity in this population are needed. [ABSTRACT FROM AUTHOR]

This research aimed to measure Special Educational Needs Co-ordinators' knowledge of the educational implications of acquired brain injury in children and young people and whether experience of working with pupils with a brain injury or additional training impacts upon this knowledge. Data was collected within one local authority in England using an online survey. The results indicated that the respondents had high levels of uncertainty regarding the impact of a brain injury although they were more confident in those areas which related most closely to their practice. The responses suggested that experience of working with a pupil with a brain injury promoted greater knowledge than receiving training; the results, however, showed that only a minority of SENCos had received any training and those who had tended to have undertaken this independently. This suggests that there is a need for SENCos to be provided with specialist training in order to increase their understanding of the impact of acquired brain injury in children and young people. [ABSTRACT FROM AUTHOR]

Background: This 7 year NIHR programme [2011-2018] tests the primary hypothesis that the NDPS diet and physical activity intervention will reduce the risk of transition to type 2 diabetes (T2DM) in groups at high risk of Type 2 diabetes. The NDPS programme recognizes the need to reduce intervention costs through group delivery and the use of lay mentors with T2DM, the realities of normal primary care, and the complexity of the current glycaemic categorisation of T2DM risk.Methods: NDPS identifies people at highest risk of T2DM on the databases of 135 general practices in the East of England for further screening with ab fasting plasma glucose and glycosylated haemoglobin [HbA1c]. Those with an elevated fasting plasma glucose [impaired fasting glucose or IFG] with or without an elevated HbA1c [non -diabetic hyperglycaemia; NDH] are randomised into three treatment arms: a control arm receiving no trial intervention, an arm receiving an intensive bespoke group-based diet and physical activity intervention, and an arm receiving the same intervention with enhanced support from people with T2DM trained as diabetes prevention mentors [DPM]. The primary end point is cumulative transition rates to T2DM between the two intervention groups, and between each intervention group and the control group at 46 months. Participants with screen detected T2DM are randomized into an equivalent prospective controlled trial with the same intervention and control arms with glycaemic control [HbA1c] at 46 months as the primary end point. Participants with NDH and a normal fasting plasma glucose are randomised into an equivalent prospective controlled intervention trial with follow up for 40 months. The intervention comprises six education sessions for the first 12 weeks and then up to 15 maintenance sessions until intervention end, all delivered in groups, with additional support from a DPM in one treatment arm.Discussion: The NDPS programme reports in 2018 and will provide trial outcome data for a group delivered diabetes prevention intervention, supported by lay mentors with T2DM, with intervention in multiple at risk glycaemic categories, and that takes into account the realities of normal clinical practice.Trial Registration: ISRCTN34805606 (Retrospectively registered 16.3.16). [ABSTRACT FROM AUTHOR]

Similar to other professional disciplines, the importance of supervision within school psychology has attracted considerable attention within recent years. Despite this, systematic review of current literature reveals a dearth of empirical literature proposing underlying theoretical structures. This study extends recent qualitative research by surveying 310 school psychology students undertaking a preparatory doctoral training programme within the 12 approved universities in England and Wales. Data were obtained from a 21-item closed questionnaire developed from previous empirical findings and subjected to Exploratory Factor Analysis. Findings reveal three key supervisory components: Safe space for authentic learning, instructional support, and reference points for professional learning. Comparisons with other theoretical models are made and implications for practice explored. A framework for professional practice, based on key findings and other important theoretical developments, is proposed. [ABSTRACT FROM AUTHOR]

