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Background: Medullary thyroid cancer (MTC) is a rare form of cancer that affects patients' health-related quality of life (HRQoL) and survival. Cabozantinib (Cometriq ® ; Ipsen, Paris, France) and vandetanib (Caprelsa ® ; Sanofi Genzyme, Cambridge, MA, USA) are currently the treatment modality of choice for treating unresectable progressive and symptomatic MTC., Objectives: (1) To evaluate the clinical effectiveness and safety of cabozantinib and vandetanib. (2) To estimate the incremental cost-effectiveness of cabozantinib and vandetanib versus each other and best supportive care. (3) To identify key areas for primary research. (4) To estimate the overall cost of these treatments in England., Data Sources: Peer-reviewed publications (searched from inception to November 2016), European Public Assessment Reports and manufacturers' submissions., Review Methods: A systematic review [including a network meta-analysis (NMA)] was conducted to evaluate the clinical effectiveness and safety of cabozantinib and vandetanib. The economic analysis included a review of existing analyses and the development of a de novo model., Results: The systematic review identified two placebo-controlled trials. The Efficacy of XL184 (Cabozantinib) in Advanced Medullary Thyroid Cancer (EXAM) trial evaluated the efficacy and safety of cabozantinib in patients with unresectable locally advanced, metastatic and progressive MTC. The ZETA trial evaluated the efficacy and safety of vandetanib in patients with unresectable locally advanced or metastatic MTC. Both drugs significantly improved progression-free survival (PFS) more than the placebo ( p  < 0.001). The NMA suggested that, within the symptomatic and progressive MTC population, the effects on PFS were similar (vandetanib vs. cabozantinib: hazard ratio 1.14, 95% credible interval 0.41 to 3.09). Neither trial demonstrated a significant overall survival benefit for cabozantinib or vandetanib versus placebo, although data from ZETA were subject to potential confounding. Both cabozantinib and vandetanib demonstrated significantly better objective response rates and calcitonin (CTN) and carcinoembryonic antigen (CEA) response rates than placebo. Both cabozantinib and vandetanib produced frequent adverse events, often leading to dose interruption or reduction. The assessment group model indicates that, within the EU-label population (symptomatic and progressive MTC), the incremental cost-effectiveness ratios (ICERs) for cabozantinib and vandetanib are > £138,000 per quality-adjusted life-year (QALY) gained. Within the restricted EU-label population (symptomatic and progressive MTC with CEA/CTN doubling times of ≤ 24 months), the ICER for vandetanib is expected to be > £66,000 per QALY gained. The maximum annual budget impact within the symptomatic and progressive population is estimated to be ≈£2.35M for cabozantinib and ≈£5.53M for vandetanib. The costs of vandetanib in the restricted EU-label population are expected to be lower., Limitations: The intention-to-treat populations of the EXAM and ZETA trials are notably different. The analyses of ZETA subgroups may be subject to confounding as a result of differences in baseline characteristics and open-label vandetanib use. Attempts to statistically adjust for treatment switching were unsuccessful. No HRQoL evidence was identified for the MTC population., Conclusions: The identified trials suggest that cabozantinib and vandetanib improve PFS more than the placebo; however, significant OS benefits were not demonstrated. The economic analyses indicate that within the EU-label population, the ICERs for cabozantinib and vandetanib are > £138,000 per QALY gained. Within the restricted EU-label population, the ICER for vandetanib is expected to be > £66,000 per QALY gained., Future Research Priorities: (1) Primary research assessing the long-term effectiveness of cabozantinib and vandetanib within relevant subgroups. (2) Reanalyses of the ZETA trial to investigate the impact of adjusting for open-label vandetanib use using appropriate statistical methods. (3) Studies assessing the impact of MTC on HRQoL., Study Registration: This study is registered as PROSPERO CRD42016050403., Funding: The National Institute for Health Research Health Technology Assessment programme., Competing Interests: Jonathan Wadsley has received personal fees from Sanofi Genzyme (Cambridge, MA, USA), Ipsen (Paris, France), Bayer AG (Leverkusen, Germany), Baxalta (Shire Pharmaceuticals, London, UK), Eisai Co. Ltd (Tokyo, Japan) and Eli Lilly and Company (Basingstoke, UK), grants and personal fees from AstraZeneca plc (Cambridge, UK), non-financial support from Swedish Orphan Biovitrum AB (Stockholm, Sweden), and personal fees and non-financial support from Novartis International AG (Basel, Switzerland) and Celgene Corporation (Summit, NJ, USA) outside the submitted work.

