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Background As a consequence of their occupation, doctors and other healthcare workers were at higher risk of contracting coronavirus disease 2019 (COVID-19), and more likely to experience severe disease compared to the general population. However, systematic information on post-acute COVID complications in doctors is very limited. Aims This study aimed to determine the symptoms, perceived determinants, health and occupational impact, and consequent needs relating to post-acute COVID complications in UK doctors. Methods An online cross-sectional survey was distributed to UK doctors self-identifying as having Long COVID or other post-acute COVID complications. Results Of 795 responses, 603 fulfilled the inclusion criteria of being a UK-based medical doctor experiencing one or more post-acute COVID complications. Twenty-eight per cent reported a lack of adequate Respiratory Protective Equipment at the time of contracting COVID-19. Eighteen per cent of eligible respondents reported that they had been unable to return to work since acquiring COVID. Conclusions Post-acute COVID (Long COVID) in UK doctors is a substantial burden for respondents to our questionnaire. The results indicated that insufficient respiratory protection could have contributed to occupational disease, with COVID-19 being contracted in the workplace, and resultant post-COVID complications. Although it may be too late to address the perceived determinants of inadequate protection for those already suffering with Long COVID, more investment is needed in rehabilitation and support of those afflicted. [ABSTRACT FROM AUTHOR]

T R ('Tim') Miles (1923–2008) was one of the most important pioneers of dyslexia research and treatment in the UK. He worked with dyslexics from the time of his appointment to a lectureship at Bangor in 1949 and later, with his wife, established the Dyslexia Centre there. Miles' professional role and theoretical contribution are reasonably well documented, not least through his own autobiographical account of them. I aim to reappraise his work in the field, against a wider set of circumstances. Tim was a great all-rounder: a noted sportsman and musician, and a committed Quaker who published books on the philosophy of religion and its experiential claims. Moreover, he operated in a Welsh environment which needs explication, one where bilingualism became increasingly a matter of public debate and contestation: an issue of obvious relevance to the study of dyslexia. Miles, who famously expanded the scope of our understanding and definition of 'dyslexia', himself deserves a broader appreciation. [ABSTRACT FROM AUTHOR]

Soil erosion on arable land in lowland Britain has been the subject of field-based surveys, which have assessed the volumes or masses of soil transported in channels across farmers' fields. These surveys provide a unique database on the extent, frequency and rates of soil loss by water. This study synthesizes the key findings from those surveys and underscores the implications for soil erosion modelling. Rill erosion occurs in a small number of fields (consistently <10%). Over ~5 yr, a considerable proportion of the farmed landscape will suffer from rill erosion, but mostly in fields that erode only once. Mean erosion rates for lowland arable landscapes are much less than mean erosion rates for individual eroded fields within that landscape. These observations pose important challenges for modelling. Rainfall and cropping vary from year to year so that risk of wash or rill erosion in the same field also varies. Due to the infrequent occurrence of rill erosion, loss rates of eroding fields cannot be spatially extrapolated across the landscape, except in the case of wash erosion which takes place a number of times in almost all fields every year. A consistent pattern of increasing wash erosion, in terms of spatial extent, is emerging in lowland Britain. Resulting losses of fine silt and clay-sized particles are small in amount and possibly insignificant in terms of loss of soil as a resource, but have significant implications for contaminant concentrations and pollution of water courses. [ABSTRACT FROM AUTHOR]

Because the sources of fine-grained sediment problems in river systems are diffuse, it is essential to assemble catchment scale information for informing management strategies. Sediment source-tracing procedures have increasingly been adopted in this respect. Accordingly, a recently refined composite tracing procedure was used to investigate contemporary sources of fine-grained channel bed sediment in 11 sub-catchments (364 km2) of the River Wensum Demonstration Test Catchment, in the eastern UK. The procedure incorporated a combination of statistical tests for discriminating source end members, plus numerical mass balance modelling incorporating weightings for within-source tracer variations and tracer-specific discriminatory power, as well as a combination of local and genetic algorithm optimisation coupled with Monte Carlo uncertainty analysis. Replicate Monte Carlo runs demonstrated the convergence of the modelling outputs within ±1% of the average medians. Relative frequency-weighted average median source type contributions were estimated to range between 27%-69% (agricultural topsoils; predicted deviate median inputs 0%-98% and 9%-100%), 0%-38% (damaged road verges; predicted deviate median inputs 0%-58% and 0%-100%) and 21%-48% (channel banks/subsurface sources; predicted deviate median inputs 0%-50% and 4%-50%). The study provides further evidence of the importance of channel banks and damaged road verges as sediment sources and the need to include such areas in catchment sediment management strategies. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Abstract: The realisation that runoff and soil erosion was a problem came late to Britain and policies to tackle the problem have evolved slowly and may well have a taken a different route to that in other countries. The perception of soil erosion and runoff in Britain by three interest groups (researchers, policy makers and farmers) has changed over time since the 1940s. Prior to 1970 none of the groups considered erosion and runoff were problems. From then to 1985 researchers found that erosion was widespread. Between 1985 and 2005 researchers not only confirmed that erosion was a problem, but that runoff and its impacts (muddy floods and pollution of water courses by sediment, phosphate and pesticides) were also problems. These widespread and costly economic and environmental impacts led policy makers to tackle the problems of erosion and runoff. From 2005 farmers have had to keep their land in ‘Good Agricultural and Environmental Condition’ by, amongst other things, attempting to curtail erosion and runoff, to comply with regulation in order to receive subsidy. Policy change was also stimulated by changes in the European Union''s Common Agricultural Policy and the passing by the EU of the ‘Water Framework Directive’. Policy, if it is to be evidence based, will always lag behind research. There is a continuing need for field-based monitoring to assess if regulation is working, to ensure compliance, and as a basis for future policy. [Copyright &y& Elsevier]

