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An increasing elderly population in the United Kingdom has led to an increasing number of older patients with head and neck cancer, resulting in a greater demand for complex head and neck reconstructive surgery in this potentially high-risk age group. A possible perceived poorer tolerance to such major treatment risks under-treating some of these patients. The purpose of this study was to assess the outcomes in the elderly population (older than 80 years) who had undergone free flap reconstruction following head and neck cancer resection. A retrospective review of 127 patients was performed. Eighteen patients were 80 or older (14.2%) and 109 under 80 (85.8%). The elderly group experienced increased number of postoperative medical complications (p = 0.01), but the surgical complications were not significantly different in the two groups (p = 0.4). The average length of hospital stay was significantly longer in the older group (p = 0.01). There was one flap failure during the study period, which belonged to the younger group of patients. Elderly patients undergoing free flap reconstruction experience an increased rate of postoperative medical complications resulting in an increased length of hospital stay. However, good surgical outcomes can still be achieved in this age group, and therefore age alone should not be considered as a primary factor in head and neck cancer management. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 imposed dramatic changes on ENT service delivery. Pre-pandemic, such changes would have been considered potentially unsafe. This study outlines the impact of lockdown on the incidence and management of ENT emergencies at a large UK centre. Methods: After modification of pre-pandemic guidelines, ENT emergency referrals data during the UK lockdown were prospectively captured. A comparative analysis was performed with retrospective data from a corresponding period in 2019. Results: An overall reduction (p < 0.001) in emergency referrals (n = 119) and admissions (n = 18) occurred during the lockdown period compared to the 2019 period (432 referrals and 290 admissions). Specifically, there were reduced admission rates for epistaxis (p < 0.0001) and tonsillar infection (p < 0.005) in the lockdown period. During lockdown, 90 per cent of patients requiring non-dissolvable nasal packing were managed as out-patients. Conclusions: Coronavirus disease 2019 compelled modifications to pre-pandemic ENT guidelines. The enforced changes to emergency care appear to be safe and successfully adopted. Arguably, the measures have both economic and patient-related implications post-coronavirus disease 2019 and during future similar pandemics and lockdowns. [ABSTRACT FROM AUTHOR]

Background: Prevalence of depression is increasing in young people, and there is a need to develop and evaluate behavioural interventions which may provide benefits equal to or greater than talking therapies or pharmacological alternatives. Exercise could be beneficial for young people living with depression, but robust, large-scale trials of effectiveness and the impact of exercise intensity are lacking. This study aims to test whether a randomised controlled trial (RCT) of an intervention targeting young people living with depression is feasible by determining whether it is possible to recruit and retain young people, develop and deliver the intervention as planned, and evaluate training and delivery. Methods: The design is a three-arm cluster randomised controlled feasibility trial with embedded process evaluation. Participants will be help-seeking young people, aged 13–17 years experiencing mild to moderate low mood or depression, referred from three counties in England. The intervention will be delivered by registered exercise professionals, supported by mental health support workers, twice a week for 12 weeks. The three arms will be high-intensity exercise, low-intensity exercise, and a social activity control. All arms will receive a 'healthy living' behaviour change session prior to each exercise session and the two exercise groups are energy matched. The outcomes are referral, recruitment, and retention rates; attendance at exercise sessions; adherence to and ability to reach intensity during exercise sessions; proportions of missing data; adverse events, all measured at baseline, 3, and 6 months; resource use; and reach and representativeness. Discussion: UK National Health Service (NHS) policy is to provide young people with advice about using exercise to help depression but there is no evidence-based exercise intervention to either complement or as an alternative to medication or talking therapies. UK National Institute for Health and Care Excellence (NICE) guidelines suggest that exercise can be an effective treatment, but the evidence base is relatively weak. This feasibility trial will provide evidence about whether it is feasible to recruit and retain young people to a full RCT to assess the effectiveness and cost-effectiveness of an exercise intervention for depression. Trial registration: ISRCTN, ISRCTN66452702. Registered 9 April 2020. [ABSTRACT FROM AUTHOR]

