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Palaeophonus arctusMatthew, 1895, from the late Carboniferous Fern Ledges of Nova Scotia, Canada, and Palaeophonus lightbodyiKjellesvig-Waering, 1954, from the Silurian of Ludford Lane in England, are problematic names proposed for fossil scorpions (Arachnida: Scorpiones). Matthew's name has been widely overlooked in the literature, but features in online resources such as the Paleobiology Database, where it currently extends the stratigraphic range of the genus PalaeophonusThorell & Lindström, 1884 from the Silurian into the Carboniferous. The fossil on which it is based cannot be interpreted with confidence as a scorpion. Kjellesvig-Waering's name is based on an isolated pedipalp chela, which lacks characters justifying its placement in Palaeophonus or any other Palaeozoic scorpion genus. Both names are treated here as nomina dubia. We also take the opportunity to synonymize AllopalaeophonusKjellesvig-Waering, 1986 with Palaeophonus. These two mid-Silurian genera are currently placed in separate infraorders, but the holotype of Allopalaeophonus caledonicus (Hunter, 1886) is very similar in habitus to the type species of Palaeophonus: Palaeophonus nunciusThorell & Lindström, 1884. The single character currently separating the genera, mesosomal sternite shape, is unconvincing. [ABSTRACT FROM AUTHOR]

Background/objectives: To examine students' beverage choice in school, with reference to its contribution to students' intake of non-milk extrinsic (NME) sugars.Subjects/methods: Beverage and food selection data for students aged 11-18 years (n=2461) were collected from two large secondary schools in England, for a continuous period of 145 (school A) and 125 (school B) school days. Descriptive analysis followed by cluster analysis of the beverage data were performed separately for each school.Results: More than a third of all items selected by students were beverages, and juice-based beverages were students' most popular choice (school A, 38.6%; school B, 35.2%). Mean NME sugars derived from beverages alone was high (school A, 16.7 g/student-day; school B, 12.9 g/student-day). Based on beverage purchases, six clusters of students were identified at each school (school A: 'juice-based', 'assorted', 'water', 'cartoned flavoured milk', 'bottled flavoured milk', 'high volume juice-based'; school B: 'assorted', 'water with juice-based', 'sparkling juice/juice-based', 'water', 'high volume water', 'high volume juice-based'). Both schools included 'high volume juice-based' clusters with the highest NME sugar means from beverages (school A, 28.6 g/student-day; school B, 24.4 g/student-day), and 'water' clusters with the lowest. A hierarchy in NME sugars was found according to cluster; students in the 'high volume juice-based' cluster returned significantly higher levels of NME sugars than students in other clusters.Conclusions: This study reveals the contribution that school beverages combined with students' beverage choice behaviour is making to students' NME sugar intake. These findings inform school food initiatives, and more generally public health policy around adolescents' dietary intake. [ABSTRACT FROM AUTHOR]

Objective The aim of the study was to describe pregnancies in HIV-infected teenagers. Methods A review of the case notes of HIV-infected pregnant teenagers aged 13-19 years from 12 London hospitals was carried out for the period 2000-2007. Results There were 67 pregnancies in 58 young women, of whom one was known to have acquired HIV vertically. The overall mother-to-child transmission (MTCT) rate of HIV was 1.5% (one of 66). There were 66 live births. Median ages at HIV diagnosis and conception were 17 and 18 years, respectively. Sixty-three per cent of women were diagnosed with HIV infection through routine antenatal screening. Eighty-two per cent of pregnancies (41 of 50) were unplanned, with 65% of women (26 of 40) using no contraception. Forty-three per cent of the women (20 of 46) had a past history of a sexually transmitted infection (STI). In 63 pregnancies, antiretroviral therapy was started postconception, with prevention of HIV MTCT the only indication in 81% of cases. Fifty-eight per cent of those on highly active antiretroviral therapy (HAART) had an undetectable HIV viral load by delivery. Eighty-seven per cent were uncomplicated pregnancies. Seventy-one per cent delivered by Caesarean section and 21% (14 of 64) had a preterm delivery (<37 weeks). In the 12 months after delivery, 45% of women received contraceptive advice and 25% of women became pregnant again. Conclusion Obstetric and virological outcomes were favourable in this group of HIV-infected young women. However, the majority of pregnancies were unplanned with poor documentation of contraception use and advice and low rates of STI screening. A quarter of women conceived again within 12 months of delivery. Effective measures to reduce STIs, unplanned pregnancies and onward HIV transmission in HIV-infected teenagers are needed. [ABSTRACT FROM AUTHOR]

