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The shrinkage limit is one of the Atterberg limits and is a fundamental geotechnical parameter used to assess the settlement of engineering soils containing clays, yet is rarely tested for as part of ground investigation. This paper describes shrinkage limit test results on a variety of soils from Britain and overseas obtained using an improved laboratory testing procedure developed at the British Geological Survey. The co-relationships with the other Atterberg limits and with density are explored. In particular, the coincidence of the shrinkage limit with thewater content at the peak bulk density achieved in the test is examined. The shrinkage behaviour for undisturbed and remoulded states and a three-way relationship between water content, density and suction are demonstrated. Some tropical residual and highly smectitic soils show a very wide range of shrinkage behaviour, albeit for a small dataset, when compared with the larger dataset of temperate soils tested. Consideration is given to limitations of the new and existing test methods. [ABSTRACT FROM AUTHOR]

Background The electronic Survey of Anxiety and Information for Dentists (eSAID) allows children to tell dentists about their feelings and coping preferences. It is a computer 'quiz' with 26 questions and free-text responses that produces a report for the children that they can then hand to their dentist. This is the first study to report the use of eSAID in a hospital paediatric dental clinic. Methods This was a randomized controlled trial to evaluate whether children thought that eSAID benefitted them, made them less anxious, and improved cooperation and their treatment satisfaction. Fifty-one children aged 8-13 years were randomized to complete either eSAID or a control version in the waiting room before their scheduled dental appointment. The study group had a 26-item questionnaire; the control had only two items. Both groups scored their anxiety on a 7-point anxiety scale at the start and again at the end of the quiz. All subjects handed the resultant eSAID report as a printout to their dentist. Dental treatment proceeded as planned. After treatment, each child reported how they thought the eSAID quiz had benefitted them by scoring on a 10 cm Visual Analogue Scale and their satisfaction on the Modified Treatment Evaluation Inventory. The operating dentists scored the children's cooperation using a 10 cm Visual Analogue Scale. Results Overall, the baseline anxiety levels were low (study: mean 1.2; control: mean 1.5). The study group's post-survey anxiety reduced by 0.4, whereas controls' increased by 0.2; this difference is statistically significant ( p = .04). However, it made no difference to the children's self-reported benefit ( p = .30), satisfaction ( p > .05), or cooperation ( p = .34). Conclusions eSAID reduced pre-treatment anxiety but made no difference to children's perceived benefit, satisfaction, or cooperation. Future study should include known anxious children. [ABSTRACT FROM AUTHOR]

Background: Stress levels and psychological morbidity are high among undergraduate medical students (UGs), but there is a lack of research into the psychological health of UK graduate-entry medical students (GEs). GEs are likely to experience different (perhaps more severe) stressors and to cope with stress differently. We compared stress levels, psychological morbidity and coping styles in GE versus UG medical students studying at the same UK medical school in the same academic year. A cross-sectional self-rated questionnaire study of all first- and second-year GE and UG medical students was conducted. Perceived stress, psychological morbidity, recent adverse life events, stress-related personality traits and coping styles were assessed using standard questionnaires. Results: 75% GEs and 46% UGs responded to the questionnaire. Both groups reported equally high levels, and similar profiles of, perceived stress and psychological morbidity. Levels of recent adverse life events and stress-related personality traits were similar in both groups. Compared to UGs, GEs were more likely to use active coping (p = 0.02) and positive reframing (p = 0.03), but were also more likely to use substances (alcohol and other drugs; p < 0.001) to help them cope. Unlike UGs, second-year GEs showed less perceived stress (p = 0.007) and psychological morbidity (p = 0.006) than first-year GEs although levels of both were still high. Conclusion: Our results show that both GE students and their younger UG counterparts on a traditional medical course have similar profiles of stress symptoms. They do, however, cope with stress differently. GEs are more likely to use active problem-focused coping strategies, and they are also more likely to cope by using substances (alcohol or other drugs). GE students need interventions to prevent maladaptive coping styles and encourage adaptive coping that are tailored to their needs. Such interventions should be targeted at first-year students. It is vital that these students develop positive coping skills to benefit them during training and in a future career that is inherently stressful. [ABSTRACT FROM AUTHOR]

Problematic eating behaviours during early childhood could be mediators of poor dietary habits. This study aims to prospectively relate early eating behaviours with fruit and vegetable (F&V) intake and a healthy diet variety score of children aged between 4 and 5 years. Eating behaviours were assessed in three European birth cohorts (Generation XXI from Portugal, ALSPAC from the UK and EDEN from France) at 4–6, 12–15, 24 and 48–54 months of age, based on the child’s feeding difficulties, mother’s perception of child’s poor eating (eating small quantities at each meal, not eating enough or needing to be stimulated to eat), food refusal and difficulties in the establishment of daily food routines. Daily servings of F&V (>1 v. ≤1 serving/d, except in Generation XXI: >3 v. ≤3) and the Healthy Plate Variety Score (categorised by the median score of each sample) were calculated using FFQ. Associations were tested by logistic regressions adjusted for maternal age, education, smoking during pregnancy, any breast-feeding and the child’s z-score BMI at 4–5 years of age. Children with more feeding difficulties, poor eating, food refusal/neophobia and difficulties in establishing a daily routine at 12–15, 24 and 48–54 months of age had in general lower F&V intake at 4–5 years of age. The association with vegetables was slightly stronger than with fruits. These early feeding problems were also inversely associated with the variety score at 4–5 years of age, particularly when eating behaviours were reported after 12–15 months of age. A better understanding of these early feeding difficulties may help define strategies to increase the dietary quality in children. [ABSTRACT FROM PUBLISHER]

Background Young patients presenting to surgical clinics with breast cancer are usually aware of their family history and frequently believe that a positive family history may adversely affect their prognosis. Tumour pathology and outcomes were compared in young British patients with breast cancer with and without a family history of breast cancer. Methods Prospective Outcomes in Sporadic versus Hereditary breast cancer ( POSH) is a large prospective cohort study of women aged less than 41 years with breast cancer diagnosed and treated in the UK using modern oncological management. Personal characteristics, tumour pathology, treatment and family history of breast/ovarian cancer were recorded. Follow-up data were collected annually. Results Family history data were available for 2850 patients. No family history was reported by 65·9 per cent, and 34·1 per cent reported breast/ovarian cancer in at least one first- or second-degree relative. Patients with a family history were more likely to have grade 3 tumours (63·3 versus 58·9 per cent) and less likely to have human epidermal growth factor receptor 2-positive tumours (24·7 versus 28·8 per cent) than those with no family history. In multivariable analyses, there were no significant differences in distant disease-free intervals for patients with versus those without a family history, either for the whole cohort (hazard ratio ( HR) 0·89, 95 per cent c.i. 0·76 to 1·03; P = 0·120) or when stratified by oestrogen receptor ( ER) status ( ER-negative: HR 0·80, 0·62 to 1·04, P = 0·101; ER-positive: HR 0·95, 0·78 to 1·15, P = 0·589). Conclusion Young British patients presenting to breast surgical clinics with a positive family history can be reassured that this is not a significant independent risk factor for breast cancer outcome. [ABSTRACT FROM AUTHOR]