This article explores the role of the chaplain in Catholic schools in England and some of the contemporary challenges. There is a focus on two issues in particular: the celebration of liturgy and the participation of non-Catholic children and the inclusion of LGBTQ+ children in the Catholic school. This article draws out some of the tensions between the pastoral sensitivities around participation in liturgy and the directives of the Prayer and Liturgy Directory and the complexity of the legal and pastoral inclusion of LGBTQ+ children. [ABSTRACT FROM AUTHOR]

For infectious disease prevention, policy-makers are typically required to base policy decisions in light of operational and monetary restrictions, prohibiting implementation of all candidate interventions. To inform the evidence-base underpinning policy decision making, mathematical and health economic modelling can be a valuable constituent. Applied to England, this study aims to identify the optimal target age groups when extending a seasonal influenza vaccination programme of at-risk individuals to those individuals at low risk of developing complications following infection. To perform this analysis, we utilise an age- and strain-structured transmission model that includes immunity propagation mechanisms which link prior season epidemiological outcomes to immunity at the beginning of the following season. Making use of surveillance data from the past decade in conjunction with our dynamic model, we simulate transmission dynamics of seasonal influenza in England from 2012 to 2018. We infer that modified susceptibility due to natural infection in the previous influenza season is the only immunity propagation mechanism to deliver a non-negligible impact on the transmission dynamics. Further, we discerned case ascertainment to be higher for young infants compared to adults under 65 years old, and uncovered a decrease in case ascertainment as age increased from 65 to 85 years of age. Our health economic appraisal sweeps vaccination age space to determine threshold vaccine dose prices achieving cost-effectiveness under differing paired strategies. In particular, we model offering vaccination to all those low-risk individuals younger than a given age (but no younger than two years old) and all low-risk individuals older than a given age, while maintaining vaccination of at-risk individuals of any age. All posited strategies were deemed cost-effective. In general, the addition of low-risk vaccination programmes whose coverage encompassed children and young adults (aged 20 and below) were highly cost-effective. The inclusion of elder age-groups to the low-risk programme typically lessened the cost-effectiveness. Notably, elderly-centric programmes vaccinating from 65-75 years and above had the least permitted expense per vaccine. Author summary: Vaccination is an established method to provide protection against seasonal influenza and its complications. Yet, a need to administer an updated vaccine on an annual basis presents significant operational challenges and sizeable costs. Consequently, policy makers typically have to decide how to deploy a finite amount of resource in a cost-effective manner. A combination of mathematical and health economic modelling can be used to address such a question. Here, we developed an age- and strain-structured mathematical model for seasonal influenza transmission dynamics that incorporates mechanisms for immunity propagation, which we used to reconstruct transmission dynamics of seasonal influenza in England from 2012 to 2018. We then performed a health economic evaluation assessing the cost-effectiveness of extending a seasonal influenza vaccination programme of at-risk individuals to also include, for targeted age groups, those individuals at low risk of developing complications following infection. The findings suggest the inclusion of low-risk vaccination programmes whose coverage encompassed children and young adults (aged 20 and below) to be highly cost-effective. In contrast, the inclusion of elder age-groups to the low-risk programme typically lessened the cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background: Patient and staff experiences provide important insights into care quality, but health systems have difficulty using these data to improve care. Little attention has been paid to understanding how patient experience feedback can act as a prompt to reflection in practice in the clinical setting. Objective: We aimed to identify the ways in which different types of patient experience feedback act as a trigger or prompt for engagement in reflection in clinical practice in acute hospital settings and identify important considerations for enhancing the value of patient experience data for reflective learning. Methods: We conducted an ethnographic study in eight acute care units in three NHS hospital trusts in England, including 140 hours of observations and 45 semi‐structured interviews with nursing, medical and managerial staff working in acute medical units and intensive care units. The data were analysed thematically. Findings: We distinguished between formal patient experience data sources: data purposively collected and collated to capture the patient experience of care, generally at organizational level, including surveys, complaints and comments; and informal sources of feedback on the patient experience recognized by staff alongside the formal data. We also identified patient narratives as an 'in between' source of data. The impact of different types of patient feedback in triggering reflection primarily depended on the extent to which the feedback was experienced as personally relevant, meaningful and emotionally salient. Discussion: Patient experience feedback is multi‐faceted, but our study suggests that all types of feedback could be harnessed more effectively to prompt reflection. [ABSTRACT FROM AUTHOR]

