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Proton magnetic resonance spectroscopy (1H‐MRS) is increasingly used for clinical brain tumour diagnosis, but suffers from limited spectral quality. This retrospective and comparative study aims at improving paediatric brain tumour classification by performing noise suppression on clinical 1H‐MRS. Eighty‐three/forty‐two children with either an ependymoma (ages 4.6 ± 5.3/9.3 ± 5.4), a medulloblastoma (ages 6.9 ± 3.5/6.5 ± 4.4), or a pilocytic astrocytoma (8.0 ± 3.6/6.3 ± 5.0), recruited from four centres across England, were scanned with 1.5T/3T short‐echo‐time point‐resolved spectroscopy. The acquired raw 1H‐MRS was quantified by using Totally Automatic Robust Quantitation in NMR (TARQUIN), assessed by experienced spectroscopists, and processed with adaptive wavelet noise suppression (AWNS). Metabolite concentrations were extracted as features, selected based on multiclass receiver operating characteristics, and finally used for identifying brain tumour types with supervised machine learning. The minority class was oversampled through the synthetic minority oversampling technique for comparison purposes. Post‐noise‐suppression 1H‐MRS showed significantly elevated signal‐to‐noise ratios (P <.05, Wilcoxon signed‐rank test), stable full width at half‐maximum (P >.05, Wilcoxon signed‐rank test), and significantly higher classification accuracy (P <.05, Wilcoxon signed‐rank test). Specifically, the cross‐validated overall and balanced classification accuracies can be improved from 81% to 88% overall and 76% to 86% balanced for the 1.5T cohort, whilst for the 3T cohort they can be improved from 62% to 76% overall and 46% to 56%, by applying Naïve Bayes on the oversampled 1H‐MRS. The study shows that fitting‐based signal‐to‐noise ratios of clinical 1H‐MRS can be significantly improved by using AWNS with insignificantly altered line width, and the post‐noise‐suppression 1H‐MRS may have better diagnostic performance for paediatric brain tumours. [ABSTRACT FROM AUTHOR]

This paper explores the impact of policy changes and budget cuts on services and support faced by people with learning disabilities. Drawing upon collaborative research in England and Scotland and interviews with commissioners and support organisations, we show how landscapes of care and support are unstable and fragmented. We identify how pressures of time, resource and precaritisation in the workforce are creating 'debilitating landscapes of care' that further erode the capacities of both the people that work in the sector and people with learning disabilities. Some challenges that people with learning disabilities face in this context include finding appropriate local support, narrowing access as a result of reductions in benefit entitlements and identifying quality providers amid a complex array of private and charitable provision. Capacity to cope with these challenges is contingent on access to quality advocacy, supportive family, friendships, productive occupational learning environments and peer support, but these are not always available. The impact of COVID-19 has only served to intensify some of the issues we identify and the urgent need for a response. Our analysis is inspired by Berlant's (2007) conception of 'slow-death' and Puar's (2017) associated conceptualisation of 'debility'. [ABSTRACT FROM AUTHOR]

Social care provision across high-income countries has been transformed over the last ten years by personalisation – a policy agenda to give people with eligible support needs more choice and control over their support. Yet the ideological underpinnings of this transformation remain highly mutable, particularly in the context of reduced welfare provision that has unfolded in many nations advancing personalisation. How the policy has manifested itself has led to an expectation for people to self-build a life as individual consumers within a care market. This article draws on a study exploring how people with learning disabilities in England and Scotland are responding to the everyday realities of personalisation as it is enacted where they live and show the relationality inherent in their practices. We propose that the personalisation agenda as it currently stands (as an individualising movement involving an increasing responsibilisation of individuals and their families) ignores the inherently relational nature of care and support. We propose that social care policy needs to recognise the relational ways in which people build their lives and to advocate a redistribution of responsibility to reduce inequalities in the allocation of care. [ABSTRACT FROM AUTHOR]

• Voluntary support organisations increasingly rely on non-state funding. • Offers a rich account of how managers navigate a difficult funding landscape. • Documents how managing care and support organisations is precarious. • Concludes that relationships with local authorities are crucial for sustainability. This paper examines voluntary sector care and support provision under a context of significantly reduced government funding. Whilst geographers have analysed the causes and aftermath of austerity on different populations, our focus is on how managers of voluntary sector organisations have had to learn and evolve through bidding for non -statutory funding to sustain their core provision. Drawing on research with voluntary support organisations in the learning disability social care sector in England and Scotland, the paper examines the effects of the state's continued reliance on the sector for core 'public' services whilst simultaneously withdrawing its funding. Using accounts from managers, the paper offers a particularly novel and potent example of voluntary sector precarity and the deepening unfinished and unsettled nature of care and support that has unfolded in the wake of austerity. Through the empirical research, attention is drawn to three levels of precarity that are experienced by those seeking to sustain voluntary support provision: voluntary sector organisation and structures, the voluntary sector workforce, and individual managers' everyday emotional and affective experiences. [ABSTRACT FROM AUTHOR]

