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Summary: We found social deprivation to be associated with higher mortality in the year following hip fracture among men and women aged 60 years and older in England. In those who did survive, deprivation was associated with longer hospital stays and greater risk of subsequent emergency readmission particularly for patients with dementia. Introduction: Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England. Methods: We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011–March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission. Results: We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2–5). Similarly, at 365 days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001). Conclusion: Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined. [ABSTRACT FROM AUTHOR]

Background: Paliperidone palmitate is one of the most widely prescribed long-acting injectable (LAI) antipsychotics in the UK. However, it is relatively expensive and there are few data comparing its effectiveness to that of other LAI antipsychotics. We sought to address this issue by analyzing a large anonymized electronic health record (EHR) dataset from patients treated with LAI antipsychotics. Methods: EHR data were obtained from 1281 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who started treatment with a LAI antipsychotic between 1 April 2011 and 31 January 2015. The number of days spent as a psychiatric inpatient and the number of admissions to a psychiatric hospital were analyzed in each of the 3 years before and after LAI prescription. Results: Patients treated with paliperidone palmitate (n = 430; 33.6%) had a greater number of inpatient days and a greater number of admissions in the year prior to treatment than those treated with other LAI antipsychotics. Nevertheless, in the 3 years after initiation there were no significant differences between paliperidone and the other LAI antipsychotics in the number of days as an inpatient (B coefficient 5.4 days, 95% confidence interval (CI) −57.3 to 68.2, p = 0.86) or number of hospital admissions (Incidence rate ratio 1.07, 95% CI 0.62 to 1.83, p = 0.82). Conclusion: Paliperidone palmitate was more likely to be prescribed in patients with more frequent and lengthy hospital admissions prior to initiation. However, the absence of differences in outcomes after initiation indicates that paliperidone palmitate was not more effective than other cheaper LAI antipsychotics. [ABSTRACT FROM AUTHOR]

Introduction Older adults who sustain a hip fracture require complex multidisciplinary care, which can challenge organisational structures within hospitals. Despite standards and guidelines, substantial variation remains in hip fracture care delivery across the UK. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the post injury period. Method A cohort of 178,757 patients aged 60+ years in England and Wales (2016–19) who sustained a hip fracture was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality data were linked to metrics from 18 hospital-level organisational audits/reports/series. Multilevel models determined the organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality, and emergency 30-day readmission. Results Overall LOS was mean 21 days (standard deviation, 20); 13,126 (7.3%) died within 30-days; and 25,239 (15.3%) were readmitted. 25 organisational factors independently predicted LOS: for example, a hospital's ability to promptly mobilise ≥90% of patients was associated with a 2-day (95%CI:1.3–2.7) shorter LOS, and hospitals where all patients received orthogeriatric assessment within 72 hours of admission had mean 1.5-day (95%CI:0.6–2.3) shorter LOS. Ten organisational factors independently predicted 30-day mortality: providing prompt surgery (≤36 hours from admission) to >80% patients was associated with the same 10% reduction in mortality (95%CI:4–15%), as was discussion of 'patient experience' feedback at clinical governance meetings (95%CI:5–15%). Nine organisational factors independently predicted readmission: knowledge of time from discharge to start of community therapy was associated with 17% (95%CI:9–24%) lower readmission rates. Organisational delivery of clinical governance, surgery, and physiotherapy were associated with all outcomes. Conclusion Multiple, potentially modifiable, organisational factors are associated with important patient outcomes post-hip fracture. These factors, if causal, indicate auditable components of hospital care where interventions can be targeted to reduce variability in hip fracture care delivery, to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Aims/PurposeTo determine the prevalence of age-related maculopathy (ARM) and age-related macular degeneration (AMD) in men aged 65-83 years living in the Speedwell region of Bristol, United Kingdom and identify modifiable risk factors.MethodsA total of 2348 men recruited to the Speedwell prospective cohort study in 1979 were followed up in 1997 with an eye questionnaire and had retinal photographs that were assessed using the International Classification System for ARM.ResultsIn all, 934 men (66.8% response rate) attended with a mean of 17.9 years (15.3-20.6 years) follow-up. Early ARM (grades 2-3) was found in 9.2% (95% confidence interval (CI) 7.4%, 11.4%) and late age-related maculopathy (grade 4, AMD) in 0.5% (95% CI 0.2%, 1.2%). The risk of ARM (grades 2-4) was increased with raised C-reactive protein and consumption of lard and solid fats, whereas triglyceride levels were associated with a lower risk. The latter were confirmed in multivariable analyses and in addition, haemodynamic measures also predicted risk (eg mean arterial pressure odds ratio (OR) per z-score 1.37, 95% CI 1.04, 1.79).ConclusionsIn a representative cohort of men aged 65-83 from Bristol, United Kingdom, many had macular changes that put them at higher risk of developing AMD. Various modifiable exposures were associated with an increased risk ARM/AMD. Opportunities for screening and undertaking secondary prevention interventions need to be explored to prevent progression of the disease and blindness. [ABSTRACT FROM AUTHOR]

Aims: To ascertain the prevalence of cataract in a representative group of men who have been followed since 1979 for cardiovascular disease.Methods: Of 2348 men aged 45-63 recruited in 1979 to the Speedwell Cardiovascular Study, 1420 were alive and willing to take part in further studies in 1997. They were sent a questionnaire about their eye health and invited to an ophthalmological examination at Bristol Eye Hospital. Cataract was graded using the Lens Opacities Classification System III (LOCS III) method.Results: Of the 1420 men, 26 died before they could be examined. Out of the remaining 1394 men, 949 presented for examination and full information was available for 936. Some information about eye health was obtainable for 394 men and 51 were not contactable. The prevalence of cataract increased with age and 36 men (3.8%) had had previous cataract surgery in either or both eyes. Of the remaining 903 men with no previous history of cataract surgery, cortical cataract was present in the right eye of 75 men (8.3%), nuclear (opalescence) in 128 (14.2%) and posterior subcapsular in 15 (1.7%). Five men (0.6%) had visual acuity of 6/60 or worse attributable to cataract in the right eye and 232 (25%) had visual acuity in one or both eyes of 6/24 or less at least partially attributable to cataract. There was no association between social class and the presence of cataract.Conclusions: The prevalence of cataract in a representative cohort of men followed since 1979 for cardiovascular disease was comparable to that previously reported in the UK and is consistent with studies from around the world. It appears that substantial amounts of visual loss, attributable to cataract, are present in men. Further studies establishing the reasons for this should be undertaken. [ABSTRACT FROM AUTHOR]