In 2002 so far, 24 pregnant women with HIV infection have been cared for through 25 pregnancies in a district general hospital (outer London) HIV clinic. 10 patients presented via the antenatal screening programme at our hospital midwifery unit at that of our neighbouring hospital (where no GU/HIV services are available on site). The remaining 14 patients were aware of their HIV status prior to this pregnancy. For seven of these women, this pregnancy was the second or third pregnancy since being diagnosed HIV positive. Two women had terminations; both knew their HIV diagnosis prior to their unplanned pregnancy. One woman who was diagnosed antenatally went on to have a spontaneous abortion in the second trimester. Of the 22 women with pregnancies progressing to term, 15 have been treated with a three drug combination; six with zidovudine monotherapy; and one is yet to commence therapy. All infants so far tested are HIV negative. No new opportunistic infections have occurred in any of the women but sadly one woman died of lactic acidosis caused by her antiretroviral regime) five days post partum. HIV and antenatal care is delivered by a multidisciplinary team consisting of an HIV liaison midwife and designated obstetric consultant on each site, GU consultants, HIV nurses, and a pharmacist. We will be able to expand on these data and discuss the workload implications of the growing number of HIV positive women who are having children. [ABSTRACT FROM AUTHOR]

Abstract: Bioremediation and activated carbon (AC) amendment were compared as remediation strategies for sediment from the River Tyne containing 16.4 ± 7.3 μg/g polycyclic aromatic hydrocarbons (PAHs) and approximately 5% coal particles by total dry sediment weight. Unamended, nutrient amended (biostimulated) and nutrient and Pseudomonas putida amended (bioaugmented) sediment microcosms failed to show a significant decrease in total sediment PAH concentrations over a one month period. Polyethylene passive (PE) samplers were embedded for 21 days in these sediment microcosms in order to measure the available portion of PAHs and accumulated 4.70 ± 0.25, 12.43 ± 1.78, and 23.49 ± 2.73 μg PAHs/g PE from the unamended, biostimulated, and bioaugmented microcosms, respectively. Higher PAH uptake by PE samplers in biostimulated and bioaugmented microcosms coincided with slower degradation of spiked phenanthrene in sediment-free filtrate from these microcosms compared to filtrate from the unamended microcosms. Microbial community analysis revealed changes in the bacterial community directly following the addition of nutrients, but the added P. putida community failed to establish itself. Addition of 2% by dry sediment weight activated carbon reduced PAH uptake by PE samplers to 0.28 ± 0.01 μg PAHs/g PE, a greater than 90% reduction compared to the unamended microcosms. [ABSTRACT FROM AUTHOR]

Marine litter is increasingly recognised as a vector for the spread of non-native species (NNS). However, our understanding of its role in the propagation of NNS in UK waters remains limited. As part of the Clean Seas Environmental Monitoring Programme, we opportunistically analysed seafloor macrolitter items trawled from various locations around the coast of England and Wales and examined each for the presence of NNS. Of the 41 litter items analysed, we identified a total of 133 taxa, including two non-native and four cryptogenic species. This confirms that NNS are settling on seafloor macrolitter in UK waters and that these can be detected using morphological taxonomic analysis. Furthermore, we propose a methodology to classify litter based on size, rugosity and polymer/material type to explore whether there were detectable patterns governing community composition and litter characteristics. This exploratory investigation provides evidence to inform future risk assessments of NNS vectors and pathways., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Introduction: The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood., Aim: To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN., Methods: Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies., Results: Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate., Discussion: Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support., Competing Interests: The authors have declared that no competing interests exist.

Background: Fracture nonunions impact on morbidity and health care costs and are associated with substantial pain, reduced mobility, prolonged morbidity, and a lower quality of life. CMF OrthoLogic 1000 (OL1000) is a bone growth stimulator used to promote fracture healing potentially reducing the need for surgical intervention. A cost analysis comparing CMF OL1000 versus surgical care for patients with nonunion tibial fractures was conducted., Methods: A Markov model was developed to compare the difference in costs between CMF OL1000 versus surgical care within the English National Health Service over a 2-year time horizon. The effectiveness of CMF OL1000 was based on recently published registry data. Cost data were derived from published sources and national cost databases. Sensitivity and scenario analyses were conducted., Results: The use of CMF OL1000 is estimated to lead to cost-savings of £1,104 per patient, a reduction in average healing time of 2.1 months and a relative risk of infection of 0.19 compared to immediate surgical intervention (standard of care). The results of the model are robust to most changes in input parameters and scenarios considered., Conclusions: This early analysis shows cost-savings for CMF OL1000 compared with surgical intervention for individuals with nonunion tibial fractures.

Treatment with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) or escalated(e)-BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisolone) remains the international standard of care for advanced-stage classical Hodgkin lymphoma (HL). We performed a retrospective, multicentre analysis of 221 non-trial ("real-world") patients, aged 16-59 years, diagnosed with advanced-stage HL in the Anglia Cancer Network between 2004 and 2014, treated with ABVD or eBEACOPP, and compared outcomes with 1088 patients in the Response-Adjusted Therapy for Advanced Hodgkin Lymphoma (RATHL) trial, aged 18-59 years, with median follow-up of 87.0 and 69.5 months, respectively. Real-world ABVD patients (n=177) had highly similar 5-year progression-free survival (PFS) and overall survival (OS) compared with RATHL (PFS 79.2% vs 81.4%; OS 92.9% vs 95.2%), despite interim positron-emission tomography-computed tomography (PET/CT)-guided dose-escalation being predominantly restricted to trial patients. Real-world eBEACOPP patients (n=44) had superior PFS (95.5%) compared with real-world ABVD (HR 0.20, p=0.027) and RATHL (HR 0.21, p=0.015), and superior OS for higher-risk (international prognostic score ≥3 [IPS 3+]) patients compared with real-world IPS 3+ ABVD (100% vs 84.5%, p=0.045), but not IPS 3+ RATHL patients. Our data support a PFS, but not OS, advantage for patients with advanced-stage HL treated with eBEACOPP compared with ABVD and suggest higher-risk patients may benefit disproportionately from more intensive therapy. However, increased access to effective salvage therapies might minimise any OS benefit from reduced relapse rates after frontline therapy.