To examine the effectiveness of one dose of the COVID-19 vaccine on care-home residents. Natural experiment. We compared the effectiveness of single doses of Pfizer/BioNTech BNT162b2 (effective at 10 days) and AstraZeneca ChAdOx1 (effective at 14 days) vaccines in vaccinated and control (unvaccinated) homes. Using routine data, all care-homes reporting COVID-19 outbreaks between 11/12/2020 and 12/3/2021 in a sub-region of North West England were included. Of 126 care-homes (4042 residents), with outbreaks, 55 (44%, 1686 residents) reported onset dates before vaccination commenced; 38 (30%, 1304 residents) reported onset < 10 (BNT162b2) and < 14 days (ChAdOx1) after vaccine administration; and 33 (26%, 1052 residents) reported onset > 10 (BNT162b2) and > 14 (ChAdOx1) days after vaccination. Eighty-nine (71%) homes used ChAdOx1 vaccine. A single dose of vaccine before the outbreak onset significantly lowered the risk of symptoms (reduced by 48%), positivity (by 65%), hospitalisation (by 68%), and death (by 81%). Some vaccine effectiveness was also noted in care-homes that received one dose of vaccine within 10–14 days of outbreak onset. The number needed to vaccinate to prevent one resident from COVID-19-related hospitalisation was 34, and death was 17. This real-world, natural experiment adds to the evidence of COVID-19 vaccine effectiveness from different studies using varying designs. In the context of lockdown's impact on infection rates and on-going care-home outbreaks, a single dose of either ChAdOx1 or BNT162b2 vaccine had a significant impact on reducing COVID-19 related hospitalisation and death in care-home residents. Natural experiments should be used more in public health. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Patients with TB have diverse and often challenging clinical and social needs that may hamper successful treatment outcomes. Understanding the need for additional support during treatment (enhanced case management, or ECM) is important for workforce capacity planning. North West England TB Cohort Audit (TBCA) has introduced a 4-level ECM classification system (ECM 0-3) to quantify the need for ECM in the region. This study describes the data from the first 2 years of ECM classification.Methods: Data collected between April 2013 and July 2015 were used to analyse the proportions of patients allocated to each ECM level and the prevalence of social and clinical factors indicating need for ECM. Single variable and multivariable logistic regression models were constructed to examine the association between ECM level and treatment outcome.Results: Of 1714 notified cases 99.8% were assigned an ECM level: 31% ECM1, 19% ECM2 and 14% ECM3. The most common factors indicating need for ECM were language barriers (20.3%) and clinical complexity (16.9%). 1342/1493 (89.9%) of drug-sensitive, non-CNS cases completed treatment within 12 months. Patients in ECM2 and 3 were less likely to complete treatment at 12 months than patients in ECM0 (adjusted OR 0.47 [95% CI 0.27-0.84] and 0.23 [0.13-0.41] respectively).Conclusions: Use of TBCA to quantify different levels of need for ECM is feasible and has demonstrated that social and clinical complexity is common in the region. Results will inform regional workforce planning and assist development of innovative methods to improve treatment outcomes in these vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: Increasing age is the biggest risk factor for dementia, of which Alzheimer's disease is the commonest cause. The pathological changes underpinning Alzheimer's disease are thought to develop at least a decade prior to the onset of symptoms. Molecular positron emission tomography and multi-modal magnetic resonance imaging allow key pathological processes underpinning cognitive impairment - including β-amyloid depostion, vascular disease, network breakdown and atrophy - to be assessed repeatedly and non-invasively. This enables potential determinants of dementia to be delineated earlier, and therefore opens a pre-symptomatic window where intervention may prevent the onset of cognitive symptoms.Methods/design: This paper outlines the clinical, cognitive and imaging protocol of "Insight 46", a neuroscience sub-study of the MRC National Survey of Health and Development. This is one of the oldest British birth cohort studies and has followed 5362 individuals since their birth in England, Scotland and Wales during one week in March 1946. These individuals have been tracked in 24 waves of data collection incorporating a wide range of health and functional measures, including repeat measures of cognitive function. Now aged 71 years, a small fraction have overt dementia, but estimates suggest that ~1/3 of individuals in this age group may be in the preclinical stages of Alzheimer's disease. Insight 46 is recruiting 500 study members selected at random from those who attended a clinical visit at 60-64 years and on whom relevant lifecourse data are available. We describe the sub-study design and protocol which involves a prospective two time-point (0, 24 month) data collection covering clinical, neuropsychological, β-amyloid positron emission tomography and magnetic resonance imaging, biomarker and genetic information. Data collection started in 2015 (age 69) and aims to be completed in 2019 (age 73).Discussion: Through the integration of data on the socioeconomic environment and on physical, psychological and cognitive function from 0 to 69 years, coupled with genetics, structural and molecular imaging, and intensive cognitive and neurological phenotyping, Insight 46 aims to identify lifetime factors which influence brain health and cognitive ageing, with particular focus on Alzheimer's disease and cerebrovascular disease. This will provide an evidence base for the rational design of disease-modifying trials. [ABSTRACT FROM AUTHOR]