The series of Creighton memorial lectures, delivered annually since 1907, reflects changing interests and priorities within British historiography. This centenary address seeks to illustrate attitudes to the history of Europe as revealed especially in the lectures, but also in the context of the development of the historical profession in this country as a whole. Many of the issues raised were already adumbrated in the work of Mandell Creighton himself. How far was Britain a part of Europe for historiographical purposes? Did a British perspective involve any particular presuppositions or yield particular insights? And in what ways did the study of individual foreign countries interplay with attitudes to Britain, and to the Continent as a whole? [ABSTRACT FROM AUTHOR]

Aim: The AT.LANTUS study compared insulin glargine initiation and titration using one of two algorithms in suboptimally controlled subjects with type 2 diabetes mellitus (T2DM) based on a primary outcome of severe hypoglycaemia. Secondary outcomes included other categories of hypoglycaemia, glycaemic control, weight changes and insulin dose. Here, we report the results of a subanalysis of the trial, which investigated whether insulin glargine can be initiated and titrated as effectively in primary [general practitioner (GP)] as secondary (hospital) care in patients with T2DM in the UK. Methods: The main study was a multicentre (n = 611), multinational (n = 59), open-label, 24-week randomized trial in 4588 suboptimally controlled subjects with T2DM. Insulin glargine was titrated to target fasting blood glucose (FBG) levels of ≤5.5 mmol/l according to algorithm 1 (clinic-driven titration) or algorithm 2 (patient-managed titration). In this substudy, 819 subjects (GP, n = 215; hospital, n = 604) from 57 primary and 130 secondary care centres were included in the subanalysis; subjects were switched to once-daily insulin glargine from baseline treatments that consisted primarily of oral antidiabetic agents (OADs) (38%) only or premixed insulin +/− OAD (23%). Results: Both the GP and the hospital groups of subjects experienced a low incidence of severe hypoglycaemia (<1%), with significant decreases in HbA1c levels (−0.51 and −0.95% respectively; p < 0.001), large reductions in FBG levels (−2.72 and 3.0 mmol/l respectively; p < 0.001) and modest weight gain of 1 and 1.2 kg respectively (p < 0.05). With the exception of absolute reductions in HbA1c and reductions in basal and prandial insulin made on switching to insulin glargine, there were few significant differences in subjects managed in primary compared with secondary care. Conclusions: This study shows that despite differences in diabetes duration and baseline glycaemic control, an insulin glargine–based therapy can be safely and effectively initiated in a diverse range of suboptimally controlled subjects with T2DM in both primary and secondary care settings in the UK. Rates of hypoglycaemia were low and consistent with the results of the main study. Absolute reductions in HbA1c were greatest in the secondary care setting, but similar levels of glycaemic control were achieved in both groups due to differences in baseline HbA1c. In the patients managed in primary care, there was an overall reduction in prandial and basal insulin used when switching to a basal insulin regimen and a lack of titration of prandial insulin. Therefore, the role of prandial insulin, its initiation and titration, appears to be an area that requires more focus in primary care. [ABSTRACT FROM AUTHOR]

Objective: To determine if headgear use by rugby players was associated with a reduced risk of head or facial laceration, abrasion, or fracture. Methods: An emergency department based case-control study in South Wales, UK, with cases being rugby players treated for superficial head and facial injuries and controls being their matched opponents during the game. A review of videos of the 41 games in the 1999 Rugby World Cup was also carried out to compare with the case-control study. Odds ratios (OR) and 95% confidence intervals (95% Cl) were used to measure association between exposure (headgear wearing) and outcome (head and facial injuries). Results: In the case-control study, 164 pairs were analysed, with headgear worn by 12.8% of cases and 21.3% of controls. Headgear use was associated with substantial but non-significant reductions in superficial head (OR = 0.43, 95% CI 0.13 to 1.19) and facial (OR = 0.57, 95% CI 0.21 to 1.46) injuries. The video study followed 547 players over 41 games, during which there were 47 bleeding injuries to the head. Headgear use significantly reduced the risk of bleeding head injury in forwards (OR = 0.14, 95% CI 0.01 to 0.99, P = 0.02), but not in backs. There was also a higher risk of facial injury among forwards, but this was not significant. Conclusions: The combined results suggest that headgear can prevent certain types of superficial head injuries in players at all levels of the game, but the evidence is strongest for superficial head injury in elite forwards. A randomised controlled trial would be the best way to study this further. [ABSTRACT FROM AUTHOR]

In the early 1980s, the Ministry of Agriculture in England and Wales took the decision to assess whether water erosion was a problem, deciding to answer the question through field-based assessment rather than by using plot experiments. Although giving valuable information on the rates, frequency and extent of erosion, as well as delivery of sediment out of catchments, the results do not allow rates to be related to individual parameters so that rates of erosion can be predicted. The results from the monitoring scheme explain why farmers think erosion is of little importance. In the vast majority of instances, erosion does not affect how the farmer manages the land nor does it lead to a large enough removal or burial of the crop to affect farm profitability. The rates of erosion in England and Wales are compared with those measured in the field in other countries. Although, within any particular environment, mean and maximum rates cover a wide range of values, mean values generally relate well to climate and soils, rates being higher where storms are more frequent, or where intense rains or rain coinciding with snowmelt fall on erodible soils. Maximum values reflect rainfall intensities and amounts falling in rare storms. A field-based approach such as that described here provides a rapid and realistic way to assess erosion and the results can be validly compared across a wide range of environments. [Copyright &y& Elsevier]