Introduction: Cinema is powerful - it can depict complex stories, spark discussion and foster reflection. Potentially, in geriatric medicine, the impact of serious diagnoses could be explored and learners’ preconceptions concerning ageing challenged. Thus, could film be used to explore and assess ‘hard-to-reach’ curriculum areas? The Mental Health in Older Adults module (MSc in Geriatric Medicine - Salford University) uses film in the oral assessed presentation. We wished to explore the utility of this Methods: Learners (North-West Speciality Registrars) were allocated different feature films exploring mental health themes. 8 learners each delivered a ten-minute presentation focusing on a topic selected after viewing the film. The audience comprised Speciality Registrars who could ask questions. The content of the presentations was reviewed. The key topics/themes tackled were analysed. Results: Learners watched one of the following: Iris, Tokyo Story, Still Alice, My Feral Heart, Firefly Dreams, The Carer, Away from Her and Amour. Each film generated 3 or more topics/themes. These were diverse and included: depression in chronic illness; loneliness; neuropsychological complications of stroke and the management and impact of dementia. Presenters set these into the film’s context and reflected on the interaction between physical health and social and psychological factors. ‘Hard-to-reach’ areas included: culture and social care, filial piety, and preconceptions of intellectual disability. Neglected areas tackled included suicide in older adults and the impact of dementia in younger adults. Audience feedback was positive. The reflective nature of the session provided new insights and was engaging Conclusions: Film is a medium that allows ‘hard-to-reach’ (and teach) areas to be tackled and assessed. The use of film was well received and importantly had utility. The topics learners reflected upon were complex and challenged their own and their audiences’ conceptions of clinical problems. [ABSTRACT FROM AUTHOR]

To quantify inter-observer variation between all the intracranial stereotactic radiosurgery (SRS) providers in England in delineating the target volumes of four brain tumour cases. Twenty-two, cross-platform SRS providers in England were instructed during a national commissioning assessment to contour the gross tumour volume (GTV) of six brain metastases, one cavernous sinus meningioma, one vestibular schwannoma and one pituitary adenoma. An expert reference group provided feedback if submitted contours were considered to be outliers and those centres were instructed to resubmit their contours. All contours were analysed in Python. The target volume contour (observed volume; V OBS), encompassing volume, 50% agreement volume (AV 50), 100% agreement volume (AV 100), concordance index (CCI) and discordance index (DCI) were calculated. Twenty-one centres participated using five different treatment platforms (CyberKnife, Gamma Knife, Varian Linac, Elekta Linac, Tomotherapy) and seven different treatment planning systems (GammaPlan, iPlan, Multiplan, Pinnacle, Eclipse, CMS Focal). The greatest variability was observed in the smallest brain metastases (GTV5 AV 50 0.0 cm3, CCI 0.28–0.84, DCI 0.00–0.70) and pituitary case (AV 50 1.1 cm3, CCI 0.42–0.82, DCI 0.01–0.40). The greatest agreement was observed with the vestibular schwannoma (AV 50 2.8 cm3, CCI 0.77–0.94, DCI 0.00–0.17). There were four resubmissions for the cavernous sinus meningioma and three resubmissions for the pituitary adenoma. Inter-observer variability was most evident with the smallest brain metastases and pituitary case. Several additional outliers and one acceptable contour were suggested using the metric-based analysis of AV 50 , CCI and DCI. Comparing contours using these metrics is an effective way to identify whether individual contours are similar to the 'true' target and to flag potentially significant deviations. • National, multicentre study of all stereotactic radiosurgery centres in England. • Evidence of inter-observer variability across a national population. • Variability most evident with the smallest volumes and geometrically complex targets. • Peer review highlighted inconsistencies in identifying acceptable and outlying contours. • AV 50 , CCI and DCI metrics can be used to identify outliers of benchmarking cases. [ABSTRACT FROM AUTHOR]

Introduction: A national audit of waiting times in England's genitourinary medicine clinics measures patient access. Data are collected by patient questionnaires, which rely upon patients' recollection of first contact with health services, often several days previously. The aim of this study was to assess the accuracy of patient-reported waiting times.Methods: Data on true waiting times were collected at the time of patient booking over a three-week period and compared with patient-reported data collected upon clinic attendance. Factors contributing to patient inaccuracy were explored.Results: Of 341 patients providing initial data, 255 attended; 207 as appointments and 48 'walk-in'. The accuracy of patient-reported waiting times overall was 52% (133/255). 85% of patients (216/255) correctly identified themselves as seen within or outside of 48 hours. 17% of patients (17/103) seen within 48 hours reported a longer waiting period, whereas 20% of patients (22/108) reporting waits under 48 hours were seen outside that period. Men were more likely to overestimate their waiting time (10.4% versus 3.1% p<0.02). The sensitivity of patient-completed questionnaires as a tool for assessing waiting times of less than 48 hours was 83.5%. The specificity and positive predictive value were 85.5% and 79.6%, respectively.Conclusion: The overall accuracy of patient reported waiting times was poor. Although nearly one in six patients misclassified themselves as being seen within or outside of 48 hours, given the under and overreporting rates observed, the overall impact on Health Protection Agency waiting time data is likely to be limited. [ABSTRACT FROM AUTHOR]

Some individuals with HIV in the UK are only diagnosed when they are admitted to hospitals with AIDS-defining illnesses. Early diagnosis and intervention are important to reduce the morbidity and mortality of HIV infection. Delays in diagnosing HIV infection may be expected to result in an increased risk of disease progression and complications. This retrospective cohort study was conducted between January 2002 and December 2003. Two hundred and nineteen new HIV infections were diagnosed in three hospitals in the south of England during the study period. Of these, 58 patients (35M, 23F) were diagnosed in non-GUM settings. The mean age was 39 years. Over 70% of the diagnoses were made within seven days. Eight percent of the diagnoses were made more than 50 days from the time of first presentation. The surgeons appeared no slower at diagnosing HIV infection in their patients than medical specialties. Late diagnosis of HIV infection remains a significant problem. HIV infection should be considered as part of the differential diagnoses to ensure early diagnosis and intervention. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence of oral diseases and their impact on oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care.Methods A survey was conducted at eight outpatient psychiatric care clinics in Tower Hamlets, London, UK. One hundred and twelve consecutive patients with mental illness were invited to participate in this study. They were clinically examined and asked to complete the oral health impact profile (OHIP) questionnaire.Results The response rate was 79% (n = 89); 57 (64%) males and 58 persons over 45 years of age (65%) participated in this survey. Overall OHIP score was 25.4 (95% CI 23.3, 27.4), 70 (78%) were smokers and 45 (51%) had been to the dentist in the last two years. Forty-seven (53%) respondents had caries in at least one tooth, 60 (67%) had 21 teeth and more, and 14 (16%) used dentures. Advanced periodontal treatment was indicated in 42 (55%) of patients and 52.8% (n = 47) patients reported current pain.Conclusion Overall, this survey found that oral health has a great impact on patients with severe mental illness being treated in the community setting and their oral health is poorer than the national adult general population. Future research should consider the causes that relate to the poorer oral health in this population and potential health promotion mechanisms in this population to encourage an upstream approach to health. [ABSTRACT FROM AUTHOR]