Background: There is a socioeconomic gradient in the uptake of screening in the English NHS Bowel Cancer Screening Programme (BCSP), potentially leading to inequalities in outcomes. We tested whether endorsement of bowel cancer screening by an individual's general practice (GP endorsement; GPE) reduced this gradient.Methods: A cluster-randomised controlled trial. Over 20 days, individuals eligible for screening in England from 6480 participating general practices were randomly allocated to receive a GP-endorsed or the standard invitation letter. The primary outcome was the proportion of people adequately screened and its variation by quintile of Index of Multiple Deprivation.Results: We enrolled 265,434 individuals. Uptake was 58.2% in the intervention arm and 57.5% in the control arm. After adjusting for age, sex, hub and screening episode, GPE increased the overall odds of uptake (OR=1.07, 95% CI 1.04-1.10), but did not affect its socioeconomic gradient. We estimated that implementing GPE could result in up to 165 more people with high or intermediate risk colorectal adenomas and 61 cancers detected, and a small one-off cost to modify the standard invitation (£78,000).Conclusions: Although GPE did not improve its socioeconomic gradient, it offers a low-cost approach to enhancing overall screening uptake within the NHS BCSP. [ABSTRACT FROM AUTHOR]

The transition from training to qualified practice is inherently challenging. Structured support following training was once available, but this no longer exists and the current climate of primary care places increasing demands on GPs. Professional learning, and the transition to independent practice, may thus be problematic. Aim To explore newly qualified GPs' experiences of professional learning following transition into qualified practice. Qualitative study using semi-structured interviews and a focus group, conducted between December 2010 and April 2011. Participants were GPs within five years of qualification, working in the East of England. Method Interviews were conducted with nine participants. These were followed by a focus group with four additional participants. Data collection, transcription and analysis were simultaneous, allowing iterative evolution of the topic guide to test emerging themes. New GPs wished to relinquish 'dependency' and become self-directed learners, yet still wanted guidance when needed. They described a situated experience of learning, in which inclusion in a practice community afforded greater learning opportunities. Social interactions also affected the issue of constructing an independent professional identity; a transitional process through which new GPs could become self-aware 'experts' with confidence in self-directed learning. Conclusion Potential harms of the transitional period may be mitigated by support, which needs to emphasise inclusion, validation, affirmation and the provision of feedback. Preferences for adult learning should be encouraged, but guidance needs to be available when requested. Recent proposals for enhanced GP training introduce an opportunity for a focus on independent practice during training. [ABSTRACT FROM AUTHOR]

For over 300 years, criminal courts have regarded sexual infidelity as sufficiently grave provocation as to provide a warrant, indeed a 'moral warrant', for reducing murder to manslaughter. While the warrant has spilled over into diminished responsibility defences, wounding, grievous bodily harm and attempted murder cases, it is provocation cases that have provided the precedents enshrining a defendant's impassioned homicidal sexual infidelity tale as excusatory. Periodically, judges and law reformers attempt to reign in provocation defences, most recently in England and Wales where provocation has been replaced by a loss of control defence that, most controversially, specifically excludes sexual infidelity as a trigger for loss of control. This paper reflects on this reform and its reception, glossing Shakespeare's scathing critique of warrants for murder in Titus Andronicus. [ABSTRACT FROM AUTHOR]

Background Socioeconomic inequalities are a key policy challenge. Studies to date have not taken a unified approach to assess how socioeconomic inequalities in health, behaviour and educationalattainment change as children age. Methods We examined maternal education inequalities in multiple offspring health, behavioural and educational outcomes and how these changed across childhood and adolescence in the Avon Longitudinal Study of Parents and Children, a cohort born in 1991/1992 in South-West England (N=5560–11 463). Results Inequalities were observed for some health measures (blood pressure (BP), height, cholesterol, bone mineral density (BMD) and fat-mass (females)) but not in other measures ( parent-assessed child health, triglycerides, fat-mass (males), high-density lipoproteincholesterol, C reactive protein). The strongest health inequality was systolic BP (mean difference comparing highest to lowest maternal education −0.28 SD (95% CI −0.35 to −0.20), approximately 2.6 mm Hg. Wide inequalities, similar in magnitude to BP, were observed for behavioural outcomes. Even greater inequalities were observed for offspring academic achievement (mean difference comparing highest to lowest maternal education 1.43 SD (95% CI 1.37 to 1.50), a difference of 22%). For all behavioural outcomes and some health indicators, inequality was stable over childhood. For some outcomes (BP, BMD and most education outcomes), inequality narrowed as children got older. Only for height and attainment in English tests was there evidence of widening inequalities with age. Conclusions Our results suggest that within this cohort, maternal education inequalities in offspring health, behaviour and educational attainment are established in childhood but do not increase up to adolescence. Maternal education inequalities in behaviour and educational attainment were considerably larger than in health measures. [ABSTRACT FROM AUTHOR]