Background:Black ethnic groups have a higher breast cancer mortality than Whites. American studies have identified variations in tumour biology and unequal health-care access as causative factors. We compared tumour pathology, treatment and outcomes in three ethnic groups in young breast cancer patients treated in the United Kingdom.Methods:Women aged 40 years at breast cancer diagnosis were recruited to the POSH national cohort study (MREC: 00/06/69). Personal characteristics, tumour pathology and treatment data were collected at diagnosis. Follow-up data were collected annually. Overall survival (OS) and distant relapse-free survival (DRFS) were assessed using Kaplan-Meier curves, and multivariate analyses were performed using Cox regression.Results:Ethnicity data were available for 2915 patients including 2690 (91.0%) Whites, 118 (4.0%) Blacks and 87 (2.9%) Asians. Median tumour diameter at presentation was greater in Blacks than Whites (26.0 mm vs 22.0 mm, P=0.0103), and multifocal tumours were more frequent in both Blacks (43.4%) and Asians (37.0%) than Whites (28.9%). ER/PR/HER2-negative tumours were significantly more frequent in Blacks (26.1%) than Whites (18.6%, P=0.043). Use of chemotherapy was similarly high in all ethnic groups (89% B vs 88.6% W vs 89.7% A). A 5-year DRFS was significantly lower in Blacks than Asians (62.8% B vs 77.0% A, P=0.0473) or Whites (62.8 B% vs 77.0% W, P=0.0053) and a 5-year OS for Black patients, 71.1% (95% CI: 61.0-79.1%), was significantly lower than that of Whites (82.4%, 95% CI: 80.8-83.9%, W vs B: P=0.0160). In multivariate analysis, Black ethnicity had an effect on DRFS in oestrogen receptor (ER)-positive patients that is independent of body mass index, tumour size, grade or nodal status, HR: 1.60 (95% CI: 1.03-2.47, P=0.035).Conclusion:Despite equal access to health care, young Black women in the United Kingdom have a significantly poorer outcome than White patients. Black ethnicity is an independent risk factor for reduced DRFS particularly in ER-positive patients. [ABSTRACT FROM AUTHOR]

UK medical school curricula incorporate training in end-of-life care as recommended by Tomorrow's Doctors. Previous research suggests that hospice staff have concerns about the burden on patients when participating in medical student teaching and may gatekeep access to patients. This qualitative study uses semistructured interviews to explore and compare the views of hospice patients and health care staff about patient involvement in medical student teaching. Fifteen patients and 14 staff members were recruited from a single UK hospice involved in teaching third year medical students. Hospice patients, who have been involved in teaching, are strongly positive about meeting medical students and staff carefully select patients based on a number of issues. [ABSTRACT FROM AUTHOR]

Objective: Associations between diet and physical activity may identify behaviours that could be changed together to prevent childhood obesity. The present study examines associations between physical activity and obesogenic dietary behaviours in a large UK adolescent cohort. Design: Cross-sectional analysis of a UK cohort. Adolescents aged 10-11 years completed three 1 d diet diaries. Average daily energy consumption, percentage energy from fat and carbohydrate, energy density and grams of fruit and vegetables were estimated. To assess physical activity participants wore an accelerometer for three or more days. Regression models were run by sex to examine the extent to which dietary variables predicted physical activity before and after controlling for pubertal status, maternal education and adiposity. Setting: The Avon Longitudinal Study of Parents and Children (ALSPAC), southwest England. Subjects: Adolescents who provided diet data at age 10 years and physical activity data at age 11 years. Results: Among boys, percentage energy from fat was consistently negatively associated with accelerometer-determined indicators of physical activity (standardized beta (β)=-0∙055 to -0∙101, P<0∙05) while total energy (β=0∙066 to 0∙091, P<0∙05) and percentage energy from carbohydrate (β=0∙054 to 0∙106, P<0∙05) were positively associated before and after adjustment for confounders. For girls fruit and vegetable intake was consistently positively associated with physical activity (β=0∙056 to 0∙074, P<0∙005). However all associations were weak. Associations were broadly comparable when participants with nonplausible dietary reports were included or excluded from the analyses. Conclusions: Obesogenic diet and physical activity behaviours were weakly associated, suggesting that interventions should focus on implementing strategies that are independently successful at changing diet or physical activity behaviours either separately or in combination. [ABSTRACT FROM AUTHOR]

The end of life care received by patients with advanced dementia and their carers is of increasing importance as the incidence of dementia is set to rise in the next 30 years. Currently, inappropriate admissions to hospital are common in the UK and patients are less likely to be referred to palliative care services, receive less pain control but undergo more invasive interventions compared to their cognitively intact counterparts. Patients and families are seldom informed of the terminal nature of dementia and advance care planning discussions are rare. The aim of this study was to improve the understanding of end of life care needs for this patient group and their carers, and to use this information to devise an intervention to improve care. Qualitative data were obtained from relatives of 20 patients with advanced dementia admitted to an inner London teaching hospital acute National Health Service (NHS) Trust and 21 health care professionals involved in their care. Framework analysis was used to analyse the transcripts. The results showed that participants' understanding of dementia and its likely progress was poor. Provision of information regarding the future was rare despite high information needs. Attitudes regarding end of life care were often driven by the participant's illness awareness. These attitudes served to guide the decision making process and appear to be a major barrier to the provision of more appropriate care. Implications for patient care are discussed and suggestions for future interventions are made. [ABSTRACT FROM AUTHOR]

Bereavement needs assessment for specialist palliative care services has been highlighted as important by NICE guidance on palliative care for adults with cancer. Identifying and implementing appropriate bereavement measurement tools has remained a challenge. This paper identifies and reviews bereavement measurement tools to determine their suitability for use within bereavement services and hospice settings. Cochrane, MEDLINE, PsycINFO and CINAHL, electronic databases were searched, yielding 486 papers. From fifty-nine full text papers appraised, 10 measurement tools were analysed in detail. Some tools had been tested on specific populations which limited transferability to specialist palliative care settings; some lacked adequate theoretical links and were not effective in discriminating between normal and complicated grief reactions; and some lacked clear evidence of validity or reliability. Based on these criteria, conclusions are drawn about the suitability of particular tools for UK bereavement services and hospice settings where intervention is delivered by both trained professionals and volunteers. [ABSTRACT FROM AUTHOR]

Linda Jones discusses the many new opportunities for nurses to develop their leadership skills. [ABSTRACT FROM AUTHOR]

Objective:To analyse whether high dietary energy density (DED) is associated with increased fat mass and risk of excess adiposity in free-living children.Design:Longitudinal, observational cohort study.Subjects:Six hundred and eighty-two healthy children from the Avon Longitudinal Study of Parents and Children.Measurements:Diet was assessed at age 5 and 7 years using 3-day diet diaries, and DED (kJ g−1) was calculated excluding drinks. Fat mass was estimated at age 9 years using Dual-Energy X-ray Absorptiometry. To adjust for body size, fat mass index (FMI) was calculated by dividing fat mass (kg) by height (m5.8). Excess adiposity was defined as the top quintile of logFMI.Results:Mean DED at age 5 years was higher among children with excess adiposity at age 9 years compared to the remaining sample (8.8±0.16 vs 8.5±0.07 kJ g−1), but there was no evidence of an association with excess adiposity at age 9 years (odds ratio (OR)=1.14, 95% confidence interval (CI) 0.90–1.44) after controlling for potential confounders. Mean DED at age 7 years was higher among children with excess adiposity compared to the remaining sample (9.1±0.12 vs 8.8±0.06 kJ g−1) and a 1 kJ g−1 rise in DED increased the odds of excess adiposity at 9 years by 36% (OR=1.36, 95% CI 1.09–1.69) after controlling for potential confounders.Conclusion:Higher DED at age 7 years, but not age 5 years, is a risk factor for excess adiposity at age 9 years, perhaps reflecting deterioration in the ability to compensate for extra calories in an energy-dense diet. DED tracks strongly from age 5 to 7 years suggesting intervention to alter dietary habits need to commence at younger ages to prevent the formation of preferences for energy dense foods.International Journal of Obesity (2008) 32, 586–593; doi:10.1038/sj.ijo.0803746; published online 2 October 2007 [ABSTRACT FROM AUTHOR]