Background: One million people in England and Wales experience sexual violence and abuse each year, with nearly half experiencing serious sexual offences; around 30,000 survivors access sexual assault referral centres., Objectives: This research was commissioned by National Institute for Health and Care Research to evaluate access, interventions and care pathways for survivors, especially those provided through sexual assault referral centres., Design, Setting, Participants: The sexual assault referral centres care pathway was investigated through six sub-studies. There were two Cochrane Reviews (4274 participants). Seventy-two providers and 5 survivors were interviewed at eight sites; the children and young people study involved 12 participants from two sexual assault referral centres. A cohort study involving three-wave data collection over 1 year (21 sites; 2602 service users screened, 337 recruited) used a multilevel modelling framework to explore risk factors for burden of post-traumatic stress disorder symptoms at baseline and change at 1 year. We analysed costs and outcomes and conducted a narrative analysis (41 survivors). We worked closely with survivors and prioritised the safety/welfare of participants and researchers., Results: Cochrane Reviews identified large effects from psychosocial interventions for post-traumatic stress disorder and depression. Sexual assault referral centres delivered a high-quality frontline service for survivors but groups experiencing domestic abuse and some ethnic and cultural minorities were under-represented. The qualitative research emphasised inter-agency collaboration for survivor benefit. The cohort study identified a risk 'triad' of adverse childhood experiences, poor mental health and economic deprivation, which was associated with baseline trauma burden. There were important improvements in trauma symptoms a year later. These improvements were unrelated to different sexual assault referral centre models. Costs and other outcomes were also similar across models. Harmful policing and justice practices/procedures were identified by 25% of participants. In this context, trauma-competent interviewing techniques, regular/timely updates and conveying case decisions with care signalled good practice., Limitations: The cohort study lacked a comparison group, reducing confidence in the finding that access to sexual assault referral centres explained the reduction observed in post-traumatic stress disorder., Conclusions and Future Work: Barriers to access call for concerted efforts to implement trauma-informed universal health services. The risk 'triad' underscores the value of holistic approaches to care at sexual assault referral centres and timely follow-on care. Poor mental health was the main barrier to service access beyond sexual assault referral centres. The persistence of trauma symptoms a year after accessing sexual assault referral centres signals urgent need for tackling counselling wait-lists, expanding support options and commitment to lifelong care. Multidisciplinary evaluation of sexual assault referral centres for better health provides a foundation for advancing trauma-informed practices in the context of sexual violence and abuse., Study Registration: This study is registered as ISRCTN30846825 https://doi.org/10.1186/ISRCTN30846825., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/117/04) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 35. See the NIHR Funding and Awards website for further award information.

Background: Foundation doctors and nurses are the clinicians most closely involved in fluid assessment, intravenous (IV) fluid prescription and administration. However, both groups report challenges regarding IV fluids. At a large NHS trust in England, adherence to the National Institute for Health and Care Excellence (NICE) guideline CG174, regarding IV fluids, was largely unknown., Aims: To assess the baseline adherence, within the hospitals, to CG174 and identify areas for improvement., Methods: A set of 12 audit standards were developed and used to collect data across 29 clinical areas between September 2022 and May 2023, with 255 patients receiving IV fluids at any time during their inpatient stay included., Findings: For two standards target adherence of 95% was achieved, with an adherence less than 50% in most. Areas of particularly poor adherence included assessing and meeting fluid and electrolyte requirements, patient reassessment and developing IV fluid management plans., Conclusion: Trust baseline adherence to NICE CG174 requires improvement, particularly regarding patient assessment and reassessment, and meeting electrolyte requirements.

Introduction: With increasing numbers of oral cancer diagnoses and guidance recommending that patients approach their doctors or dentists for assessments, when searching for information regarding mouth cancer, patients may first look to their dental practice website. This study aimed to evaluate the variance of patient information provided regarding oral cancer on dental practice websites., Materials and Methods: Dental practices within the Manchester area with an active website were included with assessment of whether there was any information provided regarding reducing oral cancer risk factors, signs to look out for and if oral cancer screening was included as part of the general check-up, using a three-point score based on the joint statement from the British and Irish Society for Oral Medicine (BISOM) and Cancer Research UK (CRUK) regarding oral cancer diagnosis and prevention., Results: In total, 66.6% (n=60) of practices provided no accessible information regarding oral cancer screening and prevention on their websites. Only 12.2% (n=11) discussed all three factors of oral screening, symptoms and reducing risk factors. Screening as part of routine examination was most frequently mentioned at 27% (n=24), risk factors were discussed by 23% (n=21) of practices and symptoms to be aware of by 13% (n=12)., Discussion: There is a lack of information available to patients on dental practice websites regarding oral cancer. To overcome lack of quality assurance on the internet, dentists can provide factual information via their dental practice websites. This could help with improving patient awareness and therefore aiding in early detection, improving patient outcomes.