This article addresses some of historical issues encountered by the Crown Prosecution Service in England and Wales and some other jurisdictions in regard to this topic with some examples and also sets out the approach of the International Association of Prosecutors and how that impacts upon the responsibilities and duties of individual prosecutors. [ABSTRACT FROM AUTHOR]

End-of-life (EoL) care is a priority in health care and aims to provide services for all those who are dying, irrespective of their location. Providing this care to those in prison services is challenging.This paper reports a project that aimed to provide an education programme to both prison nurses and officers to support their understanding of EoL care and how it may be provided within the confines of the prison environment. On offer was a mixed-methodology education programme incorporating a pre-existing university module not specifically tailored to the prison setting. The mentorship of a clinical nurse specialist already known to the prison staff proved crucial to its successful implementation. Following the educational programme, both the nurses and the prison officers reported having a deeper understanding of the issues and more confidence in providing EoL care to prisoners who are patients. Further delivery of the programme to a wider group is planned, and similar initiatives nationally may provide a flexible, affordable approach to EoL care for those ending their days in prison. [ABSTRACT FROM AUTHOR]

This study investigates discriminatory peer aggression among primary school aged children as a function of minority status (based on nationality, ethnicity, religion) of the target and the relative proportions of minority and majority children in the school. Participants were 925 8- to 12-year-olds attending schools in Britain. Children of minority status were no more likely than children of majority background to experience peer aggression in general. However, minority children were more likely to experience being the victims of discriminatory aggression. Two contrasting predictions were tested: that discriminatory aggression would be more likely when the minority group was relatively small in number or, alternatively, that as the proportions of children of minority backgrounds increased across schools, discriminatory aggression would be greater. The latter hypothesis was supported. Findings also revealed that in schools with a lower minority presence, discriminatory aggression experienced by majority children was significantly lower than that reported by minority children. When the school minority rate exceeded 81%, discriminatory aggression was more commonly experienced among majority children than among minority children. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Purpose – The purpose of this paper is to apply critical legal analysis to laws, policies and reforms focused on special educational needs (SEN) and equality in England and to suggest a Neurodiversity spectrum statement. Design/methodology/approach – The paper reviews current legal and policy initiatives in SEN, together with recent reforms in equality law. Findings – While past and current policies may have laudable aims, tensions such as a lack of integration of education, health and social services have had prejudicial outcomes for children with SEN, their families/carers, and the professionals involved. Originality/value – Legal reforms promise to remedy some problems, but must be underpinned by adequate resourcing, appeal procedures, and remedies which foster the enforcement of legal duties. Some resources for families with children with SEN are noted. [ABSTRACT FROM AUTHOR]

A biography of John Carter, a seventeenth century carpenter from St. Albans, Hertfordshire, England, is presented. It examines his family, his education, and his career. The authors discuss their use of probate documents and inventories of Carter's house in their research. They also consider Carter's house, furniture, and prosperity, commenting on remuneration for his carpentry work.

The article reports on Project "e-scape" (Electronic Solutions for Creative Assessment in Portfolio Environments), an electronic tool used to assess a student's scientific enquiry skills in England. The article describes the project as a form of assessment in which pupils could record their actions and thoughts in a mini-laptop computers which are then wirelessly linked to the teacher's laptop. The recorded responses of the children while doing the science experiments will be used as an assessment evidence to demonstrate their attainment.