Seasonal influenza poses serious problems for global public health, being a significant contributor to morbidity and mortality. In England, there has been a long-standing national vaccination programme, with vaccination of at-risk groups and children offering partial protection against infection. Transmission models have been a fundamental component of analysis, informing the efficient use of limited resources. However, these models generally treat each season and each strain circulating within that season in isolation. Here, we amalgamate multiple data sources to calibrate a susceptible-latent-infected-recovered type transmission model for seasonal influenza, incorporating the four main strains and mechanisms linking prior season epidemiological outcomes to immunity at the beginning of the following season. Data pertaining to nine influenza seasons, starting with the 2009/10 season, informed our estimates for epidemiological processes, virological sample positivity, vaccine uptake and efficacy attributes, and general practitioner influenza-like-illness consultations as reported by the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC). We performed parameter inference via approximate Bayesian computation to assess strain transmissibility, dependence of present season influenza immunity on prior protection, and variability in the influenza case ascertainment across seasons. This produced reasonable agreement between model and data on the annual strain composition. Parameter fits indicated that the propagation of immunity from one season to the next is weaker if vaccine derived, compared to natural immunity from infection. Projecting the dynamics forward in time suggests that while historic immunity plays an important role in determining annual strain composition, the variability in vaccine efficacy hampers our ability to make long-term predictions. Influenza, the flu, is a highly infectious respiratory disease that can cause serious health complications. Characterised by seasonal outbreaks, a key challenge for policy-makers is implementing measures to successfully lessen the public health burden on an annual basis. Seasonal influenza vaccine programmes are an established method to deliver cost-effective prevention against influenza and its complications. Transmission models have been a fundamental component of vaccine programme analysis, informing the efficient use of limited resources. However, these models generally treat each influenza season and each strain circulating within that season in isolation. By developing a mathematical model explicitly including multiple immunity propagation mechanisms, then fit to influenza-related vaccine and epidemiological data from England via statistical methods, we sought to quantify the extent that epidemiological events in the previous influenza season alter susceptibility at the onset of the following season. The findings suggest that susceptibility in the next season to a given influenza strain type is modulated to the greatest extent through natural infection by that strain type in the current season. Residual vaccine immunity has a lesser role. Prospectively, the adoption of influenza transmission modelling frameworks with immunity propagation would provide a comprehensive manner to assess the impact of seasonal vaccination programmes. [ABSTRACT FROM AUTHOR]