Background: Hip fracture care delivery varies between hospitals, which might explain variations in patient outcomes and health costs. The aim of this study was to identify hospital-level organisational factors associated with long-term patient outcomes and costs after hip fracture., Methods: REDUCE was a record-linkage cohort study in which national databases for all patients aged 60 years and older who sustained a hip fracture in England and Wales were linked with hospital metrics from 18 organisational data sources. Multilevel models identified organisational factors associated with the case-mix adjusted primary outcomes: cumulative all-cause mortality, days spent in hospital, and inpatient costs over 365 days after hip fracture., Findings: Between April 1, 2016, and March 31, 2019, 178 757 patients with an index hip fracture were identified from 172 hospitals in England and Wales. 126 278 (70·6%) were female, 52 479 (29·4%) were male, and median age was 84 years (IQR 77-89) in England and 83 years (77-89) in Wales. 365 days after hip fracture, 50 354 (28·2%) patients had died. Patients spent a median 21 days (IQR 11-41) in hospital, incurring costs of £14 642 (95% CI 14 600-14 683) per patient, ranging from £10 867 (SD 5880) to £23 188 (17 223) between hospitals. 11 organisational factors were independently associated with mortality, 24 with number of days in hospital, and 25 with inpatient costs. Having all patients assessed by an orthogeriatrician within 72 h of admission was associated with a mean cost saving of £529 (95% CI 148-910) per patient and a lower 365-day mortality (odds ratio 0·85 [95% CI 0·76-0·94]). Consultant orthogeriatrician attendance at clinical governance meetings was associated with cost savings of £356 (95% CI 188-525) and 1·47 fewer days (95% CI 0·89-2·05) in the hospital in the 365 days after hip fracture per patient. The provision of physiotherapy to patients on weekends was associated with a cost saving of £676 (95% CI 67-1285) per patient and with 2·32 fewer days (0·35-4·29) in hospital in the 365 days after hip fracture., Interpretation: Multiple, potentially modifiable hospital-level organisational factors associated with important clinical outcomes and inpatient costs were identified that should inform initiatives to improve the effectiveness and efficiency of hip fracture services., Funding: Versus Arthritis., Competing Interests: Declaration of interests PB reports funding by the European Commission (grant reference H2020-MSCA- ITN-2017 grant agreement identifier 7651141) and from the Hungarian Ministry of Innovation and Technology (grant reference 1783-3/2018/FEKUTSTRAT and TKP2020-IKA-02). AJu reports grants from National Institute for Health and Care Research (NIHR), Health Data Research UK, Versus Arthritis, Healthcare Quality Improvement Partnership, Royal College of Physicians, and Tommy's Health Foundation; chairs a data monitoring committee (NIHR Health Technology Assessment of the DISC trial at the University of Leicester, Leicester, UK) and a trial steering committee (NIHR Health Technology Assessment of the Gentle Years Yoga Trial, Newcastle University, Newcastle, UK); is a member of a steering committee at Nuffield Foundation (Multilevel Integrated Data for musculoskeletal health intelligence and Actions, University of Keele, Keele, UK); is a data monitoring committee member at Robotic Arthroplasty (RACER trial, Clinical Trials Unit, University of Warwick, Warwick, UK); is a sub-panel member of the NIHR Programme Grants for Applied Research programme; is on the Versus Arthritis Health Subcommittee; is co-chair of the Versus Arthritis Research Expert group; and is a member of the Nuffield Foundation Oliver Bird Fund Expert Panel. AJo is the clinical lead for the National Hip Fracture Database at the Royal College of Physicians, London, UK. JG reports an educational contract with Stryker that does not entail any relationships or activities that could have influenced the submitted work. TC is a member of the National Hip Fracture Database Advisory Board; has design and educational contracts with Stryker, Acumed, and Swemac; was a representative of the British Orthopaedic Association; previously sat on the board of the Falls and Fragility Fracture Audit Project (which includes the National Hip Fracture Database); and helped set up and perform British Orthopaedic Association multidisciplinary peer reviews for hip fractures. XLG reports funding from the NIHR Health Technology Assessment Programme; multiple other grants from NIHR for specific projects unrelated to this work; and consultancy fees from Johnson & Johnson and Stryker. MKJ reports honoraria, unrestricted research grants, and travel or subsistence expenses from Amgen, Consilient Health, Kyowa Kirin Hakin, UCB, AbbVie, Sanofi, and Besin Healthcare; participation in the committees or boards of Regeneron, International Osteoporosis Foundation Capture the Fracture Steering Committee, Fracture Liaison Service Database of England and Wales, and medical advisory board of Brittle Bone Society and Fibrous Dysplasia Support Society UK. ECB reports funding from the UK Prevention Research Partnership (Violence, Health and Society; grant reference MR-VO49879/1), the British Heart Foundation, the Scottish Government Health and Social Care Directorates, Engineering and Physical Sciences Research Council, Economic and Social Research Council, Health and Social Care Research and Development Division (Welsh Government), Medical Research Council, NIHR, Natural Environment Research Council, Public Health Agency (Northern Ireland), the Health Foundation, and the Wellcome Trust. YB-S reports book royalties from Oxford University Press and Wiley; consulting fees from Human Centric Drug Discovery; and is a member of the trial steering committee of the SIMPLIFIED trial. EMRM reports research funding from CeramTec UK, NIHR, Medical Research Council, and the Healthcare Quality Improvement Partnership; is a steering group committee advisor for an NIHR Health Services and Delivery Research grant and an NIHR Health Technology Assessment grant; and a committee member for the NIHR Research for Patient Benefit funding scheme since 2017 and NIHR Programme Grant for Applied Research funding scheme since 2023. CLG reports research grants from Wellcome Trust, Royal Osteoporosis Society, Chan Zuckerberg Donor Advised Fund, and Versus Arthritis; and is a Chair of the National Osteoporosis Guideline Group and a member of the Royal College of Physicians Falls and Fragility Fracture Scientific committee. RP reports funding from CeramTec UK on an unrelated study and after completion of the analyses for the present Article., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background/objectives: To characterise the patterns of presentation and diagnostic frequencies in Hospital Emergency Eye Care Services (HEECS) across 13 hospitals in England., Methods: Retrospective, cross-sectional, observational multi-centre (n = 13) study to assess HEECS attendances over a 28-day study period. Data derived included: number of consecutive attendances, patient demographics and diagnoses. Age and gender variations, the impact of day of the week on attendance patterns, diagnostic frequencies and estimates of the annual incidence and attendance rates were evaluated., Results: A total of 17,667 patient (mean ± standard deviation age = 49.6 ± 21.8 years) attendances were identified with an estimated HEECS annual new attendance rate of 31.0 per 1,000 population. Significantly more females (53%) than males (47%) attended HEECS (p < 0.001). Female attendances were 13% higher in those ≥50 years of age. Weekends were associated with a significant reduction in attendances compared to weekdays (χ 2  = 6.94, p < 0.001). Among weekdays, Mondays and Fridays were associated with significantly higher attendances compared with midweek (χ 2  = 2.20, p = 0.032). Presenting pathologies involving the external eye, cornea and conjunctiva accounted for 28.6% of the caseload., Conclusion: This is the largest multicentre study assessing attendance patterns in HEECS in England. We have, for the first time, observed a "weekend effect" in relation to attendance to HEECS. Differences in health-seeking behaviour and lack of awareness of HEECS weekend services may be partly attributed to the differences observed. Our findings, along with the type of presentations, have the potential to guide commissioners with future planning of HEECS., (© 2021. Crown.)