Background: Seizures are a common presenting sign in dogs with brain tumors., Hypothesis/objectives: To investigate the effect of radiotherapy on freedom from brain tumor-associated seizures and survival time in dogs., Animals: Thirty-two client-owned dogs with brain tumor-associated seizures; 18 received medical treatment and radiotherapy, 14 received medical treatment alone., Methods: Multicenter retrospective study. Baseline characteristics (seizure semiology, magnetic resonance imaging [MRI] characteristics, and treatment) and duration of seizure freedom were recorded for the 2 treatment groups. Duration of seizure freedom between groups was compared (log-rank test) using Cox's proportional hazard analysis, with baseline characteristics entered as covariates., Results: The duration of seizure freedom and survival time were significantly longer in the radiotherapy group (P < .001), with a mean of 24 months (95% confidence interval [CI], 14.3-33.8) versus 1.7 months in the control group (95% CI, 0.5-2.9) and a mean of 34.6 months (95% CI: 25.2-44.1) versus 6.2 months in the control group (95% CI, 2.6-9.7) respectively. Baseline characteristics were not associated with duration of seizure freedom after the start of treatment. In the radiotherapy group, 5 dogs were euthanized during the study period because of causes other than seizures. In the control group, recurrence of seizures was observed before death in all dogs., Conclusions and Clinical Importance: A longer period of seizure freedom and longer survival time was observed in dogs with brain tumors after radiotherapy compared to medical treatment only. The pathophysiological mechanisms of epileptogenesis and the effect of radiation therapy on seizure control are unclear to date. Further prospective studies are needed., (© 2020 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.)

Background: Children and young people with learning disabilities experience poor health outcomes and lengthier hospital admissions than those without learning disabilities. No consistently applied, systematic approach exists across the NHS to identify and record this population. This paper describes practices in English hospitals to identify children and young people with learning disabilities., Method: Interviews: 65 NHS staff. Questionnaire: 2,261 NHS staff. Conducted across 24 NHS hospitals in England., Results: No standardized approach exists to identify children or young people with a learning disability or for this information to be consistently recorded, communicated to relevant parties within a hospital, Trust or across NHS services. Staff reported a reliance on parents to inform them about their child's needs but concerns about "flagging" patients might be a significant barrier., Discussion: Without an integrated systematic way across the NHS to identify children with learning disabilities, their individual needs will not be identified., (© 2019 The Authors. Journal of Applied Research in Intellectual Disabilities Published by John Wiley & Sons Ltd.)

Background: In response to multiple United Kingdom investigations and inquiries into the care of adults with learning disabilities, Mencap produced the Getting it Right Charter which campaigned for the appointment of a Learning Disability Liaison Nurse in every hospital. More recent best practice guidelines from the Care Quality Commission included the need for all children's units to have access to a senior learning disability nurse who can support staff and help them manage difficult situations. However, little evidence exists of the extent of learning disability nurse provision in children's hospitals or the nature and impact of this role. Here we report selected findings from a national mixed methods study of hospital care for children and young people with and without learning disabilities in England. The extent of learning disability nurse provision in children's hospitals is described and perceptions of staff working in hospitals with and without such provision is compared., Methods: Semi-structured interviews were conducted with senior staff across 15 children's hospitals and an anonymous survey was sent to clinical and non-clinical staff with patient (children and young people) contact within these hospitals. The survey focused on six different elements of care for those with and without learning disability, with additional questions concerning identifying and tracking those with learning disabilities and two open-ended questions., Results: Forty-eight senior staff took part in interviews, which included a subset of nine nurses and one allied health professional employed in a dedicted learning disability nurse role, or similar. Surveys were completed by 1681, of whom 752 worked in a hospital with dedicated learning disability nurse provision. We found evidence of limited and varied learning disability nurse provision which was valued by hospital staff and shown to positively impact their perceptions of being capable to care for children and young people with learning disabilities, but not shown to increase staff perceptions of capacity or confidence, or how children and young people are valued within the hospital, their safety or access to appointments., Conclusion: Further consideration must be given to how learning disability nurse roles within children's hospitals are best operationalised in practice to have the greatest impact on staff and families, as well as how we monitor and evaluate them to ensure they are being utilised effectively and efficiently., Trial Registration: The study has been registered on the NIHR CRN portfolio 20,461 (Phase 1), 31,336 (Phases 2-4).