The aim of this study was to determine the availability of antidotes to poisons in Wales and the South West of England. A stocklist of antidotes that are available to accident and emergency departments was requested and was compared with recommendations from the International Programme on Chemical Safety (IPCS). Chief pharmacists were invited to complete a short questionnaire regarding knowledge of existing guidelines. Thirty-four of 43 centres replied (response rate 77%). No department held all 36 antidotes (mean 13, range 7–33). All departments held antidotes that were frequently used. Ninety-one percent of departments held one cyanide antidote. Eighty-eight percent held one heavy metal chelating agent. The remaining antidotes were variably stocked. New agents such as 4-methylpyrazole, hydroxocobalamin and the heavy metal chelating agents DMSA and DMPS were infrequently held. Twenty of 34 chief pharmacists were unfamiliar with existing UK guidelines. A trend exists whereby larger departments stocked more antidotes. Some antidotes to poisons are not available in a timely fashion in Wales and the South West of England. There is a lack of awareness of existing guidelines. New recommendations relevant to clinical need and local practice should ideally be developed. [ABSTRACT FROM AUTHOR]

Focuses on the erosional impacts of grazing animals on both rangeland and grasslands in Great Britain. Examination on the weakening of vegetation cover by grazing; Reduction of rainfall absorption into the soil due to land changes; Incisions to drainage lines and valley floors tracked by animals.

Esophagectomy is a mainstay in curative treatment for esophageal cancer; however, the reported techniques and outcomes can vary greatly. Thirty-day mortality of patients with an intact anastomosis is 2–3% as compared to 17–35% in patients who have an anastomotic leak. The subsequent management of leaks postesophagectomy has great global variability with little consensus on a gold standard of practice. The aim of this multicentre prospective audit is to analyze current techniques of esophagogastric anastomosis to determine the effect on the anastomotic leak rate. Leak rates and leak management will be assessed to determine their impact on patient outcomes. A 12-month international multicentre prospective audit started in April 2018 and is coordinated by a team from the West Midlands Research Collaborative. This will include patients undergoing esophagectomy over 9 months and encompassing a 90-day follow-up period. A pilot data collection period occurred at four UK centers in 2017 to trial the data collection form. The audit standards will include anastomotic leak and the conduit necrosis rate should be less than 13% and major postoperative morbidity (Clavien–Dindo Grade III or more) should be less than 35%. The 30-day mortality rate should be less than 5% and the 90-day mortality rate should be less than 8%. This will be a trainee-led international audit of esophagectomy practice. Key support will be given by consultant colleagues and anesthetists. Individualized unit data will be distributed to the respective contributing sites. An overall anonymized report will be made available to contributing units. Results of the audit will be published in peer-reviewed journals with all collaborators fully acknowledged. The key information and results from the audit will be disseminated at relevant scientific meetings. [ABSTRACT FROM AUTHOR]

Importance: Supplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly., Objective: To determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger., Design, Setting, and Participants: This open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023., Interventions: Patients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment., Main Outcomes and Measures: The prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm-related events, clinical outcomes, and cost related to the intervention., Results: A total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, -2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95% CI, $103.60-$120.19]; P <.001)., Conclusions and Relevance: For AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes., Trial Registration: ClinicalTrials.gov Identifier: NCT04053816.

The protracted form of COVID-19 known as 'long covid' was first described in 2020. Its symptoms, course and prognosis vary widely; some patients have a multi-system, disabling and prolonged illness. In 2021, ring-fenced funding was provided to establish 90 long covid clinics in England; some clinics were also established in Scotland and Wales. The NIHR-funded LOCOMOTION project implemented a UK-wide quality improvement collaborative involving ten of these clinics, which ran from 2021 to 2023. At regular online meetings held approximately 8-weekly, participants prioritised topics, discussed research evidence and guidelines, and presented exemplar case histories and clinic audits. A patient advisory group also held a priority-setting exercise, participated in quality meetings and undertook a service evaluation audit. The goal of successive quality improvement cycles aimed at changing practice to align with evidence was sometimes hard to achieve because definitive evidence did not yet exist in this new condition; many patients had comorbidities; and clinics were practically constrained in various ways. Nevertheless, much progress was made and a series of 'best practice' guides was produced, covering general assessment and management; breathing difficulties; orthostatic tachycardia and other autonomic symptoms; fatigue and cognitive impairment; and vocational rehabilitation. This paper summarises key findings with the frontline clinician in mind., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Trisha Greenhalgh reports financial support was provided by National Institute for Health and Care Research. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Surgical training programmes in the United Kingdom and Ireland (UK&I) are in a state of flux. This study aims to report the contemporary opinions of trainee and consultant surgeons on the current upper gastrointestinal (UGI) training model in the UK&I., Methods: A questionnaire was developed and distributed via national UGI societies. Questions pertained to demographics, current training evaluation, perceived requirements and availability., Results: A total of 241 responses were received with representation from all UK&I postgraduate training regions. The biggest discrepancies between rotation demand and national availability related to advanced/therapeutic endoscopy and robotic surgery, with 91.7% of respondents stating they would welcome greater geographical flexibility in training. The median suggested academic targets were 3-5 publications (trainee vs consultant <3 vs 3-5, p <0.001); <3 presentations (<3 vs 3-5, p =0.002); and 3-5 audits/quality improvement projects (<3 vs 3-5, p <0.001). Current operative requirements were considered achievable (87.6%) but inadequate for day one consultant practice (74.7%). Reassuringly, 76.3% deemed there was role for on-the-job operative training following consultant appointment. Proficiency in diagnostic endoscopy was considered a minimum requirement for Certificate of Completion of Training (CCT) yet the majority regarded therapeutic endoscopy competency as non-essential. The median numbers of index UGI operations suggested were comparable with the current curriculum requirements. Post-CCT fellowships were not considered necessary; however, the majority (73.6%) recognised their advantage., Conclusions: Current CCT requirements are largely consistent with the opinions of the UGI community. Areas for improvement include flexibility in geographical working and increasing national provisions for high-quality endoscopy training.