The establishment of national parks is motivated by the preservation of natural values and resources or, more precisely, landscape and biodiversity, as well as satisfying scientific, educational, health and recreational, tourism, cultural and other needs. They have two often conflicting purposes: to protect important natural and cultural resources and to offer the possibility to use these areas as well as to enjoy them. People love to travel to protected natural areas just because on a relatively small but representative territory they can see a large number of plant and animal species, as well as participate in recreational activities in a pristine environment. The purpose of this study was to identify the motives and constraints for visiting national parks in relation to age, education level and employment status. The research was conducted among the London residents who are potential visitors of national parks in England. A total of 107 respondents were questioned through an online survey. The results obtained in this study showed that there are differences in motives and constraints in relation to sociodemographic characteristics of the respondents. The results of this study could direct the management of national parks to focus more on identifying and meeting the needs of potential visitors because of the increasing popularity of ecotourism. [ABSTRACT FROM AUTHOR]

Introduction: During the 2013–2014 influenza season, Public Health England extended routine influenza vaccination to all 2- and 3-year-old children in England. To estimate the impact of this change in policy on influenza-related morbidity and mortality, we developed a disease transmission and surveillance model informed by real-world data. Methods: We combined real-world and literature data sources to construct a model of influenza transmission and surveillance in England. Data were obtained for four influenza seasons, starting with the 2010–2011 season. Bayesian inference was used to estimate model parameters on a season-by-season basis to assess the impact of targeting 2- and 3-year-old children for influenza vaccination. This provided the basis for the construction of counterfactual scenarios comparing vaccination rates of ~2% and ~35% in the 2- and 3- year-old population to estimate reductions in general practitioner (GP) influenza-like-illness (ILI) consultations, respiratory hospitalizations and deaths in the overall population. Results: Our model was able to replicate the main patterns of influenza across the four seasons as observed through laboratory surveillance data. Targeting 2- and 3-year-old children for influenza vaccination resulted in reductions in the general population of between 6.2–9.9% in influenza-attributable GP ILI consultations, 6.1–10.7% in influenza-attributable respiratory hospitalizations, and 5.7–9.4% in influenza-attributable deaths. The decrease in influenza-attributable ILI consultations represents a reduction of between 4.5% and 7.3% across all ILI consultations. The reduction in influenza-attributable respiratory hospitalizations represents a reduction of between 1.2% and 2.3% across all respiratory hospitalizations. Reductions in influenza-attributable respiratory deaths represent a reduction of between 0.9% and 2.4% in overall respiratory deaths. Conclusion: This study has provided evidence that extending routine influenza vaccination to all healthy children aged 2 and 3 years old leads to benefits in terms of reduced utilization of healthcare resources and fewer respiratory health outcomes and deaths. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to explore maternal-fetal medicine specialists' experiences of conducting feticide in late termination of pregnancy.Methods: Participants were recruited via email. Purposeful sampling resulted in ten maternal-fetal specialists. Semistructured interviews were used to examine their experiences of conducting feticide. Interviews occurred across four English National Health Service hospitals. Interpretative phenomenological analysis was used.Results: An ongoing doctor-patient relationship when conducting feticide facilitated participants' self-image as clinicians rather than technicians. Coping involved rationalisation, with feticide viewed as 'part of the job'. Supportive team relationships helped keep emotional expression within control. Participants were not distressed if they felt, through relationship-based decision-making, that the feticide aligned with their values and legal interpretation. To avoid negative judgements, they disclosed selectively, only telling trusted individuals that they conducted feticides.Conclusions: Participants experienced conducting feticides as difficult but necessary, eliciting pride from the skills involved. Some noted management of personal distress. Optimal conditions were involvement in the process from the initial decision-making and team support. Providing feticides was deemed as potentially stigmatising, with selective disclosure employed. Training in managing feticides and guidance on providing optimal service conditions may decrease selectivity of disclosures and enhance staff well-being and the quality of feticide provisions. © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