BackgroundMandatory reporting of methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI) has occurred in England for over 15years. Epidemiological information is recorded, but routine collection of isolates for characterisation has not been routinely undertaken. Ongoing developments in whole-genome sequencing (WGS) have demonstrated its value in outbreak investigations and for determining the spread of antimicrobial resistance and bacterial population structure. Benefits of adding genomics to routine epidemiological MRSA surveillance are unknown.AimTo determine feasibility and potential utility of adding genomics to epidemiological surveillance of MRSA.MethodsWe conducted an epidemiological and genomic survey of MRSA BSI in England over a 1-year period (1 October 2012--30 September 2013).ResultsDuring the study period, 903 cases of MRSA BSI were reported; 425 isolates were available for sequencing of which, 276 (65%) were clonal complex (CC) 22. Addition of 64 MRSA genomes from published outbreak investigations showed that the study genomes could provide context for outbreak isolates and supported cluster identification. Comparison to other MRSA genome collections demonstrated variation in clonal diversity achieved through different sampling strategies and identified potentially high-risk clones e.g. USA300 and local expansion of CC5 MRSA in South West England.ConclusionsWe demonstrate the potential utility of combined epidemiological and genomic MRSA BSI surveillance to determine the national population structure of MRSA, contextualise previous MRSA outbreaks, and detect potentially high-risk lineages. These findings support the integration of epidemiological and genomic surveillance for MRSA BSI as a step towards a comprehensive surveillance programme in England.

Background: Children and young people (CYP) with learning disabilities (LD) are a vulnerable population with increased risk of abuse and accidental injury and whose parents have reported concerns about the quality, safety and accessibility of their hospital care. The Care Quality Commission's (CQC) view of best practice for this group of patients includes: access to senior LD nurse provision; a clearly visible flagging system for identifying them; the use of hospital passports; and defined communication strategies (Glasper, Comp Child Adolesc Nurs 40:63-67, 2017). What remains unclear is whether these recommendations are being applied and if so, what difference they are making. Furthermore, what we do not know is whether parental concerns of CYP with LD differ from parents of other children with long-term conditions. The aims of this study were to 1) describe the organisational context for healthcare delivery to CYP with LD and their families and 2) compare staff perceptions of their ability to identify the needs of CYP with and without LD and their families and provide high quality care to effectively meet these needs., Methods: Individual interviews (n = 65) and anonymised online survey (n = 2261) were conducted with hospital staff working with CYP in 15 children's and 9 non-children's hospitals in England. The majority of interviews were conducted over the telephone and recorded and transcribed verbatim. Health Research Authority was obtained and verbal or written consent for data collection was obtained from all interview participants., Results: The nature and extent of organisational policies, systems and practices in place within hospitals to support the care of CYP with LD differs across England and some uncertainty exists within and across hospitals as to what is currently available and accessed. Staff perceived that those with LD were included less, valued less, and less safe than CYP without LD. They also reported having less confidence, capability and capacity to meet the needs of this population compared to those without LD., Conclusion: Findings indicate inequality with regards the provision of high quality hospital care to children and young people with LD that meets their needs. There is a pressing need to understand the impact this has on them and their families., Trial Registration: The study has been registered on the NIHR CRN portfolio 20461 (Phase 1), 31336 (Phases 2-4).

We determined the incidence, risk factors and antimicrobial susceptibility associated with Escherichia coli bacteraemia in England over a 24 month period. Case data were obtained from the national mandatory surveillance database, with susceptibility data linked from LabBase2, a voluntary national microbiology database. Between April 2012 and March 2014, 66,512 E. coli bacteraemia cases were reported. Disease incidence increased by 6% from 60.4 per 100,000 population in 2012-13 to 63.5 per 100,000 population in 2013-14 (p < 0.0001). Rates of E. coli bacteraemia varied with patient age and sex, with 70.5% (46,883/66,512) of cases seen in patients aged ≥ 65 years and 52.4% (33,969/64,846) of cases in females. The most common underlying cause of bacteraemia was infection of the genital/urinary tract (41.1%; 27,328/66,512), of which 98.4% (26,891/27,328) were urinary tract infections (UTIs). The majority of cases (76.1%; 50,617/66,512) had positive blood cultures before or within two days of admission and were classified as community onset cases, however 15.7% (10,468/66,512) occurred in patients who had been hospitalised for over a week. Non-susceptibility to ciprofloxacin, third-generation cephalosporins, piperacillin-tazobactam, gentamicin and carbapenems were 18.4% (8,439/45,829), 10.4% (4,256/40,734), 10.2% (4,694/46,186), 9.7% (4,770/49,114) and 0.2% (91/42,986), respectively. Antibiotic non-susceptibility was higher in hospital-onset cases than for those presenting from the community (e.g. ciprofloxacin non-susceptibility was 22.1% (2,234/10,105) for hospital-onset vs 17.4% (5,920/34,069) for community-onset cases). Interventions to reduce the incidence of E. coli bacteraemia will have to target the community setting and UTIs if substantial reductions are to be realised., Competing Interests: Conflicts of Interest: None declared., (This article is copyright of The Authors, 2016.)