Background Current national policy in the UK is to make all psychiatric inpatient areas non-smoking by the end of 2018. Methods A mixed qualitative approach, using a survey with a semi-structured format and a World Café method. Discussion This pilot project explored views and experiences of staff and patients in making an inpatient recovery unit a smoke-free zone. A number of issues that were causing anxiety in patients and staff members were identified. Conclusion The focus group generated a number of possible interventions which may help to achieve a smoke-free environment while supporting inpatients who are giving up smoking. [ABSTRACT FROM AUTHOR]

Background: There is consensus about the importance of 'recovery' in mental health services, but the link between recovery orientation of mental health teams and personal recovery of individuals has been underresearched.Aims: To investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England.Method: In six English mental health National Health Service (NHS) trusts, randomly chosen community adult mental health teams were surveyed. A random sample of ten patients, one team leader and a convenience sample of five clinicians were surveyed from each team. All respondents rated the recovery orientation of their team using parallel versions of the Recovery Self Assessment (RSA). In addition, service users also rated their own personal recovery using the Questionnaire about Processes of Recovery (QPR).Results: Team leaders (n = 22) rated recovery orientation higher than clinicians (n = 109) or patients (n = 120) (Wald(2) = 7.0, P = 0.03), and both NHS trust and team type influenced RSA ratings. Patient-rated recovery orientation was a predictor of personal recovery (b = 0.58, 95% CI 0.31-0.85, P<0.001). Team leaders and clinicians with experience of mental illness (39%) or supporting a family member or friend with mental illness (76%) did not differ in their RSA ratings from other team leaders or clinicians.Conclusions: Compared with team leaders, frontline clinicians and service users have less positive views on recovery orientation. Increasing recovery orientation may support personal recovery. [ABSTRACT FROM AUTHOR]

Purpose - The aim of this paper is to report the process, findings and implications of a three-year evaluation of integrated health centres (IHCs) established in three secondary schools in Cornwall by the School-Based Integrated Health Centres (SBIHC) partnership. Design/methodology/approach - When the partners had completed the capital works, an evaluation strategy was designed for 2009-2012 to identify the extent to which each of the IHCs was meeting the aims set for the IHCs, and each IHC and school was contributing to the aims of the SBIHC project. Formative and summative evaluation used annual case studies to apply data progressively regarding: the use, users and operations of each IHC; students' perceptions of the user-friendliness of the IHCs; indicators of the general health and well-being of students and their sexual and mental health; students' exposure to crime, substance abuse and poverty; and students' academic achievement, attendances and exclusions. This process culminated in this paper which reports and discusses findings, suggests implications for practice, theory and research and proposes future directions for the partnership. Findings - All three schools engaged students closely in the design and decoration of their IHCs. Student ownership was extended into the selection of Coordinators and into centre management and governance. Budehaven Community School appointed a National Health Service (NHS)-trained Coordinator for their IHC, The Haven, a mental health worker funded for one year by the NHS. After 2009-2010, his responsibilities were shared by the NHS-trained Receptionist and the Manager, an Assistant Headteacher. During Year 3, Budehaven added a "colocation" building, Kevren. About 37 professionals are now located in or visit The Haven and Kevren. Student footfall doubled to about 4,000 in the second year and increased by another 25 per cent in the third year. The wide range of general, mental and sexual health services were highly valued by the students. The Crayon, the IHC in Hayle Community School, achieved a similar footfall over three years. It started with a Receptionist and the Pupil Welfare Officer. The Manager, a Deputy Headteacher, and the Headteacher moving most student support services into the IHC at the end of Year 1. From then on the Crayon had three full-time professionals. By the end of Year 3, the Crayon had reached the limits of its facilities. A solely positive association was found between IHC usage and measured improvements to mental health and academic progress. The IHC in Penair School, Bywva, developed a wide range of general, sexual and mental health services, attracted a similarly strong footfall, and also reached capacity in Year 3. Penair refined their IHC's line management by an Assistant Headteacher and coordination by a Lead. Originality/value - This paper offers a new conceptual model of the SBIHC model of health care centred on the reciprocity and integrity of relationships between students and professionals. [ABSTRACT FROM AUTHOR]