A service development initiative was conducted to assess the impact of abdominal massage on chronic constipation in children with physical disabilities and learning needs. Twenty-five parents engaged in an abdominal massage training programme led by a specialist health visiting team (children's disability). Participants were asked to carry out abdominal massage for a total of 20 minutes per day. Quality of life indicators, descriptions of bowel movements, use of laxative medication and contact with health care services were recorded by parents. Costs and professional contact time with families was calculated. Results reported a wide range of quality of life improvements including relief in symptoms of constipation (87.5%), reduction in laxative medication (58%) and improved dietary intake (41%). Qualitative data indicated positive experiences described by parents which included enhanced parent-child relationships. [ABSTRACT FROM AUTHOR]

ABSTRACT Background There is a dearth of information on suicidal thoughts and acts or other acts of deliberate self-harm by offenders under community supervision. Aims The objective of this study is to estimate lifetime and one month prevalence of deliberate self-harm and to determine ongoing risk among offenders in the community under probation supervision. Methods One hundred and seventy-three randomly selected offenders under supervision by the probation service in one county in England were screened for mental illness. All 88 screened cases and a one-in-five sample of non-cases were interviewed according to the Mini International Neuropsychiatric Inventory Module-B. False negatives (n = 17) were used to weight calculations and estimate prevalence for the whole group. Results A third of the interviewed sample (n = 56) had a lifetime history of suicide attempts, and 9 (5%) had self-harmed in the month prior to interview. Lifetime suicide history was associated with suicidal ideation and deliberate self-harm in the prior month. Conclusions and implications Our adjusted findings indicate that 25-40% of offenders serving all or part of their sentence in the community have a lifetime history of self-harm, which is similar to the rate among prisoners, and are at very much higher risk of further such acts or completed suicide than the general population. At a time of change in delivery of probation services the implications are that rates of suicide and other forms of deliberate self-harm should be continually assessed in all probation areas, particularly with reference to service changes;, the relationship between deliberate acts of self-harm, suicidal ideation and completion of suicide should be investigated prospectively in larger studies;, probation services are likely to need mental health expertise to manage these risks Copyright © 2014 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Draper E, Alfirevic Z, Stacey F, Hennessy E, Costeloe K, for the EPICure Study Group. An investigation into the reporting and management of late terminations of pregnancy (between 22+0 and 26+6 weeks of gestation) within NHS Hospitals in England in 2006: the EPICure preterm cohort study. BJOG 2012;119:710-715. Objective To review all late terminations of pregnancy, between 22+0 and 26+6 weeks of gestation, collected as part of the EPICure2 study. Design Prospective cohort study. Setting All National Health Service (NHS) hospitals providing perinatal services for extremely preterm infants. Population All births between 22+0 and 26+6 weeks of gestation in England during 2006. Methods Data were collected for the defined cohort of births, including terminations of pregnancy, by designated unit staff using a standardised questionnaire. Rigorous validation processes were established to ensure comprehensive data collection. Gestational age was validated using a hierarchical classification of scan dates, certain date of last menstrual period and working gestation. Data for terminations of pregnancy (TOPs) were categorised into two groups, terminations for fetal abnormality and for maternal or fetal compromise, and were analysed in terms of their reporting, management and outcomes. Main outcome measures Classification, rate of feticide and outcome following TOP. Results Of 3782 births between 22+0 and 26+6 weeks of gestation, 647 (17.1%) were TOPs; of these 584 (90.3%) were for fetal abnormality and 63 (9.7%) for maternal or fetal compromise. Feticide was carried out in 489 of 584 (83.7%) TOPs for fetal abnormality, and in 38 of 63 (60.3%) of the TOPs for maternal or fetal compromise. Live births resulted following 2.2% TOPs for fetal abnormality and 4.8% TOPs for maternal or fetal compromise. Conclusion Terminations of pregnancy represent a relatively large proportion of very preterm births. Fetal abnormalities are the main cause for these terminations, and most include feticide. Better screening strategies are required to avoid the need for late terminations of pregnancy for fetal abnormalities. [ABSTRACT FROM AUTHOR]