Objectives: Despite established standards and guidelines, substantial variation remains in the delivery of hip fracture care across the United Kingdom. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the months following hip fracture., Methods: We examined a national record-linkage cohort of 178,757 patients aged ≥60 years who sustained a hip fracture in England and Wales in 2016-19. Patient-level hospital admissions datasets, National Hip Fracture Database and mortality data were linked to metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality and emergency 30-day readmission., Results: Across hospitals mean LOS ranged from 12 to 41.9 days, mean 30-day mortality from 3.7 to 10.4% and mean readmission rates from 3.7 to 30.3%, overall means were 21.4 days, 7.3% and 15.3%, respectively. In all, 22 organisational factors were independently associated with LOS; e.g. a hospital's ability to mobilise >90% of patients promptly after surgery predicted a 2-day shorter LOS (95% confidence interval [CI]: 1.2-2.6). Ten organisational factors were independently associated with 30-day mortality; e.g. discussion of patient experience feedback at clinical governance meetings and provision of prompt surgery to >80% of patients were each associated with 10% lower mortality (95%CI: 5-15%). Nine organisational factors were independently associated with readmissions; e.g. readmissions were 17% lower if hospitals reported how soon community therapy would start after discharge (95%CI: 9-24%)., Conclusions: Receipt of hip fracture care should be reliable and equitable across the country. We have identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The use of stereotactic ablative radiotherapy (SABR) in the UK has expanded over the past decade, in part as the result of several UK clinical trials and a recent NHS England Commissioning through Evaluation programme. A UK SABR Consortium consensus for normal tissue constraints for SABR was published in 2017, based on the existing literature at the time. The published literature regarding SABR has increased in volume over the past 5 years and multiple UK centres are currently working to develop new SABR services. A review and update of the previous consensus is therefore appropriate and timely. It is hoped that this document will provide a useful resource to facilitate safe and consistent SABR practice., (Copyright © 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Introduction: Substantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients' outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care., Methods and Analysis: Quantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016-2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an 'Implementation Toolkit' to inform and improve commissioning and delivery of hip fracture services., Ethics and Dissemination: This study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops., Competing Interests: Competing interests: None for RP, SD, XLG, TJ, JG, MB, KW, ECB, YB-S, RG-H, CLG. AJohansen is the clinical lead for the National Hip Fracture Database, in the Royal College of Physicians, London. TC is the British Orthopaedic Association (BOA) representative and sits on the board of the Falls and Fragility Fracture Audit Project (which includes the National Hip Fracture Database), he helped set up and perform many of the BOA multidisciplinary peer reviews for hip fractures, he has design and educational contracts with Stryker, Acumed and Swemac. MKJ has received honoraria, unrestricted research grants, travel and/or subsistence expenses from: Amgen, Consilient Health, Kyowa Kirin Hakin, UCB, Abbvie. EMRM has received funds for an unrelated independent study sponsored by CeramTec UK limited. AJudge has received consultancy fees from Freshfields, Bruckhaus, Derringer and Anthera Pharmaceuticals Ltd., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: Myocardial fibrosis occurs in end-stage heart failure secondary to mitral regurgitation (MR), but it is not known whether this is present before onset of symptoms or myocardial dysfunction. This study aimed to characterise myocardial fibrosis in chronic severe primary MR on histology, compare this to tissue characterisation on cardiovascular magnetic resonance (CMR) imaging, and investigate associations with symptoms, left ventricular (LV) function, and exercise capacity., Methods: Patients with class I or IIa indications for surgery underwent CMR and cardiopulmonary exercise testing. LV biopsies were taken at surgery and the extent of fibrosis was quantified on histology using collagen volume fraction (CVF mean ) compared to autopsy controls without cardiac pathology., Results: 120 consecutive patients (64 ± 13 years; 71% male) were recruited; 105 patients underwent MV repair while 15 chose conservative management. LV biopsies were obtained in 86 patients (234 biopsy samples in total). MR patients had more fibrosis compared to 8 autopsy controls (median: 14.6% [interquartile range 7.4-20.3] vs. 3.3% [2.6-6.1], P < 0.001); this difference persisted in the asymptomatic patients (CVF mean 13.6% [6.3-18.8], P < 0.001), but severity of fibrosis was not significantly higher in NYHA II-III symptomatic MR (CVF mean 15.7% [9.9-23.1] (P = 0.083). Fibrosis was patchy across biopsy sites (intraclass correlation 0.23, 95% CI 0.08-0.39, P = 0.001). No significant relationships were identified between CVF mean and CMR tissue characterisation [native T1, extracellular volume (ECV) or late gadolinium enhancement] or measures of LV function [LV ejection fraction (LVEF), global longitudinal strain (GLS)]. Although the range of ECV was small (27.3 ± 3.2%), ECV correlated with multiple measures of LV function (LVEF: Rho = - 0.22, P = 0.029, GLS: Rho = 0.29, P = 0.003), as well as NTproBNP (Rho = 0.54, P < 0.001) and exercise capacity (%PredVO 2 max: R = - 0.22, P = 0.030)., Conclusions: Patients with chronic primary MR have increased fibrosis before the onset of symptoms. Due to the patchy nature of fibrosis, CMR derived ECV may be a better marker of global myocardial status. Clinical trial registration Mitral FINDER study; Clinical Trials NCT02355418, Registered 4 February 2015, https://clinicaltrials.gov/ct2/show/NCT02355418.