It is difficult to define continuity of care or study its impact on health outcomes. This study took place in three stages. In stage I we conducted qualitative research with patients, their close relatives and friends, and their key health professionals from which we derived a number of self completion statements about experienced continuity that were tested for reliability and internal consistency. A valid and reliable 18-item measure of experienced continuity was developed in stage II. In stage III we interviewed 199 patients with cancer up to five times over 12 months to ascertain whether their experiences of continuity were associated with their health needs, psychological status, quality of life, and satisfaction with care. The qualitative data revealed that experienced continuity involved receiving consistent time and attention, knowing what to expect in the future, coping between service contacts, managing family consequences, and believing nothing has been overlooked. Transitions between phases of treatment were not associated with changes in experienced continuity. However, higher experienced continuity predicted lower needs for care, after adjustment for other potential explanatory factors (standardised regression coefficients ranging from -0.12 (95% CI -0.20, -0.05) to -0.32 (95% CI -0.41, -0.23)). Higher experienced continuity may be linked to lower health care needs in the future. [ABSTRACT FROM AUTHOR]

A 12-item scale, derived from the Conflict Tactics Scale, was administered to a representative sample of 1,978 heterosexual men and women in Great Britain in mid November 1994. Men and women were asked to identify conflict tactics sustained or inflicted in all past and present relationships and those sustained in current relationships. This paper reports results for physical victimization and also reports on two further questions asked to discern context and meaning ascribed to such sustained or inflicted victimization. Both sexes reported having experienced physical victimization with a higher percentage of men sustaining victimization, mainly as a result of minor acts of assault. Almost equal percentages of men and women reported inflicting victimization against partners. Additionally, incidence of physical victimization is presented according to relationship status, age, socioeconomic category, and by regional distribution. Both sexes reported a range of reasons or contexts ascribed to their sustained or inflicted victimization. [ABSTRACT FROM AUTHOR]

The article cites a study about the fire insurance policy registers accumulated by the Sun Fire Office in Great Britain in 1780. The present study, the first of its kind to endeavor to make use of the policy registers as a whole, examined the policies issued by the Sun in 1780. In that year the Sun was by far the largest insurance company in Great Britain, covering sums perhaps twice as large as the Royal Exchange Assurance. In 1796, with the Phoenix as another rival in the field, the Sun estimated its share as 38 percent of the market in London, England, and 60 percent of the provincial market, except in those few areas where local companies were active. For the purpose of the study, the latter was insignificant. Few of them were founded before 1780 and during the succeeding two decades they accounted for only about four percent of national policies. In 1780 the Sun issued about 15,000 new policies. Routine renewal policies were about seven times as numerous as new policies, but the available evidence suggests that the latter provide an acceptable sample of the whole.

The article focuses on a study which assessed the adherence to the Great Britain National Institute for Health & Clinical Excellence (NICE) glaucoma guidelines in a university hospital. Records of 50 consecutive new referrals for glaucoma from September to December 2009 were reviewed. Results showed that adherence to the NICE glaucoma guidelines is varied and depends on whether the patient is seen by a non-glaucoma or a glaucoma specialist.

Aims The aim of this study was to review current legislation and guidance on information governance and to audit clinicians' management of confidential patient information and knowledge of published guidelines in a teaching hospital.Materials and methods A questionnaire was developed based on published Department of Health, General Dental Council and National Health Service guidance. This was then piloted and distributed to clinicians to complete.Results A review of the current guidance revealed many confusing and unclear areas. However, clinicians' knowledge of information governance was generally good, with an overall correct response rate of 73%.Conclusions All clinicians have an ethical and legal obligation to protect confidential patient data and to be aware of their responsibilities. Local guidelines need to be clarified to help clinicians to manage patient data effectively. [ABSTRACT FROM AUTHOR]

Presents the feasibility of pre-admission nurse clerking of patients with vascular disease in Great Britain. Attendance of patients with planned admissions in the clinic; Comparisons between patients with arterial disease and varicose veins on their dependence to the other people in going to the clinic; Benefits of arterial disease patients from pre-admission clinic.

Aims The aim of this study was to review current legislation and guidance on information governance and to audit clinicians' management of confidential patient information and knowledge of published guidelines in a teaching hospital.Materials and methods A questionnaire was developed based on published Department of Health, General Dental Council and National Health Service guidance. This was then piloted and distributed to clinicians to complete.Results A review of the current guidance revealed many confusing and unclear areas. However, clinicians' knowledge of information governance was generally good, with an overall correct response rate of 73%.Conclusions All clinicians have an ethical and legal obligation to protect confidential patient data and to be aware of their responsibilities. Local guidelines need to be clarified to help clinicians to manage patient data effectively. [ABSTRACT FROM AUTHOR]

This is a pilot study that deals with the self-testified health deficits of individuals in a safe haven and their knowledge about the National Health Service (NHC) in Great Britain, in Cardiff initial accommodation (IA) centre. The study utilized a questionnaire composed of dichotomous and Likert scale form of questions and a face-to-face interview method. The researcher provides a list of the medical issues and concerns in relation to the NHC of the subjects. Further studies on health care facilities are recommended.

Globally important U.K. fens are in poor condition, principally due to abandonment, following cessation of traditional mowing and grazing in recent decades. In the absence of management, rich fen flora are displaced as a result of succession. This leads to an increase in competitive species and subsequent biomass accumulation. In order to reverse this trajectory and increase species richness, management consisting of a single mowing event was employed. Mowing was conducted in two degraded fen communities in north-west Wales (U.K.) across three sites: (i) a species rich, tussock alkaline mire, dominated by Schoenus nigricans and Juncus subnodulosus (SN community) and (ii) a species poor basin mire Cladio-Molinietum dominated by Cladium mariscus (CM community). The early vegetation responses were monitored over two years. Results show a large treatment effect on species richness in the CM community, where mean species richness increased by 51% in the second year following mowing. Consequently, total species number across all sites increased to 74 in the treatment compared to 44 in the control. Mowing reduced vegetation height and litter cover and increased bare ground. These treatment effects combined with a reduction in graminoid and shrub cover collectively contributed to the initial stages of rehabilitation. Conversely, the SN community showed no increase in species richness, in spite of a reduction in litter cover and increased bare ground. Strong site heterogeneity and a sustained canopy height caused by rapid re-growth of the dominant graminoid S. nigricans may have impeded treatment effects. Therefore, increased mowing frequency in alternate years, switching between autumn and summer would be necessary to develop species richness in the SN community. Ongoing intervention in each fen community is needed to achieve an optimal trajectory of increased rich fen and reduction of secondary succession species. [ABSTRACT FROM AUTHOR]

Analysis of data from a large prospective cohort study of young British breast cancer patients indicates that young obese breast cancer patients present with adverse tumour characteristics. Despite adjustment for this, obesity still independently predicts distant disease-free survival and overall survival.Background Obese breast cancer patients have a poorer prognosis than non-obese patients. We examined data from a large prospective cohort study to explore the associations of obesity with tumour pathology, treatment and outcome in young British breast cancer patients receiving modern oncological treatments. Patients and methods A total of 2956 patients aged ≤40 at breast cancer diagnosis were recruited from 126 UK hospitals from 2001 to 2007. Height and weight were measured at registration. Tumour pathology and treatment details were collected. Follow-up data were collected at 6, 12 months, and annually. Results A total of 2843 eligible patients (96.2%) had a body mass index (BMI) recorded: 1526 (53.7%) were under/healthy-weight (U/H, BMI <25 kg/m2), 784 (27.6%) were overweight (ov, BMI ≥25 to <30), and 533 (18.7%) were obese (ob, BMI ≥30). The median tumour size was significantly higher in obese and overweight patients than U/H patients (Ob 26 mm versus U/H 20 mm, P < 0.001; Ov 24 mm versus U/H 20 mm, P < 0.001). Obese and overweight patients had significantly more grade 3 tumours (63.9% versus 59.0%, P = 0.048; Ov 63.6% versus U/H 59.0% P = 0.034) and node-positive tumours (Ob 54.6% versus U/H 49.0%, P = 0.027; Ov 54.2% versus U/H 49%, P = 0.019) than U/H patients. Obese patients had more ER/PR/HER2-negative tumours than healthy-weight patients (25.0% versus 18.3%, P = 0.001). Eight-year overall survival (OS) and distant disease-free interval (DDFI) were significantly lower in obese patients than healthy-weight patients [OS: hazard ratio (HR) 1.65, P < 0.001; DDFI: HR 1.44, P < 0.001]. Multivariable analyses adjusting for tumour grade, size, nodal, and HER2 status indicated that obesity was a significant independent predictor of OS and DDFI in patients with ER-positive disease. Conclusions Young obese breast cancer patients present with adverse tumour characteristics. Despite adjustment for this, obesity still independently predicts DDFI and OS. [ABSTRACT FROM PUBLISHER]