POTRATA B., CAVET J., BLAIR S., HOWE T. & MOLASSIOTIS A. (2010) European Journal of Cancer Care 19, 721-728 'Like a sieve': an exploratory study on cognitive impairments in patients with multiple myeloma The aim of this study was to obtain a more in-depth understanding of cognitive impairments and concerns as described by patients with multiple myeloma and the strategies used to cope with them. Semi-structured qualitative interviews were undertaken with 15 multiple myeloma patients of differing age ranges and at various stages of their disease. Various cognitive impairments, such as problems with short-term memory, poor recall and lack of concentration were observed and/or expressed in at least 10 out of 15 patients, all of them long(er)-term survivors. In some patients cognitive impairments significantly interfered with their personal and professional lives, and for some patients these were described as permanent. The patients used various coping strategies, from denial, taking notes, writing diaries, reading simpler texts, using talking books and videos, to using systems for counting medication to cope with the results of their cognitive impairment. Our findings differ from much of the contemporary literature which states that if cognitive impairments in cancer patients occur, they are mostly mild and transient. More proactive supportive care is needed to help patients with multiple myeloma to cope with poorer cognitive functioning. [ABSTRACT FROM AUTHOR]

Background General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health. Aim To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England. Design of study Cross-sectional and modelling study. Setting Primary care in England. Method Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available. Results The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower-upper estimates 7-16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29-81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment. Conclusion The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered. [ABSTRACT FROM AUTHOR]

This article presents a case study of the serial killer Trevor Joseph Hardy -- who murdered three young women in Manchester, England between 1974 and 1976, and who is now one of Britain's longest serving prisoners. Even so, Hardy and his crimes are almost unknown. As such, the article uses the Hardy case to consider academic definitions of 'newsworthiness' and the assertion that the rise of the mass media has made serial killing a 'media event'. Through a series of interviews with journalists who covered the case, the article suggests possible reasons as to why Hardy has disappeared from popular and academic consciousness. [ABSTRACT FROM AUTHOR]

An essay is presented which explores some responses to the challenge of mental mapping a fictionalized world of London, England in 19th-century German novels. It indicates that such mental mapping allows London to be treated as subject, setting and process without a privileging one function over another. The author discusses the anonymity and the alienation of London that create moral stability while scientific invention and social change testify to the dynamism of the city.

The impact of potentially toxic chemicals on wildlife is commonly assessed by comparing the intake of the contaminant with the ''no observable effects level'' (NOAEL) of intake. It is known, however, that there are considerable uncertainties inherent in this method. This study presents a Monte-Carlo based model to assess the degree of risk posed to birds (dunlin, Calidris alpina) from important estuarine habitats, and to show the limitations of such risk assessments, particularly with regard to data availability. The model was applied to predict the uptake of metals (Hg, Pb) in this shorebird species in Poole Harbour and the Severn Estuary/Bristol Channel, UK, two internationally important shorebird habitats. The results show that in both areas, Pb and Hg concentrations may pose an ecologically relevant toxic risk to wading birds. For Pb, uncertainty in NOAEL values dominates the overall uncertainty. Use of lethal toxicity data (LD50/100) was investigated as a method for assessing sub-lethal impacts from Hg. It was found that this method led to a significant under-estimate of the potential impact of Hg contamination, compared with direct estimation of NOAEL. [ABSTRACT FROM AUTHOR]

Teacher burnout has long been understood to have significant negative effects on teaching efficacy. Research has indicated that student misbehaviour, often a result of disengagement, is a major predictor of teacher burnout. In part to address student disengagement, Hampshire County in England has undertaken a whole-school rights-based reform initiative called Rights, Respect and Responsibility (RRR). This study was designed to examine the effects of RRR on student engagement and teacher burnout over a three-year period. The sample initially comprised a total of 15 schools (four infant, five primary and six junior) and 127 teachers. At the second time of measure, one year later, the sample was reduced to 69 teachers from 13 of the schools. At both times teachers completed the following measures: the Maslach Burnout Inventory, the perceived effect of RRR on teaching, and student engagement. In the third year of the study we obtained data on the Maslach Burnout Inventory from 100 teachers at 12 of the schools. Findings suggest that RRR can improve student engagement and reduce teacher burnout. Of particular note was the predictive power of student participation in the classroom and school in reducing teacher burnout. [ABSTRACT FROM AUTHOR]