nicholson j., slade p. & fletcher j. (2010) Termination of pregnancy services: experiences of gynaecological nurses. Journal of Advanced Nursing 66(10), 2245–2256. Aim. This paper is a report of a study to identify the experience of gynaecological nurses involved with termination of pregnancy. Background. Staff involved with termination of pregnancy have been found to experience both positive and negative views. Varying processes and experiences for staff have been identified, from termination of pregnancy work being emotionally draining and stressful to there being a process of care that evolves with greater experience. Methods. A purposive sample of seven gynaecological nurses currently working in a termination of pregnancy service was recruited. Data were collected between October 2007 and January 2008 using interviews and standardized questionnaires. Transcripts of the interviews were analysed using Interpretive Phenomenological Analysis. Results. Eight superordinate themes emerged from the analysis: (1) Unconditional acceptance and understanding of termination of pregnancy, (2) Strategies for managing the demands and challenges, (3) What we do for patients and job satisfaction, (4) Challenges to unconditional acceptance, (5) Juggling the contrasting needs and demands of patients, (6) The most demanding aspects of the role, (7) The significance of personal experience and (8) The service context. Some of the experiences were interpreted as ways in which nurses justified their role. The themes were understood in terms of a balance between strains, coping and contextual influences. Conclusion. Providing a recognized supportive supervisory environment might allow for the acknowledgement of the unique challenges staff in termination of pregnancy services face, and might enhance a sense of validation within the organization and hence staff wellbeing. [ABSTRACT FROM AUTHOR]

The sustainability of creative producers—businesses and individuals—depends in part on the state of the urban environment, especially the one of the street. Relationships with the street differ among creative producers with different power positions and levels of embeddedness in street life. Thus an approach to the sustainability of the creative city needs to move beyond the simplistic ideals of "mixed use" and "vitality" to an understanding of the complexity and continuity inherent in the production of creative spaces with respect to the multiple transactions of both the strong and weak stakeholders involved—the "wolves" and "lambs." The example used in this article, which draws on evidence from interviews with producers, is the film and television industry in Camden Town, London, in relation to the"experience" economy. [ABSTRACT FROM AUTHOR]

Creative industries development has been underway in the city of Stoke-on-Trent for the past fifteen years. Two urban quarters, a creative industries network, 'design-led' regeneration initiatives, and live-work spaces for craft businesses are some of the main projects undertaken in this period. In the past year, this raft of developments has been augmented by a creative industries mapping exercise, and a subsequent funding bid that seeks to draw on UK government and European structural funds in order to act on the research findings, and to put their recommendations into operation. This paper reviews this process both in terms of the political, economic, social, cultural and spatial context of the city, and in terms of broader urban agendas. It provides something of a corrective to the rather 'rose-tinted' picture often drawn of the role and significance of the creative industries for future economic and cultural well-being. [ABSTRACT FROM AUTHOR]

Social exclusion is a key policy theme for the New Labour government, and has been closely associated with education policy. The emphasis is on the need to combat social exclusion by creating a globally competitive economy through the education system, and through responsible individual attitudes. However, this dominant discourse is interpreted differently at various levels of policy making that provide alternative conceptualizations of the problem, and suggest different roles for education. This paper draws upon a research project that explored the links between education governance and social exclusion, and seeks to illustrate different approaches to social exclusion and education, as these are articulated by politicians and civil servants involved in policy making, or policy implementation in England. [ABSTRACT FROM AUTHOR]

The article examines some problems of mid-Post-glacial ecology and chronology in the area south and east of the English Lake District in England. The post-glacial increase in pine pollen frequencies is discussed. The stratigraphical evidence for changes in water level during mid-Post-glacial times is detailed. Information on the radiocarbon evidence from Lonsdale is presented. A discussion is presented on the relation of pine maximum in Lonsdale to local habitat factors and the climatic implications of the pine maximum in Lonsdale.