Peripartum haemorrhage is an obstetric emergency which requires effective and timely management. A retrospective analysis was conducted at a single centre district hospital, over a 10-year period to describe factors that would lead to a peripartum hysterectomy. We sought to establish intraoperative and postoperative risks and review outcomes and complications associated with the procedure. A total of 29 cases (incidence 0.8 per 1000) were reviewed over 2001–2011. The mean parity was 1.8 and the mean maternal age was 33 years. Uterine atony was the most common indication for hysterectomy (12/29) followed by placenta praevia and accreta (4/29 and 5/29 cases, resp.). The commonest postoperative complications were sepsis and paralytic ileus. EPH most commonly occurs due to uterine atony but remains difficult to predict. Hospitals should continue to have robust systems and the necessary resources available to perform EPH where clinically indicated. [ABSTRACT FROM AUTHOR]

Objective:To determine the prevalence of thyroid malignancy in the first UK case series of patients with incidentally detected thyroid lesions on 18F-fluorodeoxyglucose positron emission tomography imaging.Methods:A total of 235 patients were evaluated with 18F-fluorodeoxyglucose positron emission tomography imaging. Incidental focal uptake in the thyroid gland was identified in nine patients (3.8 per cent). A retrospective review of their case notes was conducted.Results:The rate of malignancy was 55 per cent. The mean and standard deviation of the maximum standardised uptake value was 13.1 ± 7.3 in those patients with malignancy and a nodule identified as positive on positron emission tomography. This value was 2.8 ± 1.2 in those patients without malignancy but with a nodule identified as positive on positron emission tomography (p = 0.01). A palpable thyroid nodule was more likely in those with malignant lesions (p = 0.14).Conclusion:The prevalence of incidental thyroid lesions found on 18F-fluorodeoxyglucose positron emission tomography in patients with other primary malignancies is low, but the incidence of malignancy in these patients is high. Patients with a palpable thyroid nodule, focal uptake on 18F-fluorodeoxyglucose positron emission tomography and an increased maximum standardised uptake value require further investigation. [ABSTRACT FROM PUBLISHER]

Background Individual, family and service level characteristics and outcomes are described for adult and adolescent patients receiving specialist inpatient or day patient treatment for anorexia nervosa (AN). Potential predictors of treatment outcome are explored. Method Admission and discharge data were collected from patients admitted at 14 UK hospital treatment units for AN over a period of three years (adult units N = 12; adolescent N = 2) (patients N = 177). Results One hundred and seventy-seven patients with a severe and enduring illness with wide functional impairment took part in the study. Following inpatient care, physical improvement was moderate/good with a large increase in BMI, although most patients continued to have a clinical level of eating disorder symptoms at discharge. The potentially modifiable predictors of outcome included confidence to change, social functioning and carer expressed emotion and control. Conclusions Overall, the response to inpatient treatment was modest particularly in the group with a severe enduring form of illness. Adolescents had a better response. Although inpatient treatment produces an improvement in physical health there was less improvement in other eating disorder and mood symptoms. As predicted by the carer interpersonal maintenance model, carer behaviour contributed to the response to inpatient care as did social functioning and confidence to change. [ABSTRACT FROM AUTHOR]

Apparent losses relate to water that is consumed but not paid for. Most research carried out in the last decade particularly in the United Kingdom focused mainly on leakage. Until now, there are no set procedures and guidelines for assessment of apparent losses. Much work remains to bring it to par with the available tools and methodologies for leakage management. In the absence of adequate data and proper methodology, most developed countries use default values, which tend to be lowest values for well-managed water systems, for computation of apparent losses. These may not be appropriate for developing countries. This paper presents a methodology for the assessment of different components of apparent losses based on field audit and operational data for Kampala city's water distribution system in Uganda. Metering inaccuracies and illegal use have been found to be significant components of apparent losses. Appropriate intervention strategies have been developed based on the assessment. [ABSTRACT FROM AUTHOR]