Background: Family group conferences (FGCs) in child welfare bring immediate and wider family members together to decide on the best way to meet a child's needs. Unlike professionally led meetings, the aim is for decisions to be made by or with family members. Qualitative and mixed-method research with FGC participants tends to show positive experiences: most participants feel their voices are heard; FGCs facilitate family-driven solutions and closer relationships-within families and with social workers. Although there is existing literature on FGCs, there is a paucity of robust comparative UK evaluations, i.e., randomised controlled trials or quasi-experimental studies. Comparative studies internationally have focused on a narrow range of outcomes, not recognised the importance of context, and paid little attention to the quality of delivery. Some qualitative studies have considered process and context but there is scant measurement of these. The aims of this study are, firstly, to establish how FGCs improve outcomes for families and what factors vary their quality, and, secondly, to assess longer-term outcomes in terms of service use and associated costs., Methods: Given the importance of process and context, evaluation informed by realist and complex systems approaches is needed. This multi-method evaluation includes a survey of FGC services in all UK local authorities (n = 212) to map service provision; co-design of programme theory and evaluation measures with family members who have experienced an FGC (n = 16-24) and practitioners (n = 16-24) in two sites; a prospective single-arm study of FGC variability and outcomes after six months; and comparison of service use and costs in FGC participants (n≥300 families) and a control group (n≥1000) after two years using a quasi-experiment., Discussion: This is a pragmatic evaluation of an existing intervention, to identify what mechanisms and contexts influence effective process and longer-term outcomes. The study is registered with Research Registry (ref. 7432)., Competing Interests: Jonathan Scourfield is a trustee of the Family Rights Group, a charity that promotes better family participation in the child welfare process, and family group conferences as one way of achieving this. This non-financial interest does not alter our adherence to PLOS ONE policies on sharing data and materials, with the provisos in the data sharing statement., (Copyright: © 2024 Scourfield et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: Migraine is considered a chronic health condition that impacts both quality of life and psychological wellbeing. People with migraines use a range of management strategies, which include pharmacological and non-pharmacological treatments. The aim of this study was to explore individuals' experiences and perceptions of migraines and its treatment using the Common-Sense Model (CSM) of Illness Representations., Methods: Semi-structured, one-to-one interviews were conducted with eleven individuals with a history of migraine to explore their experiences and perceptions of migraine and its treatment. Participants were recruited from across the United Kingdom via convenience sampling using social media advertisement. Interviews were recorded, transcribed verbatim, and qualitative data were analysed using theoretical framework analysis using the CSM., Results: The three dimensions of the CSM were mapped on to the qualitative data. These were: (i) Cognitive representations of migraine, within five domains: (a) identity of migraine, (b) perceived causes, (c) perceived timeline, (d) perceived control/cure, and (e) perceived consequences; (ii) Emotional representations of migraine relating to (a) migraine specific emotions and (b) emotional representation of the impact of migraine; and (iii) Coping/self-management behaviours, namely (a) self-medicating behaviours and (b) care-seeking behaviours. No incongruous data were found; therefore, no further thematic analysis was required., Conclusion: This is the first study to apply the CSM to migraine for framework analysis of qualitative data in this way. The findings illustrate the emotional impact of migraine and the range of illness perceptions associated with appropriate self-management. The data will be used to design a questionnaire for quantitative studies to investigate the extent to which these perceptions are generalizable to the wider population of people who experience migraines., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society.)

Background: The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population., Methods: In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020)., Results: Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%., Conclusions: This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients., (© 2024. The Author(s).)

Background: The International Liaison Committee on Resuscitation has called for a randomised trial of delivery to a cardiac arrest centre. We aimed to assess whether expedited delivery to a cardiac arrest centre compared with current standard of care following resuscitated cardiac arrest reduces deaths., Methods: ARREST is a prospective, parallel, multicentre, open-label, randomised superiority trial. Patients (aged ≥18 years) with return of spontaneous circulation following out-of-hospital cardiac arrest without ST elevation were randomly assigned (1:1) at the scene of their cardiac arrest by London Ambulance Service staff using a secure online randomisation system to expedited delivery to the cardiac catheter laboratory at one of seven cardiac arrest centres or standard of care with delivery to the geographically closest emergency department at one of 32 hospitals in London, UK. Masking of the ambulance staff who delivered the interventions and those reporting treatment outcomes in hospital was not possible. The primary outcome was all-cause mortality at 30 days, analysed in the intention-to-treat (ITT) population excluding those with unknown mortality status. Safety outcomes were analysed in the ITT population. The trial was prospectively registered with the International Standard Randomised Controlled Trials Registry, 96585404., Findings: Between Jan 15, 2018, and Dec 1, 2022, 862 patients were enrolled, of whom 431 (50%) were randomly assigned to a cardiac arrest centre and 431 (50%) to standard care. 20 participants withdrew from the cardiac arrest centre group and 19 from the standard care group, due to lack of consent or unknown mortality status, leaving 411 participants in the cardiac arrest centre group and 412 in the standard care group for the primary analysis. Of 822 participants for whom data were available, 560 (68%) were male and 262 (32%) were female. The primary endpoint of 30-day mortality occurred in 258 (63%) of 411 participants in the cardiac arrest centre group and in 258 (63%) of 412 in the standard care group (unadjusted risk ratio for survival 1·00, 95% CI 0·90-1·11; p=0·96). Eight (2%) of 414 patients in the cardiac arrest centre group and three (1%) of 413 in the standard care group had serious adverse events, none of which were deemed related to the trial intervention., Interpretation: In adult patients without ST elevation, transfer to a cardiac arrest centre following resuscitated cardiac arrest in the community did not reduce deaths., Funding: British Heart Foundation., Competing Interests: Declaration of interests We declare no competing interests., (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.)