Background Concerns exist regarding the safe use of propofol by Emergency Physicians for procedural sedation. The World SIVA International Sedation Task Force has recently created an adverse event tool, in an effort to standardize reporting. We present a safety analysis of our use of propofol using this tool. Method Propofol was given according to a previously published guideline. We analysed our dedicated departmental sedation database between December 2006 and March 2012 and cross-examined the original sedation chart for each case recorded. We stratified the identified adverse events according to consensus agreement. Results Of the 1008 consecutive cases, we identified 11 sentinel (5 cases of hypoxia, 6 of hypotension), 34 moderate, 25 minor, and 3 minimal risk adverse events. There were no adverse outcomes. Conclusions Our large series of propofol sedations performed by emergency physicians supports the safety of this practice. The sentinel adverse event rate of 1% that we identify prompts review: we will in future emphasize adherence to the reduced 0.5 mg kg−1 propofol dose in the elderly, and reconsider our use of metaraminol. We believe that our application of the World SIVA adverse event tool sets a benchmark for further studies. [ABSTRACT FROM PUBLISHER]

Burkitt's lymphoma is a rare aggressive lymphoma, which responds poorly to standard chemotherapy regimens used to treat high-grade non-Hodgkin's lymphoma (NHL). The use of intensive chemotherapy protocols using alkylating agents and intensive CNS prophylaxis has dramatically altered prognosis. We have treated eight patients with Burkitt's lymphoma with a modified BFM protocol. The dose of methotrexate was reduced from 5 g/m2 to 1.5 g/m2 with the aim of reducing toxicity. Seven patients received a total of six cycles of chemotherapy each and one patient received five cycles of chemotherapy. Each cycle included high-dose methotrexate, an alkylating agent (ifosphamide or cyclophosphamide) and two triple intrathecal injections of chemotherapy. Two patients with bulky abdominal disease in addition received an autologous stem cell transplant. The regimen was well tolerated with minimal toxicity. At a median follow-up of 16 months (range 10–28), six of the eight patients (75%) were alive and in complete remission. Two patients relapsed, one 24 months post-BFM chemotherapy and the other 1-month post-autologous stem cell transplantation and 2 months post-BFM chemotherapy. [ABSTRACT FROM AUTHOR]

Background: People with severe mental illness who experience co-occurring substance use experience poor outcome including suicide, violence, relapses and use of crisis services. They struggle to access care and treatment due to a lack of an integrated and co-ordinated approach which means that some people can fall between services. Despite these concerns, there is limited evidence as to what works for this population., Objectives: To undertake a realist evaluation of service models in order to identify and refine programme theories of what works under what contexts for this population., Design: Realist synthesis and evaluation using published literature and case study data., Setting: Mental health, substance use and related services that had some form of service provision in six locations in the United Kingdom (five in England and one in Northern Ireland)., Participants: People with lived experience of severe mental illness and co-occurring substance use, carers and staff who work in the specialist roles as well as staff in mental health and substance use services., Results: Eleven initial programme theories were generated by the evidence synthesis and in conjunction with stakeholders. These theories were refined through focus groups and interviews with 58 staff, 25 service users and 12 carers across the 6 case study areas. We identified three forms of service provision (network, consultancy and lead and link worker); however, all offered broadly similar interventions. Evidence was identified to support most of the 11 programme theories. Theories clustered around effective leadership, workforce development and collaborative integrated care pathways. Outcomes that are meaningful for service users and staff were identified, including the importance of engagement., Limitations: The requirement for online data collection (due to the COVID-19 pandemic) worked well for staff data but worked less well for service users and carers. Consequently, this may have reduced the involvement of those without access to information technology equipment., Conclusion: The realist evaluation co-occurring study provides details on how and in what circumstances integrated care can work better for people with co-occurring severe mental health and alcohol/drug conditions. This requires joined-up policy at government level and local integration of services. We have also identified the value of expert clinicians who can support the workforce in sustaining this programme of work. People with co-occurring severe mental health and alcohol/drug conditions have complex and multifaceted needs which require a comprehensive and long-term integrated approach. The shift to integrated health and social care is promising but will require local support (local expert leaders, network opportunities and clarity of roles)., Future Work: Further work should evaluate the effectiveness and cost-effectiveness of service models for this group., Study Registration: This study is registered as PROSPERO CRD42020168667., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR128128) and is published in full in Health Technology Assessment ; Vol. 28, No. 67. See the NIHR Funding and Awards website for further award information.

Bipolar disorder (BD) features heterogenous clinical presentation and course of illness. It remains unclear how subphenotypes associate with genetic loadings of BD and related psychiatric disorders. We investigated associations between the subphenotypes and polygenic risk scores (PRS) for BD, schizophrenia, and major depressive disorder (MDD) in two BD cohorts from Sweden (N = 5180) and the UK (N = 2577). Participants were assessed through interviews and medical records for inter-episode remission, psychotic features during mood episodes, global assessment of functioning (GAF, function and symptom burden dimensions), and comorbid anxiety disorders. Meta-analyses based on both cohorts showed that inter-episode remission and GAF-function were positively correlated with BD-PRS but negatively correlated with schizophrenia-PRS (SCZ-PRS) and MDD-PRS. Moreover, BD-PRS was negatively, and MDD-PRS positively, associated with the risk of comorbid anxiety disorders. Finally, SCZ-PRS was positively associated with psychotic symptoms during mood episodes. Assuming a higher PRS of certain psychiatric disorders in cases with a positive family history, we further tested the associations between subphenotypes in index BD people and occurrence of BD, schizophrenia, or MDD in their relatives using Swedish national registries. BD patients with a relative diagnosed with BD had: (1) higher GAF and lower risk of comorbid anxiety than those with a relative diagnosed with schizophrenia or MDD, (2) lower risk of psychotic symptoms than those with a relative diagnosed with schizophrenia. Our findings shed light on the genetic underpinnings of the heterogeneity in clinical manifestations and course of illness in BD, which ultimately provide insights for developing personalized approaches to the diagnosis and treatment., (© 2024. The Author(s).)