The temporal variation of ambient SO and the chemical composition of particulate matters (PM and PM) were studied at National Physical Laboratory (NPL), New Delhi (28°38′N, 77°10′E). Spatial variation of SO at seven air quality monitoring stations over Delhi was also studied simultaneously. Wide range of ambient SO was recorded during winter (2.55 to 17.43 ppb) compare to other seasons. SO mixing ratio was recorded significantly high at industrial sites during winter and summer; however, no significant spatial difference in SO mixing ratio was recorded during monsoon. SO/(SO+SO) ratio was recorded high (0.74) during winter and low (0.69) during summer. Monthly variation of PSCF was analyzed using HYSPLIT seven days backward trajectories and daily average SO data. PSCF analysis suggests that, during winter (December, January, February) ambient SO at the study site might have contributed from long distance sources, located towards west and southwest directions; during monsoon (July, August, September) marine contribution was noticed; whereas, during summer (April, May and June) it was from regional sources (located within few 100 km of study site). During winter there was significant contribution from the long distance sources located in western Asia, northwestern Pakistan, Rajasthan and Punjab provinces of India. Coal used in thermal power plants at Panipat (in the northwestern side) and Faridabad (in the southeastern side), local industries, soil erosion and biomass burning may be major contributing factors for SO during summer. The study establishes that the transport sector may not be the major source of ambient SO in Delhi. [ABSTRACT FROM AUTHOR]

A postal questionnaire of UK consultant obstetricians and gynaecologists was performed to evaluate the number of hospitals which met the Royal College of Obstetricians and Gynaecologists recommended standards for urogynaecology and menopause services. A total of 359 responses were analysed. Sixty-four percent of the consultants worked in units with direct referral systems from primary care continence services, while 63% of the consultants worked in units without a dedicated menopause clinic integrated with other women's health facilities. Most of the criteria assessed for clinical service standards in these fields are not met. [ABSTRACT FROM AUTHOR]

Diet can play a key role in the management of disorders such as obesity, diabetes and hypertension, conditions highly prevalent in the British African Caribbean population. In this paper, information not previously available is provided on the dietary habits and foods consumed by a British African–Caribbean population representative of the local community. Food frequency questionnaires were obtained from 255 randomly selected subjects in Manchester (78% of Jamaican origin), the nutrient intake results of which are available elsewhere. Here, suggestions are given to ensure that complete and valid dietary assessments (by diet history) are obtained, and the need for the approach to be somewhat different to that used in the White European population, highlighted with examples. Suggestions have also been listed for methods of dietary modification for obesity, diabetes and hypertension, taking into account differences in cultural understanding and food practices. People of Caribbean origin are not from just one territory: food habits and cultural context play an important role in every island, with clear differences between each which persist in first and later generations in Britain. In this paper, we attempt to integrate experience of learning from patients themselves during consultations and from participants in this study, with direct quantitative data on types of foods and their frequency in the local African–Caribbean diet. [ABSTRACT FROM AUTHOR]

Objective: To characterise the demographics and aetiology of sudden cardiac death (SCD) in athletes referred to a tertiary cardiac pathology centre in the UK. Design: Retrospective non-case controlled analysis. Setting: Cardiac pathology centre at the National Heart and Lung Institute and Royal Brompton Hospital. Subjects: Between 1996 and 2008, the hearts of 118 athletes were referred for pathological assessment to ascertain the precise aetiology of SCD. Results: The majority of athletes (n = 113; 96%) were male and most (107; 91%) were amateurs participating predominantly in football, rugby and running. The mean (SD) age of death was 28 (12) years (range 7-59); 75% athletes were aged ⩽35 years. Most deaths (81%) occurred during or immediately after exercise. Antecedent symptoms of cardiac disease were reported in 21 (18%) subjects, and 20 (17%) had a family history of premature cardiovascular disease and/or SCD. 25 (21%) athletes had relevant past medical history which included a known history of cardiac disease. Cardiomyopathy was the commonest cause of death and accounted for 62% of all the SCDs. A significantly high proportion of athletes (23%) exhibited a morphologically normal heart. Atherosclerotic coronary disease accounted for only 3% of cases and was confined to athletes aged >35 years. Conclusions: SCD in sport is largely due to clinically silent cardiomyopathies or primary electrical disorders (morphologically normal heart). Antecedent symptoms and family history are absent in over 80% of cases, and therefore clinical screening with health questionnaires will fail to identify most athletes with potentially sinister cardiac disorders. [ABSTRACT FROM AUTHOR]