Objectives: To describe the uptake and outputs of the National Health Service Health Check (NHSHC) programme in England., Design: Observational study., Setting: National primary care data extracted directly by NHS Digital from 90% of general practices (GP) in England., Participants: Individuals aged 40-74 years, invited to or completing a NHSHC between 2012 and 2017, defined using primary care Read codes., Intervention: The NHSHC, a structured assessment of non-communicable disease risk factors and 10-year cardiovascular disease (CVD) risk, with recommendations for behavioural change support and therapeutic interventions., Results: During the 5-year cycle, 9 694 979 individuals were offered an NHSHC and 5 102 758 (52.6%) took up the offer. There was geographical variation in uptake between local authorities across England ranging from 25.1% to 84.7%. Invitation methods changed over time to incorporate greater digitalisation, opportunistic delivery and delivery by third-party providers.The population offered an NHSHC resembled the English population in ethnicity and deprivation characteristics. Attendees were more likely to be older and women, but were similar in terms of ethnicity and deprivation, compared with non-attendees. Among attendees, risk factor prevalence reflected population survey estimates for England. Where a CVD risk score was documented, 25.9% had a 10-year CVD risk ≥10%, of which 20.3% were prescribed a statin. Advice, information and referrals were coded as delivered to over 2.5 million individuals identified to have risk factors., Conclusion: This national analysis of the NHSHC programme, using primary care data from over 9.5 million individuals offered a check, reveals an uptake rate of over 50% and no significant evidence of inequity by ethnicity or deprivation. To maximise the anticipated value of the NHSHC, we suggest continued action is needed to invite more eligible people for a check, reduce geographical variation in uptake, prioritise engagement with non-attendees and promote greater use of evidence-based interventions especially where risk is identified., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Aims: This research investigated the effectiveness of an intervention for improving the prescribing and patient safety behaviour among Foundation Year doctors. The intervention consisted of simulated clinical encounters with subsequent personalised, structured, video-enhanced feedback and deliberate practice, undertaken at the start of four-month sub-specialty rotations., Methods: Three prospective, non-randomised control intervention studies were conducted, within two secondary care NHS Trusts in England. The primary outcome measure, error rate per prescriber, was calculated using daily prescribing data. Prescribers were grouped to enable a comparison between experimental and control conditions using regression analysis. A break-even analysis evaluated cost-effectiveness., Results: There was no significant difference in error rates of novice prescribers who received the intervention when compared with those of experienced prescribers. Novice prescribers not participating in the intervention had significantly higher error rates (P = .026, 95% confidence interval [CI] Wald 0.093 to 1.436; P = .026, 95% CI 0.031 to 0.397) and patients seen by them experienced significantly higher prescribing error rates (P = .007, 95% CI 0.025 to 0.157). Conversely, patients seen by the novice prescribers who received the intervention experienced a significantly lower rate of significant errors compared to patients seen by the experienced prescribers (P = .04, 95% CI -0.068 to -0.001). The break-even analysis demonstrates cost-effectiveness for the intervention., Conclusion: Simulated clinical encounters using personalised, structured, video-enhanced feedback and deliberate practice improves the prescribing and patient safety behaviour of Foundation Year doctors. The intervention is cost-effective with potential to reduce avoidable harm., (© 2020 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.)

National guidelines give advice on topics which should be covered when counselling patients with a new diagnosis of genital herpes (HSV) with the aim of reducing transmissions. This three-site UK audit of documentation of counselling for patients with a new diagnosis of genital herpes reviewed the records of 284 patients. Documentation in all areas of counselling was limited and this may result in adverse medico-legal consequences for patients and clinicians.

Objective: To investigate the method, learning and challenges of using an enhanced sample to provide small area data for the dental survey of five-year-old children in England., Design: Pilot in six London local authorities, of increased sample size during a national survey to enable a more precise sample size calculation to deliver information accurate at electoral ward level. Challenges were explored through interviews with the teams who either planned or conducted the survey., Main Outcome Measures: A revised sample size recommendation for the national guidance on carrying out dental surveys of five-year-old children in England, where caries levels are similar to those seen in the pilot areas; the challenges identified were gaining access to schools and consent from parents, making the calculation for the additional sample and securing sufficient workforce., Conclusion: This paper has described a method for delivering small area caries data by increasing the size of the sample. Learning, and understanding the outcomes and challenges from this work can inform planning and delivery of future surveys using an enhanced sample at ward level., (Copyright© 2020 Dennis Barber Ltd.)

Competing Interests: Competing interests: None declared.

Background: Uptake of influenza vaccination by healthcare workers (HCWs) may be related to how influenza campaigns are implemented. This study explores differences in annual influenza campaign implementation between NHS trusts (healthcare organisations) with higher and lower vaccine uptake., Methods: A cross-sectional survey with influenza campaign staff in 2016/2017 in 87 NHS trusts in England. The survey measured vaccination policy and uptake target, staff involvement, accessibility, use of peer vaccinators, communication strategies, strategies to address HCW concerns, use of incentives, and management support. The analysis considered implementation differences between higher (n Z 50) and lower (n Z 37) uptake trusts., Results and Conclusions: Higher uptake trusts were more likely to set higher uptake targets, involve a broader range of staff groups in the campaign, and make the vaccine easy to access by core or hard-toreach HCWs. Higher uptake trusts were also more likely to use a greater range of communication strategies, provide real-time feedback on uptake, provide a greater range of incentives to be vaccinated, and have vaccine uptake considered important by managers. Successful influenza vaccination programmes are multifaceted and involve implementation factors at a strategic, organisational, logistical, and personnel level. Lower uptake trusts could improve uptake by identifying and implementing examples of best practice from higher uptake trusts., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

This paper aims to provide a snapshot analysis of the oral health status of vulnerable adults in Plymouth; and to demonstrate the extent to which oral disease impacts on their normal functioning through the implementation of the Oral Health Impact Profile (OHIP). It is acknowledged that gaining a representative sample of a transient population such as people who are homeless, or individuals affected by problematic use of drugs and/or alcohol is difficult. An opportunity was identified to collect data within the Community Engagement Team's (CET) programme of activity within the Peninsula Dental Social Enterprise. The CET works alongside local organisations to enable dental students from Peninsula School of Dentistry to undertake outreach programmes in a variety of settings. A study was designed which aimed to analyse the oral health status of vulnerable adults accessing three day-support services in Plymouth, and to understand the extent to which oral disease impacts on their normal functioning through the OHIP-14. For all impact domains, the 44 patients in this study reported a greater impact than that found in the Adult Dental Health Survey. The most commonly reported impact domains were physical pain and psychological discomfort. The sample was divided into high and low oral health-related quality of life impact groups, and those participants in the high impact group had significantly greater median D₃MFT scores, i.e. higher levels of decay experience. This survey highlights how these vulnerable groups are characterised by a high prevalence of poor oral health, ill-health, deprivation and social exclusion., (Copyright© 2018 Dennis Barber Ltd.)