ABSTRACT Early Medieval England is described historically as a time when people migrated from the Continent to English shores. This study tests the hypothesis that those buried in the Bowl Hole cemetery, Bamburgh, Northumberland were nonlocally born, because of its royal status. Ninety-one male and female adult, and nonadult, skeletons were studied. Isotope ratios of strontium (87Sr/86Sr) and oxygen (δ18O) were generated for 78 individuals (28 females, 27 males, five 'adults,' 18 nonadults). The mean Sr value for human enamel was 0.71044, standard deviation (sd) 0.001, and the mean O (δw) value is −5.9‰, sd 1.6‰. Additionally, animal tooth enamel (mean Sr value 0.710587, sd 0.001; mean O value −6.5‰, sd 1.5‰), local soil (mean Sr value 0.709184, sd 0.0006), snail shells (mean Sr value 0.708888, sd 0.0001), and soil samples from a 5 km transect heading inland (mean Sr value 0.709121, sd 0.0003), were analyzed for an indication of the isotopic composition of bioavailable Sr in the modern environment and to assess the impact of sea-spray; water samples from a well, local rivers, and standing water were analyzed for local δ18O values (mean O value −6.4‰, relative to VSMOW, sd 2.8‰). Over 50% of those buried at Bamburgh were nonlocal. All ages and both sexes produced 'nonlocal' signatures; some suggested childhood origins in Scandinavia, the southern Mediterranean or North Africa. Stature and other indicators of health status indicated differences in quality of life between local and migrant groups. These differences did not extend to burial practices. Am J Phys Anthropol 151:462-476, 2013.© 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Objective. To critically review the evidence on the efficacy and effectiveness of practitioner-based complementary therapies for patients with osteoarthritis. We excluded t’ai chi and acupuncture, which have been the subject of recent reviews.Methods. Randomized controlled trials, published in English up to May 2011, were identified using systematic searches of bibliographic databases and searching of reference lists. Information was extracted on outcomes, statistical significance in comparison with alternative treatments and reported side effects. The methodological quality of the identified studies was determined using the Jadad scoring system. Outcomes considered were pain and patient global assessment.Results. In all, 16 eligible trials were identified covering 12 therapies. Overall, there was no good evidence of the effectiveness of any of the therapies in relation to pain or global health improvement/quality of life because most therapies only had a single randomized controlled trial. Where positive results were reported, they were often comparing an active intervention with no intervention. Therapies with multiple trials either provided null (biofeedback) or inconsistent results (magnet therapy), or the trials available scored poorly for quality (chiropractic). There were few adverse events reported in the trials.Conclusion. There is not sufficient evidence to recommend any of the practitioner-based complementary therapies considered here for the management of OA, but neither is there sufficient evidence to conclude that they are not effective or efficacious. [ABSTRACT FROM PUBLISHER]

This article documents some of the imaginative and physical journeys taken by a group of performance makers during a two-week course at Northbrook College, West Sussex in July 2011. Text, photographs and artworks are used to re-present some of the journeys we have taken together as a group and the modes of marking, map making and documentation used. MB: is an inclusive arts practitioner who works with artists with learning disabilities. Mary was coordinating the course and HM: was participating as an interested Cultural Geographer. The article is written as a dialogue and is likely to be of interest to readers interested in the geographies of performance, disability, non-representational research, innovative non-verbal methods or inclusive arts practice. [ABSTRACT FROM AUTHOR]

Background: Difficulty in controlling attention can lead to mental fatigue in the healthy population. We identified one trial reporting a benefit in patients’ attention using a homeopathic formula preparation. One component of the preparation was potassium phosphate, widely available off the shelf as Kali phos 6x for cognitive problems. The aim of this exploratory trial was to assess the effectiveness of Kali phos 6x for attention problems associated with mental fatigue. Methods: We recruited student and staff volunteers (University of York) with self-reported mental fatigue, excluding any using homeopathy or prescribed stimulants, or with a diagnosis of chronic fatigue syndrome. In a triple blind, cross-over, placebo-controlled clinical trial, 86 volunteers were randomized to receive Kali phos 6x or identical placebo 10 minutes before taking a psychological test of attention (Stroop Colour-Word Test). One week later they were crossed over and took the other preparation before repeating the test. Results: We found no evidence of a treatment effect in a comparison of Kali phos 6x with placebo (Kali phos minus placebo = −1.1 (95% CI −3.0 to 0.9, P = 0.3) Stroop score units, Cohen effect size = −0.17) even when allowing for a weak period effect with accuracy scores in the second period being higher than those in the first (P = 0.05). We observed a ceiling effect in the Stroop test which undermined our ability to interpret this result. Conclusions: Kali phos 6x was not found to be effective in reducing mental fatigue. A ceiling effect in our primary outcome measure meant that we could not rule out a type II error. Thorough piloting of an adequate outcome measure could have led to an unequivocal result. Current Controlled Trials: ISRCTN16521161 [ABSTRACT FROM AUTHOR]