Background: In England the National Health Service (NHS) is not allowed to impose 'blanket bans' on treatments, but local commissioners produce lists of 'low value' procedures that they will normally not fund. Breast surgery is one example. However, evidence suggests that some breast surgery is clinically effective, with significant health gain. National guidelines indicate the circumstances under which breast surgery should be made available on the NHS, but there is widespread variation in their implementation.The purpose of this study was to explore the work practices of 'individual funding request' (IFR) panels, as they considered 'one-off' funding requests for breast surgery; examine how the notion of 'value' is dialogically constructed, and how decisions about who is deserving of NHS funding and who is not are accomplished in practice., Methods: We undertook ethnographic exploration of three IFR panels. We extracted all (22) breast surgery cases considered by these panels from our data set and progressively focused on three case discussions, one from each panel, covering the three main breast procedures.We undertook a microanalysis of the talk and texts arising from these cases, within a conceptual framework of interpretive policy analysis., Results: Through an exploration of the symbolic artefacts (language, objects and acts) that are significant carriers of policy meaning, we identified the ways in which IFR panels create their own 'interpretive communities', within which deliberations about the funding of breast surgery are differently framed, and local decisions come to be justified. In particular, we demonstrated how each decision was contingent on [a] the evaluative accent given to certain words, [b] the work that documentary objects achieve in foregrounding particular concerns, and [c] the act of categorising. Meaning was constructed dialogically through local interaction and broader socio-cultural discourses about breasts and 'cosmetic' surgery., Conclusion: Despite the appeal of calls to tackle 'unwarranted variation' in access to low priority treatments by ensuring uniformity of local guidelines and policies, our findings suggest that ultimately, given the contingent nature of practice, this is likely to remain an illusory policy goal. Our findings challenge the scientistic thinking underpinning mainstream health policy discourse.

The English National Health Service Constitution states that patients have the right to expect all decisions about access to medicines and treatments to be made 'rationally'. Rationality in health care can be framed as instrumental, institutional or practical. In this article, we present a case example from an ethnographic study of the work of 'Individual Funding Request' panels to explore how rationality is enacted and accounted for in deliberations about the rationing of health care in the National Health Service. Our rhetorical analysis highlights how an embodied, practical rationality emerges as a significant aspect of rationality in practice, but at the same time has a problematic status in formal accounts of decision-making. We suggest that being both 'human' and 'rational' is a 'delicate balance' and creates a dilemma for Individual Funding Request panels. Aristotle's notion of phronesis provides a useful lens for theorising our observation of panel deliberations, and we argue for greater attention to the value of narrative ethics in helping us understand the challenges faced by resource allocators., (© The Author(s) 2013.)

Objective: To examine students’ school food choice in relation to school food standards and entitlement to free school meals (FSM)., Design: Cross-sectional analysis of students’ school food choices., Setting: Two large secondary schools in Yorkshire, England., Subjects: Students (n 2660) aged 11–18 years., Results: Sandwiches and pizza were the most popular main food items: 40·4 % and 31·2 %, respectively, in School A; 48·3 % and 27·3 %, respectively, in School B. More nutritionally valuable ‘dishes of the day’ accounted for 8·7 % and 8·3 % of main foods for School A and School B, respectively. FSM students were more likely (P < 0·0 0 1) to choose main foods (School A: FSM 87·04 %, non-FSM 70·28 %; School B: FSM 75·43 %, non-FSM 56·13 %). Dishes of the day were chosen on a significantly greater (P < 0·0 0 1) percentage of days by FSM v. non-FSM students (School A: FSM 15·67 %, non-FSM 7·11 %; School B: FSM 19·42 %, non-FSM 5·17 %)., Conclusions: Despite the availability of nutritionally valuable dishes of the day, the most popular food items were sandwiches, pizza and desserts. FSM students were more likely to choose the more nutritionally valuable dish of the day. School food standards should be reassessed in light of students’ preferences.

Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs)--requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: To evaluate a national programme to develop and implement centrally stored electronic summaries of patients' medical records., Design: Mixed-method, multilevel case study., Setting: English National Health Service 2007-10. The summary care record (SCR) was introduced as part of the National Programme for Information Technology. This evaluation of the SCR considered it in the context of national policy and its frontline implementation and use in three districts. Participants and methods Quantitative data (cumulative records created nationally plus a dataset of 416 325 encounters in participating primary care out-of-hours and walk-in centres) were analysed statistically. Qualitative data (140 interviews including policy makers, managers, clinicians, and software suppliers; 2000 pages of ethnographic field notes including observation of 214 clinical consultations; and 3000 pages of documents) were analysed thematically and interpretively., Results: Creating individual SCRs and supporting their adoption and use was a complex, technically challenging, and labour intensive process that occurred more slowly than planned. By early 2010, 1.5 million such records had been created. In participating primary care out-of-hours and walk-in centres, an SCR was accessed in 4% of all encounters and in 21% of encounters where one was available; these figures were rising in some but not all sites. The main determinant of SCR access was the identity of the clinician: individual clinicians accessed available SCRs between 0 and 84% of the time. When accessed, an SCR seemed to support better quality care and increase clinician confidence in some encounters. There was no direct evidence of improved safety, but findings were consistent with a rare but important positive impact on preventing medication errors. SCRs sometimes contained incomplete or inaccurate data, but clinicians drew judiciously on these data along with other sources. SCR use was not associated with shorter consultations or reduction in onward referral. Successful introduction of SCRs depended on interaction between multiple stakeholders from different worlds (clinical, political, technical, commercial) with different values, priorities, and ways of working. The programme's fortunes seemed to turn on the ability of change agents to bridge these different institutional worlds, align their conflicting logics, and mobilise implementation effort., Conclusions: Benefits of centrally stored electronic summary records seem more subtle and contingent than many stakeholders anticipated, and clinicians may not access them. Complex interdependencies, inherent tensions, and high implementation workload should be expected when they are introduced on a national scale.