There is a high prevalence of mental health need in prisons, much of which is currently unmet. Although considerable research has identified and described this mental health need, there has been limited research focussed on reviewing the delivery of mental health care in prisons. This study uses content analysis to review 36 unannounced prison inspection reports in England to establish whether mental health care was provided to an appropriate standard, and whether it is equivalent to services that are provided in the wider community. The analysis identified four main categories, each of which had further sub-categories: managing the process; staffing; range of services; and quality of service. Numerous concerns were identified, including: delays to service access; lack of appropriate interventions; low staffing levels; limited specialist support; and limited access to supervision, training and reflective practice. Despite these difficulties, many teams had adopted open referral systems to improve service access, had good working relationships and were thought to be providing care of good quality. The delivery of mental health care within prisons is still not equivalent to that which is provided in the community, and this study has identified a number of areas for further improvement., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Following growing evidence to support the safety, local control (LC) and potential improvement in overall survival (OS) in patients with oligometastatic non-small cell lung cancer (NSCLC) that have been treated with local ablative therapy such as stereotactic ablative radiotherapy (SABR) and stereotactic radiosurgery (SRS), we initiate the SARON trial to investigate the impact and feasibility of adding SABR/SRS and radical radiotherapy (RRT) following standard chemotherapy on OS., Methods and Analysis: SARON is a large, randomised controlled, multicentre, phase III trial for patients with oligometastatic EGFR, ALK and ROS1 mutation negative NSCLC (1-3 sites of synchronous metastatic disease, one of which must be extracranial). 340 patients will be recruited over 3 years from approximately 30 UK sites and randomised to receive either standard platinum-doublet chemotherapy only (control arm) or standard chemotherapy followed by RRT/SABR to their primary tumour and then SABR/SRS to all other metastatic sites (investigational arm). The primary endpoint is OS; the study is powered to detect an improvement in median survival from 9.9 months in the control arm to 14.3 months in the investigational arm with 85% power and two-sided 5% significance level. The secondary endpoints are LC, progression-free survival, new distant metastasis-free survival, toxicity and quality of life. An early feasibility review will take place after 50 randomised patients. Patients requiring both conventional thoracic RT to the primary and SABR to a thoracic metastasis will be included in a thoracic SABR safety substudy to assess toxicity and planning issues in this subgroup of patients more thoroughly., Ethics and Dissemination: All participants are given a SARON patient information sheet and required to give written informed consent. Results will be submitted for presentation at local and international conferences and expected to be published in a peer-reviewed journal., Trial Registration Number: NCT02417662., Sponsor Reference: UCL/13/0594., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The intention of personalized teaching and learning to improve clinical performance is the optimization of individual performance across a variety of tasks in different environments. Educational interventions need to have a focus on the assessment and feedback of both outcome and process of performance. An essential component of the assessment and feedback on the process of performance is how 'the will' and 'the skill' are dynamically adapted by the individual through self-regulated learning processes. Microanalysis can identify the key self-regulated learning processes and the findings used to inform self-regulated learning enhanced feedback for personalized teaching and learning. The experience of the authors in using self-regulated learning enhanced feedback for optimizing performance in prescribing by junior doctors is discussed.

This paper describes the principles applied and the challenges met while seeking user and other stakeholder perspectives before designing an oral care training package for carers in nursing and residential care facilities. The public health competencies it illustrates include the application of appropriate leadership styles, strategic management, collaborative working and knowledge of research methodology.

Introduction: There is a different perspective on diagnosis and management of common surgical problems in elderly patients. This study aimed to analyse the management of acute appendicitis in octogenarians., Methods: A retrospective study investigated all appendicectomies over five years. Patient records were studied for presenting features, pre-operative imaging, pre-operative ASA grade, site of incision, post-operative complications and length of inpatient stay., Results: Presenting symptoms included lower abdominal pain (n = 31, 93.9%), anorexia (n = 19, 57.6%), nausea and vomiting (n = 15, 45.5%) and shifting pain (n = 10, 30.3%). Twenty patients had right iliac fossa pain (60.6%) and seven had pyrexia (21.2%). The commonest co-morbidity was cardiac (n = 19; 58%). The average time from admission to theatre was greater in octogenarian patients (1.24 ± 0.90 days) than other patients (0.64 ± 0.71 days), as was the average length of stay at 11 ± 2.6 days compared with 4.3 ± 3.1 days. The majority of octogenarian patients received a Lanz incision (48.3%), with others receiving laparotomy (24.1%), lower midline (13.8%), gridiron (13.8%), and right paramedian (3.4%). Complications were more common in the octogenarian patients (63.6%) than other patients (22.55%). The most common complications in the octogenarian population were post-operative ileus (n = 7; 21%), wound infection (n = 5; 15.2%) and pneumonia (n = 5; 15.2%)., Conclusion: Appendicitis in the elderly can result in significant morbidity due to the atypical presentation causing an unnecessary delay in treatment. If indicated, age should not be a contraindication for an appendicectomy. The increased likelihood for these patients to have a post-operative complication should be at the forefront of their care., (Copyright © 2011 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.

This study was undertaken to assess the impact on patients of proposals to centralize head and neck oncology services in the UK. A retrospective audit of the 2001-2002 head and neck cancer database at South Devon district general hospital identified 85 patients (50 males: 35 females; median age 66 years; range 29-93) diagnosed with head and neck cancer. The total number of hospital visits for diagnostic, therapeutic and other management services were recorded (median number of visits 28; range 1-78). Using this data, the extra distance required to travel to a potential regional cancer centre located in Bristol during the first six months of management was extrapolated. It was calculated that each patient would have to travel on average an extra 5333 miles (median 5658; range 185-13 759). Published documents advocating centralization of oncology services make no reference to the patient burden of geographic relocation of medical services. Agencies involved with restructuring oncology services must recognize the non-clinical impact of centralization and make some provision to overcome the burden facing patients and their carers.

Demand for dermatology services is increasing, resulting in changes in service provision and the role of nurses. Technological advances have led to the development of telemedicine. This article describes how four primary care trusts and the dermatology department at Queen's Medical Centre developed a district-wide teledermatology service. The service was led by nurses and a GP with a special interest in dermatology.

Aims: To determine the extent to which informed patient consent for cardiac surgery corresponds with standard guidelines and to assess patient satisfaction with the consent process., Methods: A questionnaire developed in accordance with consent guidelines published by the Medical Defence Union (MDU) and the Practicalities Of Producing Patient information (POPPi) Guide was administered to 82 patients after they were consented for cardiac surgery., Results: Patients were informed about i) type of operation [n=80, 97.5%] ii) reason for surgery [n=78, 95%] iii) surgical procedure [n=77, 94%] iv) length of hospital stay [n=73, 89%] and v) post-surgical care [n=79, 96.3%]. However, a decreasing number of patients were notified about i) possible risks of surgery [n=64, 78%] and ii) consequences of no surgery [n=62, 75.6%]. Interestingly, patients received less adequate information about i) alternative methods of treatment (n=34, 41.4%], ii) future lifestyle (n=55, 67%] and iii) medications following surgery [n=40, 48.7%]. 81% (n=67) were overall 'satisfied' with the information provided. More than 95% (n=78) patients were invited to ask questions. The most commonly asked questions were about i) quality of life ii) length of operation and hospital stay iii) surgical procedure iv) consequences of no surgery., Conclusions: The study has highlighted areas of informed consent in cardiac surgical patients that need attention. Although, patients were generally satisfied and well informed about the procedure, less information was presented covering alternative treatments, future lifestyle and medications. This was reflected in the questions asked by patients and their suggested improvements for the consent procedure.