Aim: Due to extensive treatment switching in the MAVORIC trial, lack of UK regulatory licence for the comparator, overall survival (OS) with mogamulizumab was compared with patients with previously treated advanced mycosis fungoides/Sézary syndrome (MF/SS) in real-world setting. Design, setting & participants: Data were from the Hospital Episode Statistics database (all patients in NHS secondary care system in 2009-2019). Patients were selected according to trial inclusion criteria, then trial and HES samples were matched on selected variables with significant imbalance. Outcomes: The analysis indicated significant improvement in OS for mogamulizumab treatment compared with UK clinical practice (hazard ratio: 0.36, 95% CI: 0.24, 0.53). Conclusion: Results suggest an OS advantage for patients with advanced MF/SS treated with mogamulizumab in MAVORIC trial compared with UK clinical practice.

Background: Snacking is associated with a higher daily energy intake and dietary guidelines recommend snacks of no more than 200 kcal for adults and 100 kcal for children. The present study examines the energy content, nutritional quality and price of single-serving snack food products sold by major supermarket and coffee shop chains in the UK., Methods: Energy content, nutritional content and price of single-serving snack products were recorded in 2019 via the websites of 14 major chains (seven supermarkets; seven coffee shops)., Results: The mean energy content of all eligible snack products (n = 2283) was 186 kcal [95% confidence interval (CI) = 182-190]. The mean energy content of the snack products sold at coffee shops (n = 379; 282 kcal [95% CI = 269-295]) was significantly higher than the energy content of the snack products sold at supermarkets (n = 1904; 167 kcal [95% CI = 164-170]). Seventy nine % of supermarket snacks exceeded energy recommendations for children and 32% for adults. In coffee shops, 91% exceeded recommendations for children and 73% for adults. Forty one % of snacks were high in fat, 42% were high in saturated fat, 39% were high in sugar and 7% were high in salt. Cheaper snack products were more likely to be of lower nutritional quality., Conclusions: The high proportion of snack products that do not meet public health recommendations for energy content may contribute to the association between snacking and increased energy intake. Public health measures to increase the availability and reduce the price of snack products that meet public health energy content recommendations may reduce population-level obesity., (© 2021 British Dietetic Association.)

Background: Teachers are at heightened risk of poor mental health and well-being, which is likely to impact on the support they provide to students, and student outcomes. We conducted a cluster randomised controlled trial, to test whether an intervention to improve mental health support and training for high school teachers led to improved mental health and well-being for teachers and students, compared to usual practice. We also conducted a cost evaluation of the intervention., Methods and Findings: The intervention comprised (i) Mental Health First Aid training for teachers to support students; (ii) a mental health awareness session; and (iii) a confidential staff peer support service. In total 25 mainstream, non-fee-paying secondary schools stratified by geographical area and free school meal entitlement were randomly allocated to intervention (n = 12) or control group (n = 13) after collection of baseline measures. We analysed data using mixed-effects repeated measures models in the intention-to-treat population, adjusted for stratification variables, sex, and years of experience. The primary outcome was teacher well-being (Warwick-Edinburgh Mental Well-being Scale). Secondary outcomes were teacher depression, absence, and presenteeism, and student well-being, mental health difficulties, attendance, and attainment. Follow-up was at months 12 (T1) and 24 (T2). We collected process data to test the logic model underpinning the intervention, to aid interpretation of the findings. A total of 1,722 teachers were included in the primary analysis. Teacher well-being did not differ between groups at T2 (intervention mean well-being score 47.5, control group mean well-being score 48.4, adjusted mean difference -0.90, 95% CI -2.07 to 0.27, p = 0.130). The only effect on secondary outcomes was higher teacher-reported absence among the intervention group at T2 (intervention group median number of days absent 0, control group median number of days absent 0, ratio of geometric means 1.04, 95% CI 1.00 to 1.09, p = 0.042). Process measures indicated little change in perceived mental health support, quality of relationships, and work-related stress. The average cost of the intervention was £9,103 per school. The study's main limitations were a lack of blinding of research participants and the self-report nature of the outcome measures., Conclusions: In this study, we observed no improvements to teacher or student mental health following the intervention, possibly due to a lack of impact on key drivers of poor mental health within the school environment. Future research should focus on structural and cultural changes to the school environment, which may be more effective at improving teacher and student mental health and well-being., Trial Registration: www.isrctn.com ISRCTN95909211., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Competing interests: None declared.