Cleft lip and/or cleft palate affects about 1:700 babies born in the UK and may occur as a single anomaly or in association with other congenital abnormalities as part of a syndrome. This article, the first in a series, provides a brief overview of the different types of cleft lip and palate and describes the organisation of regional cleft services in England and Wales.

Objective: To explore the introduction of a centrally stored, shared electronic patient record (the summary care record (SCR)) in England and draw wider lessons about the implementation of large scale information technology projects in health care., Design: Multi-site, mixed method case study applying utilisation focused evaluation., Setting: Four early adopter sites for the SCR in England-three in urban areas of relative socioeconomic deprivation and the fourth in a relatively affluent rural area. Data sources and analysis Data included 250 staff interviews, 1500 hours of ethnographic observation, interviews and focus groups with 170 patients and carers, 2500 pages of correspondence and documentary evidence, and incorporation of relevant surveys and statistics produced by others. These were analysed by using a thematic approach drawing on (and extending) a theoretical model of complex change developed in a previous systematic review. Main findings The mixed fortunes of the SCR programme in its first year were largely explained by eight interacting influences. The first was the SCR's material properties (especially technical immaturity and lack of interoperability) and attributes (especially the extent to which potential adopters believed the benefits outweighed the risks). The second was adopters' concerns (especially about workload and the ethicality of sharing "confidential" information on an implied consent model). The third influence was interpersonal influence (for example, opinion leaders, champions, facilitators), and the fourth was organisational antecedents for innovation (for example past experience with information technology projects, leadership and management capacity, effective data capture systems, slack resources). The fifth was organisational readiness for the SCR (for example, innovation-system fit, tension for change, power balances between supporters and opponents, baseline data quality). The sixth was the implementation process (including the nature of the change model and the extent to which new routines associated with the SCR aligned with existing organisational routines). The seventh influence was the nature and quality of links between different parts of the system, and the final one was the wider environment (especially the political context of the programme)., Conclusion: Shared electronic records are not plug-in technologies. They are complex innovations that must be accepted by individual patients and staff and also embedded in organisational and inter-organisational routines. This process is heavily influenced at the micro-level by the material properties of the technology, individuals' attitudes and concerns, and interpersonal influence; at the meso-level by organisational antecedents, readiness, and operational aspects of implementation; and at the macro-level by institutional and socio-political forces. A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care.

Background: On 1 June 2005, amendments to the Coroners Rules 1984 were introduced in England and Wales. These principally cover the retention of tissues from autopsies and their subsequent disposal. This study assesses regional variations in the interpretations of the amendments, and their impact on local autopsy practice in Oxford., Methods: A questionnaire was circulated to pathologists in 120 coronial jurisdictions, addressing conditions under which histological material could be retained. A local review of autopsy practice was conducted before and after the introduction of the amendments., Results: Questionnaires were returned from 71 coronial jurisdictions. 35 (49%) coroners provided written guidelines on their interpretation of the amendments. In 52 (73%) jurisdictions, pathologists are authorised to retain material to confirm/refine causes of death from natural causes. In 77% of jurisdictions, coroner's officers are responsible for obtaining instructions from the next of kin on subsequent retention, use or disposal of retained tissues. In Oxford, there has been a reduction in the proportion of cases in which histology is taken, but an increase in the proportion of cases in which a histology report is issued., Conclusions: There is considerable regional variation in the interpretation of the 2005 Coroners Rules Amendments. These variations have potentially important implications for clinical practice.

Objective: To describe the process of establishing and implementing a social support infant feeding intervention., Design: This paper outlines the initial stages of a randomised controlled trial which assessed the effectiveness of a social support intervention on a range of infant feeding outcomes. Details are presented of the processes involved in recruiting, training and supporting a group of volunteers who provided support to the study sample., Setting: Camden and Islington, London, UK., Results: Initial networking with local agencies and organisations provided invaluable information and contacts. Employing a dedicated volunteer co-ordinator is vitally important in the recruitment, training and support of volunteers. Providing child care and travel expenses is an essential incentive for volunteers with young children. Advertisements placed in local newspapers were the most successful means of recruiting volunteers. Appropriate training is needed to equip volunteers with the necessary knowledge and skills to provide effective support. Particular emphasis in the training focused upon developing the necessary interpersonal skills and self-confidence. The evaluation of the training programme demonstrated that it improved volunteers' knowledge and reported confidence. The provision of ongoing support is also essential to maintain volunteers' interest and enthusiasm. The retention of volunteers is, however, a key challenge., Conclusions: The processes outlined in this paper have demonstrated the feasibility of successfully establishing, implementing and maintaining a community-based social support infant feeding programme. The experiences described provide useful insights into the practical issues that need to be addressed in setting up a social support intervention.