Background and Aim of the Study: An increasing number of elderly patients are now requiring mitral valve surgery (MVS). However, due to a perceived increase in risk of morbidity and mortality following cardiac surgery, many elderly patients tend to be neglected or not referred for surgery., Methods: The outcome of MVS in terms of hospital morbidity and mortality, length of intensive care unit (ICU) and hospital stays, and change in NYHA functional class and quality of life following surgery was assessed in 43 elderly patients (18 males, 25 females; median age 77 years (IQR 75-82 years)) who underwent primary open mitral valve repair (MVRr) or replacement (MVR) between November 1994 and September 1997. Their preoperative clinical characteristics, incidence of hospital morbidity, hospital mortality and length of ICU and hospital stays following MVS were recorded. At follow up, NYHA class was assessed and quality of life parameters monitored using the SF-36 questionnaire., Results: At surgery, 69% of patients were in NYHA class III/IV, 36% underwent non-elective surgery and 44% had symptoms of more than three years' duration. Among patients, 80% presented with mitral incompetence and MVRr was undertaken in 51%. The median bypass and cross-clamp times for MVRr were significantly longer than for MVR. After surgery, 98% of patients required inotropic support, 9% renal dialysis, and 42% ventilatory support for >24 h. In addition, 37% developed respiratory complications, 12% renal failure, 19% needed re-exploration for bleeding, and 5% suffered a stroke. The mean ICU stay after surgery was three days; average in-hospital stay was 10 days. The 30-day mortality rate was 22.7% after MVRr and 38% after MVR. There was a significant improvement in energy, and role limitation due to physical and mental health after MVS., Conclusions: Elderly patients underwent MVS, usually after a degree of clinical deterioration. Although morbidity and mortality following mitral valve surgery were high, at follow up there was a significant improvement in both symptoms and quality of life of survivors.

Aim: To compare the clinical characteristics, at the time of admission and after coronary revascularization by bypass surgery, among British patients of Indo-Asian and white Caucasian descent., Method: One hundred and ninety-four pairs of patients admitted between November 1994 and January 1997 were matched for age (within 3 years), sex and date of admission (within 3 months). Their clinical characteristics at the time of admission for coronary artery bypass grafting surgery, and the incidence of hospital morbidity, hospital mortality and length of stay in the intensive therapy unit or hospital following coronary artery bypass grafting were determined., Results: A higher proportion of Indo-Asian patients underwent coronary revascularization on a non-elective basis (43% vs 32% white Caucasian patients, P =0.018), had a higher prevalence of diabetes (39% vs 12%, P =0.0001), a lower prevalence of smoking (36% vs 80%, P =0.0001) and a lower rate of previous myocardial infarction (47% vs 62%, P =0.012). As regards revascularization, although there was no significant difference in the number of vessels revascularized, there was a lower use of the arterial conduit (internal mammary artery) in the Indo-Asian patients (72% vs 81%, P =0.028) particularly for those undergoing emergency/urgent surgery (59% vs 72%, P =0.001) and with a previous myocardial infarction (65% vs 81%;P =0.01) when compared with their white Caucasian counterparts. Following surgery there were no differences in the types of support required for vital functions. There was no significant difference in the proportion of major post-operative complications, that is, haemorrhage, cerebrovascular accident, renal failure requiring dialysis or respiratory failure. Similarly, there were no differences in the length of intensive therapy unit stay (median stay 1 day vs 1 day, P =0.4) and hospital stay following surgery (median stay 6 days vs 6 days, P =0.5) between the two groups. Although there was a trend towards a higher in-hospital (30 day) mortality (6.7% [95% confidence intervals CI 3.18-10.21] vs 2.6% [CI 0.35-4.9;P =0.0618]), in Indo-Asians compared to white Caucasians this trend disappeared when patients in the two groups undergoing non-elective surgery only were compared (9% vs 7%;P =0.7)., Conclusions: A higher proportion of Indo-Asians underwent non-elective coronary revascularization, with a significantly lower use of the arterial conduit and a relatively higher in-hospital mortality. Following coronary revascularization the medical management, length of stay and hospital morbidity in Indo-Asian patients was no different from that of their white Caucasian counterparts. This is despite a perceived poorer outcome in Indo-Asians compared to white Caucasians., (Copyright 1999 The European Society of Cardiology.)

To survey the in-hospital morbidity, mortality, length of stay in the intensive therapy unit (ITU) and hospital and quality of life in patients of Indo-Asian origin following coronary artery bypass (CABG) surgery, 345 consecutive patients (mean age 58 years; SD 8.9; range 32-88 years) undergoing primary, isolated CABG were studied. Non-elective CABG was undertaken in 41% of patients. The left anterior descending artery (LAD) was grafted in 89%, although in 30% of these the internal mammary artery (IMA) was not used. Following CABG, the hospital morbidity and mortality was within the expected range, although there was a trend towards higher in-hospital mortality in the Parsonnet low risk group of patients. The length of ITU and hospital stay was not prolonged. Using the SF-36 questionnaire in postoperative patients, low quality of life scores were obtained for six of the eight modalities tested including physical functioning, bodily pain and general health perception. The low quality of life scores and IMA usage in Indo-Asians needs to be addressed.

Random samples of people aged 40 years and over were drawn from lists of patients registered with two neighbouring inner-city general practices: one predominantly with Asian patients and the other predominantly with European patients. The people selected were invited to attend specially arranged eye clinics for examination by an ophthalmologist and an optician. We examined 377 people and found that, compared to people of European descent, Asians had a significantly higher prevalence of age-related cataract: 30% compared to 3% in people aged under 60 years and 78% compared to 54% in those aged 60 years and over. The age of onset of cataract seems to be earlier in Asians. After adjustment for age, there were no statistically significant ethnic differences in the prevalences of open-angle glaucoma, macular degeneration or diabetic retinopathy.

A community based ophthalmic survey has been carried out in the city of Leicester. Samples of Asians and Caucasians aged 40 years and over were randomly selected from the patients of four general practitioners and invited to have an ophthalmic examination. After adjustment for age, the prevalence rate of age-related cataract was significantly higher in the Asians when compared to the Caucasians. Age-related cataract was found to develop earlier in the Asians. A strict vegetarian diet was found to be a significant risk factor for age-related cataract in the Asian Community in Leicester.