Introduction: Health Data Research UK designated seven UK-based Hubs to facilitate health data use for research. PIONEER is the Hub in Acute Care. PIONEER delivered workshops where patients/public citizens agreed key principles to guide access to unconsented, anonymised, routinely collected health data. These were used to inform the protocol., Methods: This paper describes the PIONEER infrastructure and data access processes. PIONEER is a research database and analytical environment that links routinely collected health data across community, ambulance and hospital healthcare providers. PIONEER aims ultimately to improve patient health and care, by making health data discoverable and accessible for research by National Health Service, academic and commercial organisations. The PIONEER protocol incorporates principles identified in the public/patient workshops. This includes all data access requests being reviewed by the Data Trust Committee, a group of public citizens who advise on whether requests should be supported prior to licensed access., Ethics and Dissemination: East Midlands-Derby REC (20/EM/0158): Confidentiality Advisory Group (20/CAG/0084). www.PIONEERdatahub.co.uk., Competing Interests: Competing interests: SG, GP, HP, GMC, CJ, BR, LF, BLC, CA, KWD, EM, CC, ML, SM, SP, JA, RDoal, RDormer, AR and HF have no conflicts of interest. GG reports funding from HDR-UK. ES reports funding from the Wellcome Trust, MRC, HDR-UK, Alpha 1 Foundation (A1F), British Lung Foundation and NIHR., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background: The study assessed the cost-utility of selective internal radiation therapy (SIRT) with Y-90 resin microspheres versus sorafenib in UK patients with unresectable hepatocellular carcinoma ineligible for transarterial chemoembolization. Materials & methods: A lifetime partitioned survival model was developed for patients with low tumor burden (≤25%) and good liver function (albumin-bilirubin grade 1). Efficacy, safety and quality of life data were from a European Phase III randomized controlled trial and published studies. Resource use was from registries and clinical surveys. Results: Discounted quality-adjusted life-years were 1.982 and 1.381, and discounted total costs were £29,143 and 30,927, for SIRT and sorafenib, respectively. Conclusion: SIRT has the potential to be a dominant (more efficacious/less costly) or cost-effective alternative to sorafenib in patients with unresectable hepatocellular carcinoma.

Background: Patients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group., Methods: An observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies., Results: 148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%)., Conclusions: The risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Preoperative anaemia affects a high proportion of patients undergoing major elective surgery and is associated with poor outcomes. We aimed to test the hypothesis that intravenous iron given to anaemic patients before major open elective abdominal surgery would correct anaemia, reduce the need for blood transfusions, and improve patient outcomes., Methods: In a double-blind, parallel-group randomised trial, we recruited adult participants identified with anaemia at preoperative hospital visits before elective major open abdominal surgery at 46 UK tertiary care centres. Anaemia was defined as haemoglobin less than 130 g/L for men and 120 g/L for women. We randomly allocated participants (1:1) via a secure web-based service to receive intravenous iron or placebo 10-42 days before surgery. Intravenous iron was administered as a single 1000 mg dose of ferric carboxymaltose in 100 mL normal saline, and placebo was 100 mL normal saline, both given as an infusion over 15 min. Unblinded study personnel prepared and administered the study drug; participants and other clinical and research staff were blinded to treatment allocation. Coprimary endpoints were risk of the composite outcome of blood transfusion or death, and number of blood transfusions from randomisation to 30 days postoperatively. The primary analysis included all randomly assigned patients with data available for the primary endpoints; safety analysis included all randomly assigned patients according to the treatment received. This study is registered, ISRCTN67322816, and is closed to new participants., Findings: Of 487 participants randomly assigned to placebo (n=243) or intravenous iron (n=244) between Jan 6, 2014, and Sept 28, 2018, complete data for the primary endpoints were available for 474 (97%) individuals. Death or blood transfusion occurred in 67 (28%) of the 237 patients in the placebo group and 69 (29%) of the 237 patients in the intravenous iron group (risk ratio 1·03, 95% CI 0·78-1·37; p=0·84). There were 111 blood transfusions in the placebo group and 105 in the intravenous iron group (rate ratio 0·98, 95% CI 0·68-1·43; p=0·93). There were no significant differences between the two groups for any of the prespecified safety endpoints., Interpretation: Preoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10-42 days before elective major abdominal surgery., Funding: UK National Institute of Health Research Health Technology Assessment Program., (Copyright © 2020 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.)

To explore possible distinctive features of online memorials for youth suicides, amid concerns about glorification, we compared public Facebook memorials for suicides and road traffic accident deaths, using Linguistic Inquiry and Word Count software. People who posted on memorial sites wrote at greater length about suicides, using longer words and more quotation marks. Words suggesting causation and achievement were more prevalent in suicide memorials. Thematic content for the two types of death was more similar than different. Suicide memorial posts had more tentative words, non-fluencies, and question marks, suggesting that people were struggling to make sense of these deaths.