Aim: To investigate the impact of the COVID-19 pandemic on core and higher breast radiology training in the UK from the perspective of trainees and new consultants.Materials and Methods: A survey comprising 25 questions was distributed to UK radiology trainees via the regional Junior Radiologists Forum representatives under the auspices of the British Society of Breast Radiology (BSBR).Results: Sixty-nine eligible responses were received representing all UK training regions. Fifty-five per cent of respondents completing either a core or higher breast rotation felt that the pandemic had a negative effect on their breast training. There was an overall reduction in exposure to the key breast imaging methods when rotations took place during the pandemic. Completing a core breast rotation during the pandemic was less likely to attract trainees to higher breast training. Three out of four breast radiology consultants in their first year after receiving their Certificate of Completion of Training (CCT) felt the pandemic reduced their preparedness for becoming consultants. Positive outcomes included the increased use of online educational resources and remote multidisciplinary meetings.Conclusions: As well as having a negative impact on breast radiology training overall, the pandemic has had a detrimental effect on attracting trainees to breast radiology as a future career. It is of key importance that trainees have a positive core breast rotation as this experience appears central to many trainees' decisions to pursue higher breast training. Increased use of online learning resources has also been positively received and is a valuable approach to learning that can be maintained in the longer term. [ABSTRACT FROM AUTHOR]

Background: Depression is common in people with chronic kidney disease, yet little is known about how depression is identified and managed as part of routine kidney care., Objectives: The primary objective was to survey all UK adult kidney centres to understand how depression is identified and managed. A secondary objective was to broadly describe the variability in psychosocial care., Design: Online survey., Methods: The survey comprised of three sections: (1) general kidney care, (2) psychological provision and (3) social work provision., Results: 48/68 (71%) of centres responded to the general survey with 20 and 13 responses from psychological and social work module respectively. Only 31.4% reported having both in centre psychological and social work practitioners. Three centres reported no access to psychosocial provision. Of the 25 centres who reported on pathways, 36.0% reported having internal pathways for the identification and management of depression. Within services with psychological provision, screening for depression varied across modality/group (e.g., 7.1% in mild/moderate chronic kidney disease vs. 62.5% in kidney donors). Cognitive Behavioural Therapy and Acceptance and Commitment Therapy were the most common interventions offered. Most psychosocial services were aware of the National Institute for Health and Care Excellence guidelines for managing depression in long-term conditions (n = 18, 94.7%) yet few fully utilised (n = 6, 33.3%). Limited workforce capacity was evident., Conclusions: There is considerable variability in approaches taken to identify and treat depression across UK kidney services, with few services having specific pathways designed to detect and manage depression. Workforce capacity remains a significant issue., (© 2024 The Authors. Journal of Renal Care published by John Wiley & Sons Ltd on behalf of European Dialysis & Transplant Nurses Association/European Renal Care Association.)

Background: The overseas applicant's capability of practising safely and effectively is proven through the tests of competence which consist of computer-based tests and the Objective Structured Clinical Examination (OSCE). All prospective applicants to the Nursing and Midwiferey Council (NMC) register must be able to demonstrate that their skills, knowledge and behaviours are at the level required to meet the NMC preregistration nursing or midwifery standards for the United Kingdom (UK)., Aim: The aim of this review is to explore the challenges faced whilst undertaking these tests of competence, the OSCE, by overseas educated nurses who aspire for Nursing and Midwifery Council (NMC) registration in the UK., Methods: A scoping review using the Arksey and O'Malley (2005) framework was conducted to explore and produce a profile of the existing literature on the registration requirements of the NMC. A search of CINAHL, Medline and Scopus resulted in 150 records, which were then screened against the inclusion criteria - English Language, publication between 2015 onwards and discussed the language tests/competency tests required for gaining entry to the NMC register. A total of nine articles met the criteria and are included in this scoping review. The PRISMA-ScR framework is used to present the review., Results: There was a paucity of studies that addressed the experience of overseas nurses who faced the OSCE. An interpretative stance was adopted to formulate the themes which were: competence/practice disparity, arbitrary issues for failing, failure to capture the digital health agenda, financial implications, and consequences of failing the OSCE. The results raise concern whether the nurses from overseas are held to higher standards than those trained in the UK and whether the assessment process is realistic and not pedantic., Conclusions: This scoping review demonstrates there is a lack of robust research evaluating the effectiveness of tests of competencies. The review indicates there is no due acknowledgement of the previous skills and knowledge of the overseas nurses. Future research should focus on exploring the feasibility of tests of competence and its role in the integration of the nursing workforce.