Background: Early weight loss is an established predictor for treatment outcomes in weight management interventions for people with obesity. However, there is a paucity of additional, reliable, and clinically actionable early predictors in weight management interventions. Novel blended-care weight management interventions combine coach and app support and afford new means of structured, continuous data collection, informing research on treatment adherence and outcome prediction., Objective: Against this backdrop, this study analyzes app engagement as a predictor for weight loss in large-scale, real-world, blended-care interventions. We hypothesize that patients who engage more frequently in app usage in blended-care treatment (eg, higher logging activity) lose more weight than patients who engage comparably less frequently at 3 and 6 months of intervention., Methods: Real-world data from 19,211 patients in obesity treatment were analyzed retrospectively. Patients were treated with 3 different blended-care weight management interventions, offered in Switzerland, the United Kingdom, and Germany by a digital behavior change provider. The principal component analysis identified an overarching metric for app engagement based on app usage. A median split informed a distinction in higher and lower engagers among the patients. Both groups were matched through optimal propensity score matching for relevant characteristics (eg, gender, age, and start weight). A linear regression model, combining patient characteristics and app-derived data, was applied to identify predictors for weight loss outcomes., Results: For the entire sample (N=19,211), mean weight loss was -3.24% (SD 4.58%) at 3 months and -5.22% (SD 6.29%) at 6 months. Across countries, higher app engagement yielded more weight loss than lower engagement after 3 but not after 6 months of intervention (P 3 months <.001 and P 6 months =.59). Early app engagement within the first 3 months predicted percentage weight loss in Switzerland and Germany, but not in the United Kingdom (P Switzerland <.001, P United Kingdom =.12, and P Germany =.005). Higher age was associated with stronger weight loss in the 3-month period (P Switzerland =.001, P United Kingdom =.002, and P Germany <.001) and, for Germany, also in the 6-month period (P Switzerland =.09, P United Kingdom =.46, and P Germany =.03). In Switzerland, higher numbers of patients' messages to coaches were associated with higher weight loss (P 3 months <.001 and P 6 months <.001). Messages from coaches were not significantly associated with weight loss (all P>.05)., Conclusions: Early app engagement is a predictor of weight loss, with higher engagement yielding more weight loss than lower engagement in this analysis. This new predictor lends itself to automated monitoring and as a digital indicator for needed or adapted clinical action. Further research needs to establish the reliability of early app engagement as a predictor for treatment adherence and outcomes. In general, the obtained results testify to the potential of app-derived data to inform clinical monitoring practices and intervention design., (©Marco Lehmann, Lucy Jones, Felix Schirmann. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 07.06.2024.)

Background: Acute inpatient mental health services report high levels of safety incidents. The application of patient safety theory has been sparse, particularly concerning interventions that proactively seek patient perspectives., Objective(s): Develop and evaluate a theoretically based, digital monitoring tool to collect real-time information from patients on acute adult mental health wards about their perceptions of ward safety., Design: Theory-informed mixed-methods study. A prototype digital monitoring tool was developed from a co-design approach, implemented in hospital settings, and subjected to qualitative and quantitative evaluation., Setting and Methods: Phase 1: scoping review of the literature on patient involvement in safety interventions in acute mental health care; evidence scan of digital technology in mental health contexts; qualitative interviews with mental health patients and staff about perspectives on ward safety. This, alongside stakeholder engagement with advisory groups, service users and health professionals, informed the development processes. Most data collection was virtual. Phase 1 resulted in the technical development of a theoretically based digital monitoring tool that collected patient feedback for proactive safety monitoring. Phase 2: implementation of the tool in six adult acute mental health wards across two UK NHS trusts; evaluation via focused ethnography and qualitative interviews. Statistical analysis of WardSonar data and routine ward data involving construction of an hour-by-hour data set per ward, permitting detailed analysis of the use of the WardSonar tool., Participants: A total of 8 patients and 13 mental health professionals participated in Phase 1 interviews; 33 staff and 34 patients participated in Phase 2 interviews., Interventions: Patients could use a web application (the WardSonar tool) to record real-time perceptions of ward safety. Staff could access aggregated, anonymous data to inform timely interventions., Results: Coronavirus disease 2019 restrictions greatly impacted the study. Stakeholder engagement permeated the project. Phase 1 delivered a theory-based, collaboratively designed digital tool for proactive patient safety monitoring. Phase 2 showed that the tool was user friendly and broadly acceptable to patients and staff. The aggregated safety data were infrequently used by staff. Feasibility depended on engaged staff and embedding use of the tool in ward routines. There is strong evidence that an incident leads to increased probability of further incidents within the next 4 hours. This puts a measure on the extent to which social/behavioural contagion persists. There is weak evidence to suggest that an incident leads to a greater use of the WardSonar tool in the following hour, but none to suggest that ward atmosphere predicts future incidents. Therefore, how often patients use the tool seems to send a stronger signal about potential incidents than patients' real-time reports about ward atmosphere ., Limitations: Implementation was limited to two NHS trusts. Coronavirus disease 2019 impacted design processes including stakeholder engagement; implementation; and evaluation of the monitoring tool in routine clinical practice. Higher uptake could enhance validity of the results., Conclusions: WardSonar has the potential to provide a valuable route for patients to communicate safety concerns. The WardSonar monitoring tool has a strong patient perspective and uses proactive real-time safety monitoring rather than traditional retrospective data review., Future Work: The WardSonar tool can be refined and tested further in a post Coronavirus disease 2019 context., Study Registration: This study is registered as ISRCTN14470430., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128070) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 14. See the NIHR Funding and Awards website for further award information.

Background: Visual impairment (V.I.) has been associated with a negative impact on social functioning, while social support can impact on well-being in those with V.I. Adults from minority ethnic communities (MEC) are projected to make up an increasing proportion of adults living with V.I. in the UK, but limited research has explored their social functioning. This article provides a preliminary insight into social functioning among MEC adults living with V.I. in the UK., Methods: The article reports findings from a secondary analysis of V.I. Lives survey data. V.I. Lives was a UK telephone survey, which explored the life experiences of people with V.I. across a wide range of topics including social functioning. This secondary analysis explored social participation, support, isolation, and relationships among a matched control sample of 77 MEC and 77 adults aged 18 and over from White communities (WC). Participants were matched on age, gender, UK region and urban/rural setting. Subgroup analyses were also conducted for the two largest subgroups within the MEC group, Asian ( n  = 46) and Black participants ( n  = 22)., Results: Contact with like-minded people ( U  = 2174.50, p  = 0.003, r  = -0.24) and opportunities to take part in more social activities ( U  = 2253.50, p  = 0.007, r  = -0.22) was significantly more important to MEC than WC participants. Moreover, MEC participants were significantly less likely to feel supported by friends/family ( U  = 3522.50, p  = 0.017, r  = 0.19) and had fewer people they could ask for help ( U  = 3775.50, p  = 0.001, r  = 0.26), but there were no significant differences in the perceived impact of V.I. on their friendships/social life and marriage/relationship, their ability to take part in a range of activities, nor their marital status. Asian participants were significantly more likely than Black participants to feel cut off from the people and places around them ( U  = 655.50, p  = 0.042, r  = 0.25). Effect sizes were overall small. Although there were no further statistically significant differences between the two groups, Asian participants were also less likely to be able to take part in activities, and more likely to report a negative impact on their social life/friendships and on their marriage/relationship, as well as a smaller social network., Conclusion: The findings suggest that V.I. may have had a greater impact on social functioning among Asian participants in this sample, including on experiences of social isolation and participation in social activities. Future research will need to confirm these findings and explore the possible reasons., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Heinze and Jones.)