Background: Remote ischaemic conditioning with transient ischaemia and reperfusion applied to the arm has been shown to reduce myocardial infarct size in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). We investigated whether remote ischaemic conditioning could reduce the incidence of cardiac death and hospitalisation for heart failure at 12 months., Methods: We did an international investigator-initiated, prospective, single-blind, randomised controlled trial (CONDI-2/ERIC-PPCI) at 33 centres across the UK, Denmark, Spain, and Serbia. Patients (age >18 years) with suspected STEMI and who were eligible for PPCI were randomly allocated (1:1, stratified by centre with a permuted block method) to receive standard treatment (including a sham simulated remote ischaemic conditioning intervention at UK sites only) or remote ischaemic conditioning treatment (intermittent ischaemia and reperfusion applied to the arm through four cycles of 5-min inflation and 5-min deflation of an automated cuff device) before PPCI. Investigators responsible for data collection and outcome assessment were masked to treatment allocation. The primary combined endpoint was cardiac death or hospitalisation for heart failure at 12 months in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT02342522) and is completed., Findings: Between Nov 6, 2013, and March 31, 2018, 5401 patients were randomly allocated to either the control group (n=2701) or the remote ischaemic conditioning group (n=2700). After exclusion of patients upon hospital arrival or loss to follow-up, 2569 patients in the control group and 2546 in the intervention group were included in the intention-to-treat analysis. At 12 months post-PPCI, the Kaplan-Meier-estimated frequencies of cardiac death or hospitalisation for heart failure (the primary endpoint) were 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio 1·10 [95% CI 0·91-1·32], p=0·32 for intervention versus control). No important unexpected adverse events or side effects of remote ischaemic conditioning were observed., Interpretation: Remote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI., Funding: British Heart Foundation, University College London Hospitals/University College London Biomedical Research Centre, Danish Innovation Foundation, Novo Nordisk Foundation, TrygFonden., (Copyright © 2019 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: Adolescence can be a challenging time, characterized by self-consciousness, heightened regard for peer acceptance, and fear of rejection. Interpersonal concerns are amplified by unpredictable social interactions, both online and offline. This developmental and social context is potentially conducive to the emergence of paranoia. However, research on paranoia during adolescence is scarce., Method: Our aim was to examine the prevalence, structure, and probabilistic causal mechanisms of adolescent paranoia. A representative school cohort of 801 adolescents (11-15 y) completed measures of paranoia and a range of affective, cognitive, and social factors. A Bayesian approach with Directed Acyclic Graphs (DAGs) was used to assess the causal interactions with paranoia., Results: Paranoid thoughts were very common, followed a continuous distribution, and were hierarchically structured. There was an overall paranoia factor, with sub-factors of social fears, physical threat fears, and conspiracy concerns. With all other variables controlled, DAG analysis identified paranoia had dependent relationships with negative affect, peer difficulties, bullying, and cognitive-affective responses to social media. The causal directions could not be fully determined, but it was more likely that negative affect contributed to paranoia and paranoia impacted peer relationships. Problematic social media use did not causally influence paranoia., Conclusions: There is a continuum of paranoia in adolescence and occasional suspicions are common at this age. Anxiety and depression are closely connected with paranoia and may causally contribute to its development. Paranoia may negatively impact adolescent peer relationships. The clinical significance of paranoia in adolescents accessing mental health services must now be established., (© The Author(s) 2018. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.)

Introduction: Following centralisation of UK paediatric intensive care, specialist retrieval teams were established who travel to general hospitals to stabilise and transport sick children to regional paediatric intensive care units (PICUs). There is national variation among these PICU retrieval teams (PICRTs) in terms of how quickly they reach the patient's bedside and in the care provided during transport. The impact of these variations on clinical outcomes and the experience of stakeholders (patients, families and healthcare staff) is however unknown. The primary objective of this study is to address this evidence gap., Methods and Analysis: This mixed-methods project involves the following: (1) retrospective analysis of linked data from routine clinical audits (2014-2016) to assess the impact of service variations on 30-day mortality and other secondary clinical outcomes; (2) a prospective questionnaire study conducted at 24 PICUs and 9 associated PICRTs in England and Wales over a 12-month period in 2018 to collect experience data from parents of transported children as well as qualitative analysis of in-depth interviews with a purposive sample of patients, parents and staff to assess the impact of service variations on patient/family experience; (3) health economic evaluation analysing transport service costs (and other associated costs) against lives saved and longer term measurements of quality of life at 12 months in transported children and (4) mathematical modelling evaluating the costs and potential impact of different service configurations. A final work stream involves a series of stakeholder workshops to synthesise study findings and generate recommendations., Ethics and Dissemination: The study has been reviewed and approved by the Health Research Authority, ref: 2 18 569. Study results will be actively disseminated through peer-reviewed journals, conference presentations, social media, print and broadcast media, the internet and stakeholder workshops., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Improvement in long-term renal allograft survival is impeded by incomplete or erroneous coding of causes of allograft loss. This study reports 13-year trends in causes of graft failure across the UK., Methods: National Health Service Blood and Transplant (NHSBT) and UK Renal Registry data were linked to describe UK kidney patients transplanted in 2000-13. NHSBT graft failure categories were used, with 'other' recoded when free text was available. Adjusted analyses examined the influence of age, ethnicity and donor type on causes of graft failure., Results: In 22 730 recipients, 5389 (23.7%) grafts failed within a median follow-up of 5 years. The two most frequent causes were death with a functioning graft (40.8%) and alloimmune pathology (25.0%). Graft survival was higher in recipients who were younger (mean 47.3 versus 50.7 years), received a pre-emptive transplant (20.2% versus 10.4%), spent less time on dialysis (median 1.6 versus 2.4 years) and received a living donor transplant (36.3% versus 22.2%), with no differences by sex, ethnicity or human leucocyte antigen mismatch. Allograft failure within 2 years of transplantation fell from 12.5% (2000-4) to 9.8% (2009-13). Surgical- and alloimmune-related failures decreased over time while death with a functioning graft became more common. Age, ethnicity and donor type were factors in recurrent primary disease and alloimmune pathology., Conclusions: Since 2000 there have been reductions in surgical and alloimmune graft failures in the UK. However, graft failure codes need to be revised if they are to remain useful and effective in epidemiological and quality improvement trials.