Invasive meningococcal disease (IMD), caused by infection with the bacterium Neisseria meningitidis, usually manifests as meningitis or septicemia and can be severe and life-threatening (1). Six serogroups (A, B, C, W, X, and Y) account for most cases (2). N. meningitidis is transmitted person-to-person via respiratory droplets and oropharyngeal secretions. Asymptomatic persons can carry N. meningitidis and transmit the bacteria to others, potentially causing illness among susceptible persons. Outbreaks can occur in conjunction with large gatherings (3,4). Vaccines are available to prevent meningococcal disease. Antibiotic prophylaxis for close contacts of infected persons is critical to preventing secondary cases (2)., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Jay Lucidarme, Stephen A. Clark, and Ray Borrow report performing contract research on behalf of the UK Health Security Agency (UKHSA) for GSK, Pfizer, and Sanofi. Muhamed-Kheir Taha reports performing contract research on behalf of the Institut Pasteur for GSK, Pfizer, and Sanofi. Shamez N. Ladhani reports performing contract research on behalf of the UKHSA and St. George’s University of London for GSK, Pfizer, Merck Sharp & Dohme, and Sanofi. Helen Campbell and Mary Ramsay report receipt of a recovery charge by the Immunisation and Vaccine Preventable Diseases Division at UKHSA for provision to vaccine manufacturers (GSK, Pfizer, and Sanofi) of postmarketing surveillance reports on meningococcal, Haemophilus influenzae, and pneumococcal infections, which are required by the U.K. Licensing Authority in compliance with their risk management strategy. Jennifer Zipprich reports that her spouse is employed by Pfizer. No other potential conflicts of interest were disclosed.