Background: Women with bipolar disorder (BD) are at high risk of postpartum psychosis (PP). The factors that increase risk of PP among women with BD are not fully understood. Here, we examine whether sleep disruption in the perinatal period (poor sleep quality in late pregnancy and sleep deprivation related to childbirth) is associated with PP in a longitudinal study of pregnant women with BD., Methods: Participants were 76 pregnant women with lifetime DSM-5 bipolar I disorder or schizoaffective-BD, followed from week 12 of pregnancy to 12 weeks postpartum. Demographics and lifetime psychopathology were assessed at baseline via semi-structured interview (Schedules for Clinical Assessment in Neuropsychiatry). Psychopathology and sleep disruption within the current perinatal period were assessed in the third trimester and at 12 weeks postpartum. Data were supplemented by clinician questionnaires and case-note review., Results: After controlling for prophylactic use of mood stabilising medication, the loss of at least one complete night of sleep across labour/delivery was associated with five times the odds of experiencing PP compared to no or less than one night of sleep loss across labour/delivery (OR 5.19, 95 % CI 1.45-18.54; p = 0.011). Sleep quality in late pregnancy was not associated with PP, and perinatal sleep disruption was not associated with postpartum depression., Limitations: Lack of objective measures of sleep factors., Conclusions: In the context of other aetiological factors, severe sleep loss associated with childbirth/the immediate postpartum may act as a final trigger of PP. These findings could have important clinical implications for risk prediction and prevention of PP., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Despite an increased risk of certain eye conditions which can lead to visual impairment (V.I.), there is evidence of a greater delay to treatment-seeking among adults from minority ethnic communities (MEC). MEC adults may also be underrepresented on V.I. registers, within early intervention services, and among the beneficiaries of national V.I. charities. However, much of this evidence is outdated or anecdotal., Methods: This secondary analysis of V.I. Lives survey data explored use of eye health and support services and mobility aids among a matched control sample of 77 MEC and 77 adults aged 18 and over from white communities (WC). Participants were matched on age, gender, UK region and urban/rural setting. Additional subgroup analysis was conducted for Asian ( n  = 46) and black participants ( n  = 22)., Results: There were no significant group differences in areas such as eye health service use, registration status, contact with charities, and level of practical support received. But MEC participants were significantly more likely than WC participants to have received direct payments from social services to cover their care needs, Χ 2 (1, 154) = 8.27, p  = 0.004, and to use apps on their mobile for mobility, Χ 2 (1, 154) = 5.75, p  = 0.017. In contrast, WC participants were significantly more likely to agree that they were getting the level of emotional support to get on with their life, U  = 3,638, p  = 0.010, to feel confident to ask their friends for support, U  = 2,416, p  = 0.040, and to have a guide dog for mobility, Χ 2 (1, 154) = 3.62, p  = 0.057, although the latter did not reach statistical significance. Within the MEC group, Asian participants were significantly more likely than black participants to use a long cane, Χ 2 (1, 68) = 7.24, p  = 0.007, but they were significantly less likely to agree that they had received the right level of support when they started to experience V.I., U  = 236.5, p  = 0.040., Conclusion: The preliminary findings suggests that there is scope to increase support provided by V.I. charities and the V.I. register, although, contrary to existing evidence, there were no statistically significant differences in eye health service use, registration status and use of wider support services. Further research is required to confirm these findings and explore reasons for differences., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Heinze and Jones.)

Background: Detailed demographic data on people with hereditary angioedema (HAE) and acquired C1 inhibitor deficiency in the United Kingdom are relatively limited. Better demographic data would be beneficial in planning service provision, identifying areas of improvement, and improving care., Objective: To obtain more accurate data on the demographics of HAE and acquired C1 inhibitor deficiency in the United Kingdom, including treatment modalities and services available to patients., Methods: A survey was distributed to all centers in the United Kingdom that look after patients with HAE and acquired C1 inhibitor deficiency to collect these data., Results: The survey identified 1152 patients with HAE-1/2 (58% female and 92% type 1), 22 patients with HAE with normal C1 inhibitor, and 91 patients with acquired C1 inhibitor deficiency. Data were provided by 37 centers across the United Kingdom. This gives a minimum prevalence of 1:59,000 for HAE-1/2 and 1:734,000 for acquired C1 inhibitor deficiency in the United Kingdom. A total of 45% of patients with HAE were on long-term prophylaxis (LTP) with the most used medication being danazol (55% of all patients on LTP). Eighty-two percent of patients with HAE had a home supply of acute treatment with C1 inhibitor or icatibant. A total of 45% of patients had a supply of icatibant and 56% had a supply of C1 inhibitor at home., Conclusions: Data obtained from the survey provide useful information about the demographics and treatment modalities used in HAE and acquired C1 inhibitor deficiency in the United Kingdom. These data are useful for planning service provision and improving services for these patients., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Current definitions and clinical heterogeneity in bipolar disorder are major concerns as they obstruct aetiological research and impede drug development. Therefore, stratification of bipolar disorder is a high priority. To inform stratification, our analysis aimed to examine the patterns and relationships between polygenic liability for bipolar disorder, major depressive disorder (MDD), and schizophrenia with multidimensional symptom representations of bipolar disorder., Methods: In this analysis, data from the UK Bipolar Disorder Research Network (BDRN) were assessed with the Operational Checklist for Psychotic Disorders. Individuals with bipolar disorder as defined in DSM-IV, of European ancestry (self-reported), aged 18 years or older at time of interview, living in the UK, and registered with the BDRN were eligible for inclusion. Psychopathological variables obtained via interview by trained research psychologists or psychiatrists and psychiatric case notes were used to identify statistically distinct symptom dimensions, calibrated with exploratory factor analysis and validated with confirmatory factor analysis (CFA). CFA was extended to include three polygenic risk scores (PRSs) indexing liability for bipolar disorder, MDD, and schizophrenia in a multiple indicator multiple cause (MIMIC) structural equation model to estimate PRS relationships with symptom dimensions., Findings: Of 4198 individuals potentially eligible for inclusion, 4148 (2804 [67·6%] female individuals and 1344 [32·4%] male individuals) with a mean age at interview of 45 years (SD 12·03) were available for analysis. Three reliable dimensions (mania, depression, and psychosis) were identified. The MIMIC model fitted the data well (root mean square error of approximation 0·021, 90% CI 0·019-0·023; comparative fit index 0·99) and suggests statistically distinct symptom dimensions also have distinct polygenic profiles. The PRS for MDD was strongly associated with the depression dimension (standardised β 0·125, 95% CI 0·080-0·171) and the PRS for schizophrenia was strongly associated with the psychosis dimension (0·108, 0·082-0·175). For the mania dimension, the PRS for bipolar disorder was weakly associated (0·050, 0·002-0·097)., Interpretation: Our findings support the hypothesis that genetic heterogeneity underpins clinical heterogeneity, suggesting that different symptom dimensions within bipolar disorder have partly distinct causes. Furthermore, our results suggest that a specific symptom dimension has a similar cause regardless of the primary psychiatric diagnosis, supporting the use of symptom dimensions in precision psychiatry., Funding: Wellcome Trust and UK Medical Research Council., Competing Interests: Declaration of interests We declare no competing interests., (Crown Copyright © 2023 Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Background: There is growing awareness of the health inequalities experienced by minority ethnic communities, who make up an increasing proportion of the United Kingdom (UK) population and have been found to be at increased risk of visual impairment (V.I.). V.I. impacts on a wide range of life domains including employment, social functioning and activities of daily living. Considering existing health inequalities, the increased risk of V.I. and its wide-ranging impact, it is important to understand the experiences of adults from minority ethnic communities living with V.I. in the UK., Methods: A rapid evidence review of academic and gray literature published since 2005 and in English was performed. A search of AMED, CINAHL Plus and MEDLINE via EBSCOhost identified 969 articles. Articles were included in the review if they reported findings relating to the UK-context, to adults from minority ethnic communities living with V.I., and to experiences of V.I. and the eyecare pathway., Results: A total of 11 academic articles and 4 charity reports presented findings relating to perceptions of V.I. and eye disease ( n = 3), access to services and service use ( n = 5), impact of interventions ( n = 7), the wider impact of V.I. ( n = 2), and registration status ( n = 1). Much of the literature focused on primary eyecare resulting in a comprehensive list of barriers and recommendations to increase eye tests. Less research addressed experiences and use of services further along the eyecare pathway although use of services may be low. Overall, the research on the experiences of adults with V.I. from minority ethnic communities in the UK remains anecdotal, outdated or unavailable. There are substantial gaps in the evidence relating to the wider impact of V.I., the impact of perceptions of V.I., and the use of services beyond primary eyecare., Conclusions: This review summarizes our current knowledge of the experiences of adults from minority ethnic communities living with V.I. in the UK and highlights substantial gaps in the evidence. The findings provide practical implications for practitioners and researchers committed to addressing health inequalities in the field of eyecare in the UK., Competing Interests: NH and LJ were employed by BRAVO VICTOR. BM is the chair person of BAME Vision., (Copyright © 2023 Heinze, Jones and Makwana.)