Background: In Liverpool, injecting drug users (IDUs), men-who-have-sex-with-men (MSM) and UK Africans experience a disproportionate burden of HIV, yet services do not reach out to these groups and late presentations continue. We set out to: increase testing uptake in targeted marginalized groups through a community and genitourinary medicine (GUM)-based point of care testing (POCT) programme; and conduct a process evaluation to examine service provider inputs and document service user perceptions of the programme. Methods: Mixed quantitative, qualitative and process evaluation methods were used. Service providers were trained to use fourth generation rapid antibody/antigen HIV tests. Existing outreach services incorporated POCT into routine practice. Clients completed a semi-structured questionnaire and focus group discussions (FGDs) were held with service providers. Results: Between September 2009 and June 2010, 953 individuals underwent POCT (GUM: 556 [59%]; community-based sites: 397 [42%]). Participants in the community were more likely to be male (p = 0.028), older (p < 0.001), of UK African origin (p < 0.001) and IDUs (p < 0.001) than participants from the GUM clinic. Seventeen new HIV diagnoses were confirmed (prevalence = 1.8%), 16 of whom were in risk exposure categories (prevalence: 16/517, 3.1%). Questionnaires and FGDs showed that clients and service providers were supportive of POCT, highlighting benefits of reaching out to marginalised communities and incorporating HIV prevention messages. Conclusions: Community and GUM clinic-based POCT for HIV was feasible and acceptable to clients and service providers in a low prevalence setting. It successfully reached target groups, many of whom would not have otherwise tested. We recommend POCT be considered among strategies to increase the uptake of HIV testing among groups who are currently underserved. [ABSTRACT FROM AUTHOR]

In this paper I explore some of the ways in which people with visual impairments see landscape and participate in visual cultures of landscape apprehension. I draw on ethnographic and interview material, developed while acting as a sighted guide for specialist blind and visually impaired walking groups who visit the landscapes of the Lake District and Peak District in Britain. Through this research material I show how landscape is likely to become present for people with blindness or visual impairment through both their individual capacities for sight and a complex mix of discursive, material, social, and historical relations. Specifically, I argue that there is an intercorporeal, collective dimension to this emergence of landscape and this intercorporeality is evident at both a perceptual and a discursive level. I suggest that future research needs to attend further to how landscape emerges and becomes present through intercorporeal processes. [ABSTRACT FROM AUTHOR]

The article examines the creation and growth of a Centre for Enterprise (CfE), an entrepreneurial venture in higher education. It states that the researchers focused on the concept of strategic space to demonstrate the way in which several crises were negotiated during the growth of CfE, which is based in Manchester Metropolitan University (MMU) Business School in England. In connection, the strategy, which emerged as crises of knowing was important and evolutionary rather than based on the classical rational model associated with Ans off.

Abstract Objective To determine whether a short course of traditional acupuncture improves longer term outcomes for patients with persistent non-specific low back pain in primary care. Design Pragmatic, open, randomised controlled trial. Setting Three private acupuncture clinics and 18 general practices in York, England. Participants 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. Interventions 10 individualised acupuncture treatments from one of six qualified acupuncturists (160 patients) or usual care only (81 patients). Main outcome measures The primary outcome was SF-36 bodily pain, measured at 12 and 24 months. Other outcomes included reported use of analgesics, scores on the Oswestry pain disability index, safety, and patient satisfaction. Results 39 general practitioners referred 289 patients of whom 241 were randomised. At 12 months average SF-36 pain scores increased by 33.2 to 64.0 in the acupuncture group and by 27.9 to 58.3 in the control group. Adjusting for baseline score and for any clustering by acupuncturist, die estimated intervention effect was 5.6 points (95% confidence interval-0.2 to 11.4) at 12 months (n=213) and 8.0 points (2.8 to 13.2) at 24 months (n=182). The magnitude of the difference between the groups was about 10%-15% of the final pain score in the control group. Functional disability was not improved. No serious or life threatening events were reported. Conclusions Weak evidence was found of an effect of acupuncture on persistent non-specific low back pain at 12 months, but stronger evidence of a small benefit at 24 months. Referral to a qualified traditional acupuncturist for a short course of treatment seems safe and acceptable to patients with low back pain. Trial registration 1SRCTN80764175. [ABSTRACT FROM AUTHOR]