Aims: Sudden cardiac death (SCD) may occur in apparently healthy individuals, including athletes. The aim was to investigate the diagnostic role of post-mortem genetic testing, molecular autopsy (MA), in elucidating the cause of SCD in athletes., Methods and Results: We reviewed a database of 6860 consecutive cases of SCD referred to our specialist cardiac pathology centre. All cases underwent detailed cardiac autopsy, and 748 were deemed to be athletes. Of these, 42 (6%) were investigated with MA (28 using a targeted sequencing, 14 exome sequencing). Variants were classified as pathogenic, likely pathogenic, or variant of unknown significance using international guidelines. Clinical information was obtained from referring coroners who completed a detailed health questionnaire. Out of the 42 decedents (average age 35 years old, 98% males) who were investigated with MA, the autopsy was in keeping with a structurally normal heart [sudden arrhythmic death syndrome (SADS)] in n = 33 (78%) cases, followed by arrhythmogenic cardiomyopathy (ACM) in eight (19%) individuals and idiopathic left ventricular fibrosis in one (2%). Death occurred during exercise and at rest in 26 (62%) and 16 (38%) individuals, respectively. Variants that were adjudicated clinically actionable were present in seven cases (17%). There was concordance between the genetic and phenotypic findings in two cases of ACM (in FLNC and TMEM43 genes). None of the variants identified in SADS cases were previously linked to channelopathies. Clinically actionable variants in cardiomyopathy-associated genes were found in five cases of SADS., Conclusion: The yield of MA in athletes who died suddenly is 17%. In SADS cases, clinically actionable variants were found in cardiomyopathy-associated genes and not in channelopathy-associated genes. Arrhythmogenic cardiomyopathy is a common cause of SCD in athletes, and one in four decedents with this condition had a clinically actionable variant in FLNC and TMEM43 genes., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Diabetes mellitus and central obesity are more common among South Asian populations than among White British people. This study explores the differences in diabetes and obesity in South Asians with stroke living in the United Kingdom, India, and Qatar compared with White British stroke patients., Methods: The study included the UK, Indian, and Qatari arms of the ongoing large Bio-Repository of DNA in Stroke (BRAINS) international prospective hospital-based study for South Asian stroke. BRAINS includes 4580 South Asian and White British recruits from UK, Indian, and Qatar sites with first-ever ischemic stroke., Results: The study population comprises 1751 White British (WB) UK residents, 1165 British South Asians (BSA), 1096 South Asians in India (ISA), and 568 South Asians in Qatar (QSA). ISA, BSA, and QSA South Asians suffered from higher prevalence of diabetes compared with WB by 14.5% (ISA: 95% confidence interval (CI) = 18.6-33.0, p  < 0.001), 31.7% (BSA: 95% CI = 35.1-50.2, p  < 0.001), and 32.7% (QSA: 95% CI = 28.1-37.3, p  < 0.001), respectively. Although WB had the highest prevalence of body mass index (BMI) above 27 kg/m 2 compared with South Asian patients (37% vs 21%, p  < 0.001), South Asian patients had a higher waist circumference than WB (94.8 cm vs 90.8 cm, p  < 0.001). Adjusting for traditional stroke risk factors, ISA, BSA, and QSA continued to display an increased risk of diabetes compared with WB by 3.28 (95% CI: 2.53-4.25, p  < 0.001), 3.61 (95% CI: 2.90-4.51, p  < 0.001), and 5.24 (95% CI: 3.93-7.00, p  < 0.001), respectively., Conclusion: South Asian ischemic stroke patients living in Britain and Qatar have a near 3.5-fold risk of diabetes compared with White British stroke patients. Their body composition may partly help explain that increased risk. These findings have important implications for public health policymakers in nations with large South Asian populations., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Services for patients with kidney disease underwent radical adaptations in response to the COVID-19 pandemic. We undertook an online national survey of UK kidney centres to understand the nature, range, and degree of variation in these changes and to explore factors contributing to differing practice., Methods: The survey was designed by a multidisciplinary team of kidney professionals, service users and researchers. It enquired about centre services and staffing, including psychosocial provision, and changes to these in response to the COVID-19 pandemic. Links to the survey were sent to all 68 UK kidney centres and remained active from December 2021 to April 2022, and a revised version to nurses in late 2022 for additional data. Quantitative data were analysed descriptively. Content analysis on free-text responses identified common themes., Results: Analysable responses were received from 41 out of the 68 UK centres (60%), with partial data from an additional 7 (11%). Adaptations were system-wide and affected all aspects of service provision. Some changes were almost universal such as virtual consultations for outpatient appointments, with significant variation in others. Outpatient activity varied from fully maintained to suspended. Many centres reduced peritoneal dialysis access provision but in some this was increased. Centres considered that changes to transplant surgical services and for patients with advanced CKD approaching end-stage kidney disease had the greatest impact on patients. Few centres implemented adjustments aimed at vulnerable and underrepresented groups, including the frail elderly, people with language and communication needs, and those with mental health needs. Communication issues were attributed to rapid evolution of the pandemic, changing planning guidance and lack of resources. Staffing shortages, involving all staff groups particularly nurses, mainly due to COVID-19 infection and redeployment, were compounded by deficiencies in staffing establishments and high vacancy levels. Centres cited three main lessons influencing future service delivery, the need for service redesign, improvements in communication, and better support for staff., Conclusion: Kidney centre responses to the pandemic involved adaptations across the whole service. Though some changes were almost universal, there was wide variation in other areas. Exploring the role of centre characteristics may help planning for potential future severe service disruptions., (© 2023. The Author(s).)

Competing Interests: Disclosures None.