Background: Randomised controlled trials are the cornerstone of evidence-based health care, yet many trials struggle with recruitment and retention. All too often the methodologies employed to address these problems are not evidence-based, as rigorous methodological research on these issues is rare. The current research sought to identify barriers to the routine implementation of methodology research around recruitment and retention., Methods: All registered UK clinical trials unit directors were sent a short questionnaire and invited to interview. Representatives of funding bodies and other stakeholders were also approached. Interviews were recorded and the content analysed., Results: Data were grouped into four themes: acceptance of the need for methodological research; trial funding and development; trial processes; and organisational factors. The need to improve the evidence base for trials methodology is well established, but numerous barriers to implementation were perceived., Conclusions: The knowledge and expertise required to routinely implement methodology research exists within the current research structures, and there are clear opportunities to develop the evidence base. However, for this to be achieved there is also a need for clear strategic coordination within the sector and promotion of the necessary resources.

From 1st May 2013 to 30th April 2014 there were 35 episodes of Methicillin resistant Staphylococcus aureus (MRSA) bacteraemia in established renal failure patients on dialysis. This is now fairly stable year-on-year equating to a rate of 0.15 episodes per 100 dialysis patient years, following an initial decline in rates from 4.0 episodes per 100 dialysis patient years in 2005 when reporting began. Methicillin sensitive Staphylococcus aureus (MSSA) bacteraemia rates were slightly higher this year at 2.23 per 100 dialysis patient years (compared with 1.59 episodes per 100 dialysis patient years last year) with 526 episodes of blood stream infection reported. In 2005, the first year this was reported, there were 1,114 MSSA bacteraemias in 54 centres. There were 247 Clostridium difficile infection episodes with a rate of 1.05 per 100 dialysis patient years, slightly higher than last year at 0.55 episodes per 100 dialysis patient years. Escherichia coli infections occurred at a rate of 1.49 per 100 dialysis patient years, very similar to the rate reported last year (1.32 episodes per 100 dialysis patient years). This report has utilised a new methodology to identify cases, linking all established renal failure cases known to the UK Renal Registry (UKRR) with all infections reported to Public Health England and avoids the need for the local microbiology team to flag the patient as a renal patient. This may have increased the reliability of diagnosis at the UKRR level. In each infection for which access data were collected, the presence of a central venous catheter appeared to correlate with increased risk.

Objectives: To examine the evidence base for telemonitoring designed for patients who have chronic obstructive pulmonary disease and heart failure, and to assess whether telemonitoring fulfils the principles of monitoring and is ready for implementation into routine settings., Design: Qualitative data collection using interviews and participation in a multi-path mapping process., Participants: Twenty-six purposively selected informants completed semi-structured interviews and 24 individuals with expertise in the relevant clinical and informatics domains from academia, industry, policy and provider organizations and participated in a multi-path mapping workshop., Results: The evidence base for the effectiveness of telemonitoring is weak and inconsistent, with insufficient cost-effectiveness studies. When considered against an accepted definition of monitoring, telemonitoring is found wanting. Telemonitoring has not been able so far to ensure that the technologies fit into the life world of the patient and into the clinical and organizational milieu of health service delivery systems., Conclusions: To develop effective telemonitoring for patients with chronic disease, more attention needs to be given to agreeing the central aim of early detection and, to ensure potential implementation, engaging a wide range of stakeholders in the design process, especially patients and clinicians., (© 2011 Blackwell Publishing Ltd.)

Unicompartmental knee replacement (UKR) for anteromedial osteoarthritis is a well-established technique. Numerous clinical outcome studies demonstrate good medium and long-term results. The aim of this prospective study was to compare the complications and short-term clinical outcome of the St. Georg Sled, a fixed bearing UKR, with the Oxford mobile bearing UKR. Outcome at 2 years was assessed using the Bristol knee score and the Oxford knee score; in addition, complications occurring since formal scoring at 2-year follow-up were recorded. A total of 47 Oxford UKRs and 57 St. Georg Sled UKRs were performed in 91 patients, none of whom were lost to follow-up. At 2 years, both outcome measures were better for the St. Georg Sled Group. The pain component of the Bristol knee score was significantly better for this group (p-value = 0.013). Three patients in the Oxford group had bearing dislocations and a further four patients required revision (mean time to revision 3.0 years). In the St. Georg Sled group, three patients required revisions (mean time to revision 3.4 years). These results demonstrate that in the short-term, the Oxford mobile bearing prosthesis has a higher re-operation rate and that the St. Georg Sled achieves better pain relief. The functional scores of the two groups were similar.

This prospective, controlled trial with crossover group design compares the effectiveness of active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) and standard CPR on the outcomes of victims of prehospital cardiac arrest. In three UK cities, victims of non-traumatic, out of hospital cardiac arrest, over the age of 8 years received either standard or ACD-CPR on arrival of ambulance personnel. Main outcome measures were return of spontaneous circulation, survival to be admitted to the intensive care unit, survival to hospital discharge, and neurological outcome. A total of 576 patients (STD-CPR, n=309; ACD-CPR, n=267) were analysed. The treatment groups were similar with respect to age, gender, proportion of witnessed arrests, initial cardiac rhythm, and call to advanced life support interval. The proportion of patients receiving bystander CPR was higher in the ACD group (37.1% vs. 28.5%; P=0.028). The interval between collapse and defibrillation was longer in the ACD group (12.3 min vs. 10.4 min; P=0.028). There was no difference between the STD-CPR and ACD-CPR groups in survival to admission to the intensive care unit (13.6% vs. 13.8%; P=0.93) or hospital discharge (4.8% vs. 6.0%; P=0.67). There was no difference between the groups with respect to the neurological outcome of those patients surviving to hospital discharge. Analysis of important subgroups also showed no benefit for ACD-CPR. We conclude that there was no improvement in outcome with ACD-CPR when used by ambulance personnel in Cardiff and Portsmouth.