This paper examines the process of technological and organisational innovation within a SME (small and medium-sized enterprise) located in a relatively remote area of northwest England. Supply chain networks provide a mechanism by which closer relations can create opportunities to improve competitiveness of all the partners. It is argued that these opportunities can be extended geographically by the use of information and communications technologies (ICTs). The paper focuses on the accumulation of innovation capabilities developed through RWL's close relationship with its main customer, BNFL, and other firms within the supply chain. These relationships have enabled knowledge to be transferred both upstream and downstream creating a `virtual cluster' facilitated through reciprocal relationships between the main actors. Our conclusion is that virtual technologies depend heavily on shared perceptions of those participating in such networks. Furthermore, close relationships central to the sharing of tacit knowledge are best achieved through regular face-to-face interaction. [ABSTRACT FROM AUTHOR]

Apoptosis, or programmed cell death, is perturbed in many cancers. We tested the hypothesis that coding polymorphisms of the death receptor 4 (DR4), caspase-8 (CASP8), and caspase-10 (CASP10) genes might act as low-penetrance breast cancer genes. Single-nucleotide polymorphisms (SNPs) of these genes were genotyped in a series of 999 breast cancer case patients and 996 control subjects from Sheffield, U.K., and in a second, independent U.K. population of 2192 case patients and 2262 control subjects from East Anglia. In the Sheffield study, the rare H allele of CASP8, D302H, was associated with a reduced risk of breast cancer in a dose-dependent manner (P(trend) = .007). Furthermore, the CASP8 D302H association, but not that of the other CASP8 SNPs examined (T21914C, G50121A, and G50358A), was replicated in the East Anglian study. The combined adjusted odds ratios for breast cancer were 0.83 (95% confidence interval [CI] = 0.74 to 0.94) for the DH heterozygote and 0.58 (95% CI = 0.39 to 0.88) for the HH homozygote (P(trend) = .0002, adjusted for study). The reproducible, dose-dependent association of CASP8 D302H with breast cancer indicates the potential importance of inherited variation in the apoptosis pathway in breast cancer susceptibility. [ABSTRACT FROM AUTHOR]

This article examines the nature and timing of U.S. foreign direct investment (FDI) in the London legal market. Evidence from a survey of thirty–eight U.S. subsidiaries suggests that FDI has taken place primarily to serve U.S. clients located within the United Kingdom. The evidence also suggests that early investors (pre–1990) belong to a core group of multinational companies with headquarters located in first–tier U.S. cities (New York, Chicago, Los Angeles). Later investors more typically hail from smaller cities. The evidence reveals a number of important differences between early versus late investors. Specifically, subsidiaries that were established prior to 1990 are more likely to enjoy local decision–making autonomy than are their counterparts that entered the London market more recently. The article concludes with a brief discussion of the implications of the survey findings for future research on FDI in professional services. [ABSTRACT FROM AUTHOR]

Discusses the Research and Analysis (R&A) branch of the U.S. Office of Strategic Services (OSS) in London, England. Contribution of R&A to intelligence; Practical realities of forging links with the British intelligence establishment; Post-war reputation of R&A as a unique collection of scholarly operatives mobilized by William J. Donovan.

The new undergraduate medical curriculum in Manchester uses problem-based learning (PBL) throughout the course. However, the major difference from other PBL schools is that in years 3 & 4 (phase 2) the students can use clinical experience when discussing the paper cases. The process is then developed further in year 5 (phase 3), in which there are no set PBL 'triggers' and students bring their own cases to the groups for discussion. In this study, we have explored what happens in the phase 3 (year 5) group sessions and how the students view them. A questionnaire and focus groups were used to generate data, from which a model was developed of what happens in a 'good' group session. The data suggest that most groups run on a case-presentation and discussion format, most commonly about clinical management and diagnosis. Students want tutors to act as an expert resource and to be flexible in allowing students to direct the discussions. University guidance about the group sessions was not generally used. [ABSTRACT FROM AUTHOR]