Background: COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of seven COVID-19 vaccines used as a third booster dose in June 2021. Monovalent messenger RNA (mRNA) COVID-19 vaccines were subsequently widely used for the third and fourth-dose vaccination campaigns in high-income countries. Real-world vaccine effectiveness against symptomatic infections following third doses declined during the Omicron wave. This report compares the immunogenicity and kinetics of responses to third doses of vaccines from day (D) 28 to D242 following third doses in seven study arms., Methods: The trial initially included ten experimental vaccine arms (seven full-dose, three half-dose) delivered at three groups of six sites. Participants in each site group were randomised to three or four experimental vaccines, or MenACWY control. The trial was stratified such that half of participants had previously received two primary doses of ChAdOx1 nCov-19 (Oxford-AstraZeneca; hereafter referred to as ChAd) and half had received two doses of BNT162b2 (Pfizer-BioNtech, hereafter referred to as BNT). The D242 follow-up was done in seven arms (five full-dose, two half-dose). The BNT vaccine was used as the reference as it was the most commonly deployed third-dose vaccine in clinical practice in high-income countries. The primary analysis was conducted using all randomised and baseline seronegative participants who were SARS-CoV-2 naïve during the study and who had not received a further COVID-19 vaccine for any reason since third dose randomisation., Results: Among the 817 participants included in this report, the median age was 72 years (IQR: 55-78) with 50.7% being female. The decay rates of anti-spike IgG between vaccines are different among both populations who received initial doses of ChAd/ChAd and BNT/BNT. In the population that previously received ChAd/ChAd, mRNA vaccines had the highest titre at D242 following their vaccine dose although Ad26. COV2. S (Janssen; hereafter referred to as Ad26) showed slower decay. For people who received BNT/BNT as their initial doses, a slower decay was also seen in the Ad26 and ChAd arms. The anti-spike IgG became significantly higher in the Ad26 arm compared to the BNT arm as early as 3 months following vaccination. Similar decay rates were seen between BNT and half-BNT; the geometric mean ratios ranged from 0.76 to 0.94 at different time points. The difference in decay rates between vaccines was similar for wild-type live virus-neutralising antibodies and that seen for anti-spike IgG. For cellular responses, the persistence was similar between study arms., Conclusions: Heterologous third doses with viral vector vaccines following two doses of mRNA achieve more durable humoral responses compared with three doses of mRNA vaccines. Lower doses of mRNA vaccines could be considered for future booster campaigns., Competing Interests: Declaration of Competing Interest KC acts on behalf of University Hospital Southampton as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Janssen, Medimmune, Merck, Pfizer, Sanofi and Valneva. She receives no personal financial payment for this work. SNF acts on behalf of University Hospital Southampton NHS Foundation Trust as an Investigator and/or providing consultative advice on clinical trials and studies of COVID-19 and other vaccines funded or sponsored by vaccine manufacturers including Janssen, Pfizer, AstraZeneca, GlaxoSmithKline, Novavax, Seqirus, Sanofi, Medimmune, Merck and Valneva vaccines and antimicrobials. He receives no personal financial payment for this work. ALG is named as an inventor on a patent covering use of a particular promoter construct that is often used in ChAdOx1-vectored vaccines and is incorporated in the ChAdOx1 nCoV-19 vaccine. ALG may benefit from royalty income paid to the University of Oxford from sales of this vaccine by AstraZeneca and its sublicensees under the University’s revenue-sharing policy. JH has received payments for presentations for AstraZeneca, Boehringer Ingelheim, Chiesi, Ciple & Teva. VL acts on behalf of University College London Hospitals NHS Foundation Trust as an Investigator on clinical trials of COVID-19 vaccines funded or sponsored by vaccine manufacturers including Pfizer, AstraZeneca and Valneva. He receives no personal financial payment for this work. PM acts on behalf of University Hospital Southampton NHS Foundation Trust and The Adam Practice as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Novavax, Medicago, and Sanofi. He received no personal financial payment for this work. JSN-V-T was seconded to the Department of Health and Social Care, England until 31st March 2022. He has subsequently received lecture fees from AstraZeneca, Sanofi Pasteur and has performed paid consultancy for Janssen and Seqirus. MR has provided post marketing surveillance reports on vaccines for Pfizer and GSK for which a cost recover charge is made. MDS acted until September 2022 on behalf of the University of Oxford as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Pfizer, Novavax. Janssen, Medimmune and MCM vaccines. He received no personal financial payment for this work. MDS became an employee of Moderna in September 2022 and holds stock options in this company. He did not perform this study in relation to his new employment and Moderna have had no a priori access to the data., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Spontaneous coronary artery dissection (SCAD) and myocardial infarction with nonobstructed coronary arteries (MINOCA) are increasingly recognized causes of acute coronary syndrome and potentially of sudden cardiac death (SCD). SCAD has been correlated to coronary fibromuscular dysplasia (FMD), but the prevalence of SCAD and FMD among SCD victims is unclear. Therefore, we sought to assess characteristics of decedents with SCAD found at autopsy and to compare their clinical and pathological profile with MINOCA victims., Methods: We reviewed a database of 5325 consecutive cases of SCDs referred to our cardiac pathology center between 1994 and 2017., Results: We identified 18 (0.3%) cases with SCAD and 37 (0.7%) with MINOCA. No signs of coronary FMD were found among SCAD and MINOCA victims. Compared to MINOCA, SCAD decedents were mostly females (78% versus 38%, P =0.006) and SCD occurred during peripartum more frequently in SCAD rather than MINOCA female victims (28% versus 3%, P =0.012) Infarcted myocardium was identified in all cases of MINOCA but only in 5 (28%) of SCAD decedents ( P <0.001). Premortem cardiac symptoms were present in 100% of SCAD and 49% of MINOCA victims ( P <0.001); substances use or abuse was reported in none of SCAD versus 43% of MINOCA decedents ( P =0.001)., Conclusions: SCAD and MINOCA are rare causes of SCD. At autopsy, coronary FMD is not present among SCAD victims. Compared to MINOCA, SCAD victims are more frequently females, are linked to pregnancy, and always experienced premortem cardiac symptoms. Among MINOCA victims' substance use or abuse is common.