Objectives: To determine if the lunchtime food provided to schoolchildren adheres to nutritional standards and to examine the influence of children's food choice on nutrient intake at lunchtime., Subjects/setting: Seventy-four children aged 11-12 years were recruited from three secondary schools. The school populations spanned a spectrum of socio-economic deprivation. Lunchtime food and nutrient intake was assessed over a 5 day period., Design: Cross-sectional study of menu composition and children's food choice in relation to nutrient intake., Methods: Dietary recording was by an indirect weighing method of menu composition and nutrient intake over a 5 day period. Statistical analysis was carried out using general linear modelling techniques including: t-test, one-way ANOVA and ANCOVA., Results: One school met the standards on food group provision. Intakes of total fat, saturated fatty acids and monounsaturated fatty acids were greater in boys. Intake of folate was greater in girls. There were between-school differences (independent of gender) for intake of fatty acids, starch, calcium and folate, with socio-economic deprivation associated with a lesser nutrient intake. Children could have chosen meals higher in calcium, iron, folate and zinc and lower in starch and fat, from the extensive cafeteria menu of between 26 and 42 food. For some nutrients, providing 'healthier' food influences intake of those nutrients whilst for other nutrients, children's food choice predominates. The majority of children did not meet the recommended targets for lunchtime nutrient intake, especially for micronutrients., Conclusions: Food provision in two out of three schools did not meet government guidelines and socio-economic deprivation was associated with worse food provision. Children from deprived areas were more likely to choose those foods of limited nutritional value than those from more privileged backgrounds. The statutory nutritional standards on their own, without a pricing policy to encourage healthier food choice or restrictions in food choice towards less healthy food are unlikely to catalyse the dietary changes that are so needed to ensure improved nutrient intakes amongst schoolchildren in England.

Background: The definition, classification, and choice of management of acute renal failure (ARF) in the setting of the intensive care unit (ICU) remain subjects of debate. To improve our approach to ARF in the ICU setting, we retrospectively applied the new classification of ARF put forward by the Acute Dialysis Quality Initiative group, RIFLE (acronym indicating Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure), to evaluate its sensitivity and specificity to predict renal and patient outcomes., Methods: RIFLE classification was applied to 183 patients with ARF admitted to the ICU (2002 to 2003) at the Northern General Hospital, Sheffield, UK. Patients were divided into 4 groups according to percentage of decrease in glomerular filtration rate from baseline. The risk group included 60 patients; injury group, 56 patients; failure group, 43 patients; and control group, 24 patients. Demographic, biochemical, hematologic, clinical, and long-term health status were studied and compared in the 4 groups. An attempt was made to evaluate, by means of logistic regression analysis and receiver operator characteristic curve analysis, the predictive value of RIFLE classification for mortality in the ICU., Results: The failure group showed the worst parameters with regard to Acute Physiology and Chronic Health Evaluation (APACHE) II score, pH, lowest and highest mean arterial pressures, and Glasgow Coma Scale (P < 0.001). Mortality rate in the ICU (1 month) was significantly greater in the failure group compared with all groups (32 of 43 patients [74.4%]; P < 0.001) and, again, 6-month mortality rate (37 of 43 patients [86%]; P < 0.001). Receiver operator characteristic curve analysis showed that Simplified Acute Physiology Score (SAPS) II was more sensitive than APACHE II score for prediction of patient death in the risk and injury groups compared with the failure and control groups (risk group: SAPS II, 0.8 +/- 0.06; P < 0.001; APACHE II, 0.63 +/- 0.07; P = 0.14; injury group: SAPS II, 0.76 +/- 0.08; P < 0.001; APACHE II, 0.72 +/- 0.07; P = 0.006)., Conclusion: RIFLE classification can improve the ability of such older and established ICU scoring systems as APACHE II and SAPS II in predicting outcome of ICU patients with ARF.

This paper describes some of the more prohibitive aspects of HIV prevention among gay men in England. It argues that much current HIV prevention work assumes that prohibition is the most appropriate means of governing gay male sexual practice--most particularly in relation to the treatment of unprotected anal sex or bare-backing. The prohibitive approach constructs an opposition between the good gay citizen who privileges health maximisation and the evil irresponsible bare-backer who embodies the transgressive pleasure of unprotected sex. It becomes impossible to represent bare-backing outside of this cycle of prohibition and transgression without being re-inscribed within it through the sickness of low self-esteem.

In the UK, a small private health care sector has always existed alongside the national health service (NHS). The conventional assumption is that doctors who work as salaried employees of the NHS are guided in their clinical practice by professional values which encourage them to put their patients' interests first. A common suspicion is that doctors undertaking fee-for-service practice in the private sector are motivated by self-interest, with commitment to their patients compromised by consideration for their purse. The great majority of hospital consultants are salaried employees of the NHS, but most also undertake some private practice. This paper uses findings from an interview study of 60 surgeons and physicians engaged in dual practice of this kind to investigate their reasons for working in this way and look at how they reconcile their personal, professional and public sector values and responsibilities with the temptations of the market. The existence of the private sector and their own engagement in it was regarded by almost all respondents as a net benefit, not only to themselves and their private patients, but also to the NHS, so long as they handled it properly. The interviews revealed a complex range of beliefs and assumptions through which these doctors justify their activities and a variety of informal principles for dealing with such conflicts of interest as they acknowledge. Neither their values nor their actions can be adequately explained using generic concepts of professional self-interest or public service values without consideration of what such concepts represented in the specific social, economic, professional and policy context of health care in south-east England at the time of the study., (Copyright 2003 Elseiver Ltd.)