In a standard care planning cycle, all 139 patients on the Gloucester Rehabilitation Register were involved in multi-disciplinary care programme approach assessment, generating 366 formal treatment goals (mean 2.6 goals per patient). At review 1 year later, 68% of goals were fully and 11% partially achieved. Goals were no more likely to be achieved in any care setting (i.e. with professional supervision/living independently), or any particular diagnosis. However, goals targeting the drug treatment of psychiatric syndromes were most likely to be fully successful (84%) while approaches to self-care skills, side effects, physical/medical problems, family relationships, were moderately successful. Least successful were the attempts to promote structured day care/activities, and to treat substance abuse, fully successful in 39% and 17%, respectively. Possible reasons for treatment success in different areas, including the positive impact of the introduction of 'atypical' antipsychotic drugs, were discussed. The present model of evaluating clinical outcome may have wider application in a health service which increasingly values evidence-based clinical practice. [ABSTRACT FROM AUTHOR]

Abstract Objective To evaluate the cost effectiveness of acupuncture in the management of persistent non-specific low back pain. Design Cost effectiveness analysis of a randomised controlled trial. Setting Three private acupuncture clinics and 18 general practices in York, England. Participants 241 adults aged 18-65 with non-specific low back pain of 4-52 weeks' duration. Interventions Ten individualised acupuncture treatments over three months from acupuncturists trained in traditional Chinese medicine (n = 160) or usual care only (n = 81). Main outcome measure Incremental cost per quality adjusted life year (QALY) gained over two years. Results Total costs to the United Kingdom's health service during the two year study period were higher on average for the acupuncture group (£460; €673; $859) than for the usual care group (£345) because of the costs associated with initial treatment. The mean incremental health gain from acupuncture at 12 months was 0.012 QALYs (95% confidence interval - 0.033 to 0.058) and at 24 months was 0.027 QALYs (-0.056 to 0.110), leading to a base case estimate of £4241 per QALY gained. This result was robust to sensitivity analysis. The probabilistic sensitivity analysis showed acupuncture to have a more than 90% chance of being cost effective at a £20 000 cost per QALY threshold. Conclusion A short course of traditional acupuncture for persistent non-specific low back pain in primary care confers a modest health benefit for minor extra cost to the NHS compared with usual care. Acupuncture care for low back pain seems to be cost effective in the longer term. Trial registration ISRCTN80764175. [ABSTRACT FROM AUTHOR]

In Nottingham we have assessed the acceptability of oral hormone replacement therapy (HRT) for an at-risk group of post-menopausal women for osteoporosis. One hundred post-menopausal women between the ages of 50 and 70 years who had sustained a distal radial fracture were offered oral HRT. There was a 36% overall uptake of HRT with 9% of patients unable to take HRT because they had medical contraindications. The uptake in the 50-55 year age group was 54%. We conclude that in prospective studies of HRT for osteoporosis up to 50% of patients may not wish to take HRT and therefore study design should allow for this level of uptake. [ABSTRACT FROM AUTHOR]

Background: Chronic neck pain is a common condition in the adult population. More research is needed to evaluate interventions aiming to facilitate beneficial long-term change. We propose to evaluate the effect of Alexander Technique lessons and acupuncture in a rigorously conducted pragmatic trial with an embedded qualitative study.Methods/design: We will recruit 500 patients who have been diagnosed with neck pain in primary care, who have continued to experience neck pain for at least three months with 28% minimum cut-off score on the Northwick Park Neck Pain Questionnaire (NPQ). We will exclude patients with serious underlying pathology, prior cervical spine surgery, history of psychosis, rheumatoid arthritis, ankylosing spondylitis, osteoporosis, haemophilia, cancer, HIV or hepatitis, or with alcohol or drug dependency currently or in the last 12 months, or actively pursuing compensation or with pending litigation.The York Trials Unit will randomly allocate participants using a secure computer-based system. We will use block randomisation with allocation to each intervention arm being unambiguously concealed from anyone who might subvert the randomisation process.Participants will be randomised in equal proportions to Alexander Technique lessons, acupuncture or usual care alone. Twenty 30-minute Alexander Technique lessons will be provided by teachers registered with the Society of Teachers of the Alexander Technique and twelve 50-minute sessions of acupuncture will be provided by acupuncturists registered with the British Acupuncture Council. All participants will continue to receive usual GP care.The primary outcome will be the NPQ at 12 months, with the secondary time point at 6 months, and an area-under-curve analysis will include 3, 6 and 12 month time-points. Adverse events will be documented. Potential intervention effect modifiers and mediators to be explored include: self-efficacy, stress management, and the incorporation of practitioner advice about self-care and lifestyle. Qualitative material will be used to address issues of safety, acceptability and factors that impact on longer term outcomes.Discussion: This study will provide robust evidence on whether there are significant clinical benefits to patients, economic benefits demonstrating value for money, and sufficient levels of acceptability and safety.Trial Registration: Current Controlled Trials ISRCTN15186354. [ABSTRACT FROM AUTHOR]

Information about several papers discussed at a conference organized by the European Blood Alliance and America's Blood Centers held in London, England is presented. The conference highlights the role of blood centers in transfusion recipient care as well as development of technologies and techniques to assure better tracking of blood from the donor to the patient. Several medical personnel were featured like Robert Carden, Michael F. Murphy, and Sunny Dzik.