In European and many African, Middle Eastern and southern Asian populations, lactase persistence (LP) is the most strongly selected monogenic trait to have evolved over the past 10,000 years 1 . Although the selection of LP and the consumption of prehistoric milk must be linked, considerable uncertainty remains concerning their spatiotemporal configuration and specific interactions 2,3 . Here we provide detailed distributions of milk exploitation across Europe over the past 9,000 years using around 7,000 pottery fat residues from more than 550 archaeological sites. European milk use was widespread from the Neolithic period onwards but varied spatially and temporally in intensity. Notably, LP selection varying with levels of prehistoric milk exploitation is no better at explaining LP allele frequency trajectories than uniform selection since the Neolithic period. In the UK Biobank 4,5 cohort of 500,000 contemporary Europeans, LP genotype was only weakly associated with milk consumption and did not show consistent associations with improved fitness or health indicators. This suggests that other reasons for the beneficial effects of LP should be considered for its rapid frequency increase. We propose that lactase non-persistent individuals consumed milk when it became available but, under conditions of famine and/or increased pathogen exposure, this was disadvantageous, driving LP selection in prehistoric Europe. Comparison of model likelihoods indicates that population fluctuations, settlement density and wild animal exploitation-proxies for these drivers-provide better explanations of LP selection than the extent of milk exploitation. These findings offer new perspectives on prehistoric milk exploitation and LP evolution., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

Introduction: Antimicrobial resistance is an urgent medical challenge. In this two-part study, we investigated the epidemiology and management of carbapenem non-susceptible (Carb-NS) Gram-negative bacteria (GNB) in the UK., Methods: We conducted a retrospective review of data from UK hospitals (ten in part 1, nine in part 2). In part 1, epidemiological data were collected from patients hospitalised between April 2017 and March 2018 with any laboratory detection of Carb-NS GNB, encompassing both colonisation and infection. In part 2, diagnosis and management pathways in a randomly selected population of adults from part 1 with confirmed Carb-NS GNB infection were assessed. Data were obtained from a detailed medical chart review for ≥ 3 months from index (collection date of first positive Carb-NS GNB sample)., Results: Of 42,340 GNB isolates from 36,098 patients colonised/infected with GNB in part 1, 7% were Carb-NS. In 157 patients included in part 2, 234 GNB index samples were collected, of which 197 (82%) were Carb-NS (median number of Carb-NS pathogens per patient, 1; range 1-3). The most frequent Carb-NS isolates were Pseudomonas aeruginosa (36%), Stenotrophomonas maltophilia (29%) and Klebsiella pneumoniae (10%). Median length of hospitalisation was 34 days. Median time from index to appropriate therapy was 3 days, with empirical therapy initiated a median of 1 day before index. Carb-NS infection was believed to contribute to 21 (28%) of 76 deaths during the study., Conclusions: This study highlights the high incidence of Carb-NS GNB colonisation and infection in the UK and the need for improved management of patients with Carb-NS GNB infection., (© 2022. The Author(s).)

Reforms to social care in response to the COVID-19 pandemic, in the UK and internationally, place data at the heart of proposed innovations and solutions. The principles are not well established of what constitutes core, or minimum, data to support care home residents. Often, what is included privileges data on resident health over day-to-day care priorities and quality of life. This Personal View argues for evidence-based principles on which to base the development of a UK minimum data set (MDS) for care homes. Co-produced work involving care home staff and older people working with stakeholders is required to define and agree the format, content, structure, and operationalisation of the MDS. Implementation decisions will determine the success of the MDS, affecting aspects including data quality, completeness, and usability. Care home staff who collect the data need to benefit from the MDS and see value in their contribution, and residents must derive benefit from data collection and synthesis., Competing Interests: All authors are researchers funded by the National Institute for Health Research (NIHR)-funded DACHA study (HS&DR NIHR127234)., (© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.)

The vascular flora of Britain and Ireland is among the most extensively studied in the world, but the current knowledge base is fragmentary, with taxonomic, ecological and genetic information scattered across different resources. Here we present the first comprehensive data repository of native and alien species optimized for fast and easy online access for ecological, evolutionary and conservation analyses. The inventory is based on the most recent reference flora of Britain and Ireland, with taxon names linked to unique Kew taxon identifiers and DNA barcode data. Our data resource for 3,227 species and 26 traits includes existing and unpublished genome sizes, chromosome numbers and life strategy and life-form assessments, along with existing data on functional traits, species distribution metrics, hybrid propensity, associated biomes, realized niche description, native status and geographic origin of alien species. This resource will facilitate both fundamental and applied research and enhance our understanding of the flora's composition and temporal changes to inform conservation efforts in the face of ongoing climate change and biodiversity loss., (© 2022. The Author(s).)

Increased breast density is a risk factor for breast cancer and can mask cancer on mammography. This survey attempts to understand clinician views regarding breast density notification in the United Kingdom. Two separate breast density surveys were distributed to radiologists and breast surgeons between May 2019 and May 2020. Invited participants were members of the British Society of Breast Radiology and the Association of Breast Surgeons. We received 232 completed questionnaires from 109 surgeons (71%) and 123 radiologists (41%). Fourteen percent of the surgeons reported discussing the increased risk of developing cancer with their patients, and 20% of the surgeons recommended further imaging compared with 50% of the radiologists. Fifty-two percent of surgeons and 28% of radiologists felt women should not be informed of their breast density scores considering the lack of National Health Service-funded supplementary imaging. Almost all respondents of this survey called for guidelines regarding the reporting and management of UK patients with increased breast density (90%). Density notification is becoming increasingly central to breast screening, and our results highlight an urgent need for a national consensus., Competing Interests: Disclosure The authors have stated that they have no conflicts of interest., (Copyright © 2021. Published by Elsevier Inc.)

Background: For more than 150 years, controversy over the status of post-partum psychosis has hindered research and caused considerable confusion for clinicians and women, with potentially negative consequences. We aimed to explore the hypothesis that genetic vulnerability differs between women with first-onset post-partum psychosis and those with bipolar disorder more generally., Methods: In this case-control study on first-onset post-partum psychosis and bipolar disorder in the UK, we included 203 women with first-onset post-partum psychosis (defined as a manic, mixed, or psychotic depression episode within 6 weeks of delivery without a psychiatric history) and 1225 parous women with a history of bipolar disorder. Information on women with bipolar disorder was obtained from the Bipolar Disorder Research Network database, and participants were recruited through screening community mental health teams across the UK and via the media and patient support organisations. All were assessed using a semistructured face-to-face psychiatric interview and psychiatric case note review. 2809 women from the general population were recruited via the national UK Blood Services and the 1958 Birth Cohort (UK National Child Development Study) as controls and matched to cases according to genetic ancestry. All self-reported their ethnicity as White and were recruited from across the UK. Polygenic risk scores (PRSs) were generated from discovery genome-wide association studies of schizophrenia, bipolar disorder, and major depression. Logistic regression was used to model the effect of each PRS on diagnosis, and the RRs and ORs presented were adjusted for ten principal components of genetic variation to account for population stratification., Findings: 203 women with first-onset post-partum psychosis (median age at interview: 46 years [IQR 37-55]) and 1225 women with bipolar disorder (49 years [41-58]) were recruited between September, 1991, and May, 2013, as well as 2809 controls. Women with first-onset post-partum psychosis had similar bipolar disorder and schizophrenia PRSs to women with bipolar disorder, which were significantly higher than those of controls. When compared with controls, women with first-onset post-partum psychosis had an adjusted relative risk ratio (RR) for bipolar disorder PRSs of 1·71 (95% CI 1·56-1·86, p<0·0001) and for schizophrenia PRSs of 1·82 (1·66-1·97, p<0·0001). The effect sizes were similar when comparing women with bipolar disorder to controls (adjusted RR 1·77 [1·69-1·84], p<0·0001 for bipolar disorder PRSs; 2·00 (1·92-2·08), p<0·0001 for schizophrenia PRSs). Although women with bipolar disorder also had higher major depression PRSs than did controls (1·24 [1·17-1·31], p<0·0001), women with first-onset post-partum psychosis did not differ from controls in their polygenic liability to major depression (0·97 (0·82-1·11), p=0·63)., Interpretation: Our study supports the recognition of first-onset post-partum psychosis as a separate nosological entity within the bipolar disorder spectrum both in research and clinical settings., Funding: Wellcome Trust and Medical Research Council., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Shifting baseline syndrome (SBS) describes changing perceptions of biological conditions due to a loss of historical knowledge. Perceptions of 'normal' environmental conditions are continually updated, leading to underestimation of the true magnitude of long-term ecological change and potential setting of unambitious management targets. There has been speculation as to the presence and impacts of SBS within conservation management since Daniel Pauly's seminal paper in 1995, which outlined the potential effects of SBS on target-setting in fisheries management. Previous case studies have suggested that SBS may not occur in management, despite empirical evidence of SBS in other systems. In this study, 44 professionals and volunteers involved in bird species management, monitoring and target-setting across England were interviewed. Interviews asked for personal perceptions of current, maximum and target abundance, long-term trends, and perceived conservation priority for six bird species. Using paired tests, this study found no significant effect of experience on perceptions of current, maximum or target abundance of all species, despite differences in national abundance and trends, and differences in participant experience. Further power analysis indicated that even if SBS was statistically detectible with a larger sample, the practical implications of the syndrome would be minimal due to small effect sizes. Finally, the effect of experience on individual perceptions of species conservation priority varied between species, with generational amnesia in the form of 'lifting baselines' suggested for only one of the six species. This study suggests that shifting baseline syndrome may not be as significant a threat in conservation management as first thought., (Copyright © 2021. Published by Elsevier Ltd.)