Periodically, new disease-associated variants of the human pathogen Neisseria meningitidis arise. These meningococci diversify during spread, and related isolates recovered from different parts of the world have different genetic and antigenic characteristics. An example is the ET-5 complex, members of which were isolated globally from the mid-1970s onwards. Isolates from a hyperendemic outbreak of meningococcal disease in Worcester, England, during the late 1980s were characterized by multilocus sequence typing and sequence determination of antigen genes. These data established that the Worcester outbreak was caused by ET-5 complex meningococci which were not closely related to the ET-5 complex bacteria responsible for a hyperendemic outbreak in the nearby town of Stroud during the years preceding the Worcester outbreak. A comparison with other ET-5 complex meningococci established that there were at least three distinct globally distributed subpopulations within the ET-5 complex, characterized by particular housekeeping and antigen gene alleles. The Worcester isolates belonged to one of these subpopulations, the Stroud isolates belonged to another, and at least one representative of the third subpopulation identified in this work was isolated elsewhere in the United Kingdom. The sequence data demonstrated that ET-5 variants have arisen by multiple complex pathways involving the recombination of antigen and housekeeping genes and de novo mutation of antigen genes. The data further suggest that either the ET-5 complex has been in existence for many years, evolving and spreading relatively slowly until its disease-causing potential was recognized, or it has evolved and spread rapidly since its first identification in the 1970s, with each of the subpopulations attaining a distribution spanning several continents.

A community outbreak of infection with Vero cytotoxin producing Escherichia coli O157 (VTEC 0157) occurred in a small area of north west England in 1996. An outbreak control team was established to investigate the outbreak and implement control measures. Nine people developed symptomatic infections with VTEC O157, and a further three were found to be excreting the bacteria. All were infected with the same genotype of VTEC O157. Three children under 5 years of age and one adult were admitted to hospital. One child developed haemolytic uraemic syndrome. All cases recovered. All primary cases had consumed milk from a particular farm dairy. No other common foods were identified. The farm dairy had a faulty pasteuriser and the potential for post pasteurisation contamination existed. VTEC O157 was isolated from a milk sock specimen and from two cows, but these strains differed from that infecting the cases. All local doctors and the public were alerted and advised about preventative measures. Distribution of unpasteurised milk from the farm was discontinued as was the sale of pasteurised milk when the faulty pasteuriser was discovered. A replacement pasteuriser was installed and checked before milk was released for human consumption. No conclusive evidence of the origin of this outbreak was found, but the farm was the most probable source. The investigations raised concerns about the distribution of VTEC O157 colonised dairy cattle, the natural history of such colonisation, the effectiveness of pasteurisation with respect to the elimination of VTEC O157, and the effectiveness of current legislation for the prevention and control of milkborne infection.

In a project concerned with establishing a glossary and thesaurus for the medical informatics domain, various approaches to the task have been investigated. The developers take the view that a glossary should be a coherent system of terms, reflecting a coherent system of concepts that underlies a body of knowledge about a domain. A framework for the conceptual analysis of the concepts/terms underlying the domain has been developed. The emphasis of this framework is on how the concepts relate together. This work has given an important insight into how the practical task of establishing well-structured vocabularies for a field can be better achieved. An eclectic approach to term selection was adopted. Criteria for assessing what constitutes good definitions for concepts in a field were examined. Using all these approaches glossaries, thesauri and domain models of the medical informatics field are being developed. Another aspect of our work of particular interest is the development of attributed definitions from which inheritance patterns can be defined.

The term "last illness factor" is used to indicate the proportion of diagnostic X-ray exposure which occurs in the patient's last illness. An assessment was made of this by determining the number of radiographic examinations made in the patients' last illnesses of persons dying in 1985 in Manchester Central District, and comparing this with the 1985 workload in the diagnostic department. This suggests the last illness factor is about 5% and is thus very small compared with the other factors to be taken into account in assessing the harm from diagnostic radiation.

Patients in seven hospitals for the mentally handicapped were screened for markers of hepatitis B infection. Of 2239 patients, 123 (5.5 per cent) were carriers of hepatitis B surface antigen (HBsAg) and a third of these were 'infectious' (negative for antibody to hepatitis B e antigen). Patients with Down's syndrome (DS) were 18 times more likely to be 'infectious' carriers than those without, and male patients were six times more likely to be 'infectious' carriers than female patients. There was a wide difference in carrier rate among the various hospitals. In the hospital with the highest carrier rate (12.5 per cent), 60 per cent of male patients with DS were carriers of HBsAg and of these two-thirds were 'infectious'. The carrier rate decreased with age, but the proportion of carriers who were hepatitis B e antigen positive was unaffected by age.