Information about the topic discussed at the conference organized by the European Blood Alliance and America's Blood Centers in London, England is presented. The topic focuses on the study conducted by the U.S. General Accounting Office, which claims that blood services had saved about four million patient lives each year. Speakers also highlight the increasing blood and hospital revenue in the U.S. as well as higher transfusion-related costs.

Background. Rapid Access Chest Pain Clinics have recently been introduced to assist in the management of primary care patients experiencing suspected cardiac chest pain. Objective. To study the longer term outcome for patients referred to a Rapid Access Chest Pain Clinic and then given a non-cardiac diagnosis. Methods. The study collected retrospective data from a cohort of all patients attending the Rapid Access Chest Pain Clinic based in the cardiorespiratory Department at the York District Hospital, England. Questionnaires were sent to all patients who attended the Rapid Access Chest Pain Clinic during the previous 14 months and were diagnosed with non-cardiac chest pain. Participants reported on their chest pain, subsequent episodes of primary and secondary care and their beliefs about causation of pain. Results. Of the patients referred to the Rapid Access Chest Pain Clinic, 235 (52%) did not have cardiac chest pain. Of these patients, 161 (69%) returned the questionnaire, nearly half of whom reported ongoing chest pain. The mean time since Clinic attendance was approximately 8 months and the median duration of ongoing chest pain was 5.4 months. Women were twice as likely as men to continue to be experiencing pain but did not report more frequent or severe pain on average. More than 50% of the non-cardiac group were not convinced by their negative cardiac diagnosis. Conclusion. There is an ongoing challenge to support patients with non-cardiac chest pain, including the provision of reassurance that their pain is very unlikely to be caused by their heart. [ABSTRACT FROM AUTHOR]

Presents survey results of private nursing homes in England. Percentage of death of discharged residents in nursing homes; Difference in proportion between 1989 and 1991; Decline in the proportion of residents admitted to hospital from nursing home.

An area of Mid-Anglo-Saxon deposits at Sandtun in West Hythe first studied in 1947-48 by Gordon Ward was re-examined between 1993-98 during assessments made in advance of housing development and in a research excavation. The site was occupied front at least c. 700 until 850-75 with some later reuse. It lay among sand dunes formed on a sand bank near the mouth of a gradually silting inlet. A range of activities was practised by the community there, including fishing, spindlewhorl manufacture and bone-working, in addition to salt-making recorded in a charter of 732, The metalwork was not significantly different from finds on contemporary' rural sites. Amongst the bones was a considerable number from fish and birds which were caught locally. The ceramic assemblage included a high proportion of imported continental pottery and it is concluded that the site may have been a landing-place for trading ships. The implications of the site for the interpretation of the development of urbanism in Mid-Anglo-Saxon England and the operation of trade are examined. [ABSTRACT FROM AUTHOR]

Background Genetic predisposition to inflammatory bowel disease (IBD) has been shown by epidemiological and linkage studies. Genetic linkage of IBD to chromosome 16 has been previously observed and replicated in independent populations. The recently identified NOD2 gene is a good positional and functional candidate gene since it is located in the region of linkage on chromosome 16q12, and activates nuclear factor (NF) kappaB in response to bacterial lipopolysaccharides. Methods We sequenced the coding region of the NOD2 gene and genotyped an insertion polymorphism affecting the leucine-rich region of the protein product in 512 individuals with IBD from 309 German or British families, 369 German trios (ie, German patients with sporadic IBD and their unaffected parents), and 272 normal controls. We then tested for association with Crohn's disease and ulcerative colitis. Findings Family-based association analyses were consistently positive in 95 British and 99 German affected sibling pairs with Crohn's disease (combined p<0.0001); the association was confirmed in the 304 German trios with Crohn's disease. No association was seen in the 115 sibling pairs and 65 trios with ulcerative colitis. The genotype-specific disease risks conferred by heterozygous and homozygous mutant genotypes were 2.6 (95% CI 1.5-4.5) and 42.1 (4.3-infinity), respectively. Interpretation The insertion mutation in the NOD2 gene confers a substantially increased susceptibility to Crohn's disease but not to ulcerative colitis.