Background: NHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling of care. However, data assessing this strategy are sparse, especially for the use of CPAP as a ceiling of care, and particularly when delivered outside of a traditional critical care environment. We describe a cohort of patients from Liverpool, UK, who received CPAP on a dedicated respiratory surge unit at the start of the second wave of the COVID-19 pandemic in UK., Methods: Retrospective cohort analysis of consecutive patients receiving CPAP for the treatment of respiratory failure secondary to COVID-19 on the respiratory surge unit at the Royal Liverpool Hospital, Liverpool, UK from 21 September until 30 November 2020., Results: 88 patients were included in the analysis. 56/88 (64%) were deemed suitable for escalation to invasive mechanical ventilation (IMV) and received CPAP as a trial; 32/88 (36%) received CPAP as a ceiling of care. Median age was 63 years (IQR: 56-74) and 58/88 (66%) were men. Median SpO 2 /FiO 2 immediately prior to CPAP initiation was 95 (92-152). Among patients for escalation to IMV, the median time on CPAP was 6 days (IQR 4-7) and survival at day 30 was 84% (47/56) with 14/56 (25%) escalated to IMV. Of those patients for whom CPAP was ceiling of care, the median duration of CPAP was 9 days (IQR 7-11) and 18/32 (56%) survived to day 30. Pulmonary barotrauma occurred in 9% of the cohort. There were no associations found on multivariant analysis that were associated with all-cause 30-day mortality., Conclusions: With adequate planning and resource redistribution, CPAP may be delivered effectively outside of a traditional critical care setting for the treatment of respiratory failure due to COVID-19. Clinicians delivering CPAP to patients with COVID-19 pneumonitis should be alert to the dangers of pulmonary barotrauma. Among patients who are for escalation of care, the use of CPAP may avoid the need for IMV in some patients. Our data support the NHS England recommendation to consider CPAP as a ceiling of care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

In A Local Authority v JB and A Local Authority v AW, the Court of Appeal and Court of Protection, respectively, had to consider questions regarding decision-making about sexual relationships. This case commentary suggests that both decisions are to be welcomed in many ways, not least in the primacy they give to the role of consent within sexual relationships. However, working through their implications also reveals a number of perplexing legal and practical binds that cannot easily be overcome, and that in fact stem from the way that the Mental Capacity Act 2005 itself works. In light of this, the commentary concludes by suggesting that it is likely that there will be continued dissatisfaction with this area of law and hints that the time may have come to rethink sexual capacity., (© The Author(s) 2020. Published by Oxford University Press; All rights reserved. For permissions, please email: journals.permissions@oup.com.)

DNA barcoding and metabarcoding provide new avenues for investigating biological systems. These techniques require well-curated reference libraries with extensive coverage. Generating an exhaustive national DNA barcode reference library can open up new avenues of research in ecology, evolution and conservation, yet few studies to date have created such a resource. In plant DNA barcoding, herbarium collections provide taxonomically robust material but also pose challenges in lab processing. Here, we present a national DNA barcoding resource covering all of the native flowering plants and conifers of the United Kingdom. This represents 1,482 plant species, with the majority of specimens (81%) sourced from herbaria. Using Sanger sequencing of the plant DNA barcode markers, rbcL, matK, and ITS2, at least one DNA barcode was retrieved from 98% of the UK flora. We sampled from multiple individuals, resulting in a species coverage for rbcL of 96% (4,477 sequences), 90% for matK (3,259 sequences) and 75% for ITS2 (2,585 sequences). Sequence recovery was lower for herbarium material compared to fresh collections, with the age of the specimen having a significant effect on the success of sequence recovery. Species level discrimination was highest with ITS2, however, the ability to successfully retrieve a sequence was lowest for this region. Analyses of the genetic distinctiveness of species across a complete flora showed DNA barcoding to be informative for all but the most taxonomically complex groups. The UK flora DNA barcode reference library provides an important resource for many applications that require plant identification from DNA., (© 2021 The Authors. Molecular Ecology Resources published by John Wiley & Sons Ltd.)

Context: Shortage of physicians in the UK has been a long-standing issue. Graduate entry medicine (GEM) may offer a second point of entry for potential doctors. However, the challenges of developing and implementing these programmes are still unrecognised. This small-scale study aimed to briefly explore the opportunities and challenges facing students at two UK GEM programmes., Methods: Two case studies were conducted at Imperial College and Scotland's GEM (ScotGEM) and used a triangulated qualitative approach via semi-structured and elite interviews. Data analysis, informed by grounded theory, applied thematic and force-field analysis in an empirical approach to generate evidence and instrumental interpretations for Higher Education Institutions., Results: Although GEM forms an opportunity for graduates to enter medicine, the different drivers of each programme were key in determining entry requirements and challenges experienced by postgraduates. Three key dilemmas seem to influence the experiences of learners in GEM programmes: (a) postgraduate identity and the everchanging sense-of-self; (b)self-directed and self-regulated learning skills, and (c) servicescape, management and marketing concepts., Conclusions: Graduate entry programmes may support policy makers and faculty to fill the workforce gap of healthcare professionals. However, their successful implementation requires careful considerations to the needs of graduates to harness their creativity, resilience and professional development as future healthcare workers.

Decreasing floral resources as a result of habitat loss is one of the key factors in the decline of pollinating insects worldwide. Understanding which plants pollinators use is vital to inform the provision of appropriate floral resources to help prevent pollinator loss. Using a globally important pollinator, the honeybee, we show how changes in agricultural intensification, crop use and the spread of invasive species, have altered the nectar and pollen sources available in the UK. Using DNA metabarcoding, we analysed 441 honey samples from 2017 and compared these to a nationwide survey of honey samples from 1952. We reveal that shifts in major plants foraged by honeybees are driven by changes in the availability of these plants within the landscape. Improved grasslands are the most widespread habitat type in the UK, and management changes within this habitat have the greatest potential to increase floral resource availability.