Background: Causes and precipitating factors of sudden cardiac death (SCD) in adolescents are poorly understood., Objectives: The authors sought to investigate the etiologies of SCD and their association with physical activity in a large cohort of adolescents., Methods: Between 1994 and June 2022, 7,675 cases of SCD were consecutively referred to our national cardiac pathology center; 756 (10%) were adolescents. All cases underwent detailed autopsy evaluation by expert cardiac pathologists. Clinical information was obtained from referring coroners., Results: A structurally normal heart, indicative of sudden arrhythmic death syndrome was the most common autopsy finding (n = 474; 63%). Myocardial diseases were detected in 163 cases (22%), including arrhythmogenic cardiomyopathy (n = 36; 5%), hypertrophic cardiomyopathy (n = 31; 4%), idiopathic left ventricular hypertrophy (n = 31; 4%), and myocarditis (n = 30; 4%). Coronary artery anomalies were identified in 17 cases (2%). Decedents were competitive athletes in 128 cases (17%), and 159 decedents (21%) died during exercise. Arrhythmogenic cardiomyopathy was diagnosed in 8% of athletes compared with 4% of nonathletes (P = 0.05); coronary artery anomalies were significantly more common in athletes (9% vs 1%; P < 0.001), as well as commotio cordis (5% compared with 1% in nonathletes; P = 0.001). The 3 main comorbidities were asthma (n = 58; 8%), epilepsy (n = 44; 6%), and obesity (n = 40; 5%)., Conclusions: Sudden arrhythmic death syndrome and myocardial diseases are the most common conditions diagnosed at autopsy in adolescent victims of SCD. Among causes of SCD, arrhythmogenic cardiomyopathy, coronary artery anomalies, and commotio cordis are more common in young athletes than in similar age sedentary individuals., Competing Interests: Funding Support and Author Disclosures The charity Cardiac Risk in the Young fund the Cardiac Risk in the Young Cardiovascular Pathology Laboratories. Dr Finocchiaro is partly funded by the charity Cardiac Risk in the Young. Dr Westaby is funded by the National Institute for Health and Care Research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: To explore the current and potential role for UK pharmacists in the transition to adult services for young people with chronic health problems., Methods: UK hospital pharmacists were surveyed using an online questionnaire with closed and open questions covering their involvement in a transition programme, demography and scope of work, experiences of transition, and the barriers encountered in providing an effective transition service., Results: Overall, 74 pharmacists completed the questionnaire. Most were female (70% (52/74)), had ≥6 years of experience (62% (46/74)), were paediatric pharmacists (74% (55/74)), and were based in a teaching hospital practice setting (70% (52/74)). Many participants (57% (42/74)) had a transition programme in place in their hospital; of these, 55% (23/42) were not a part of the service. Respondents identified unique skills that pharmacists could contribute to the transition service, including knowledge of medications (including formulations and unlicensed medications), awareness of medication services beyond paediatrics, commissioning of medications, and familiarity with adult services. Most commonly identified barriers to transition included 'time constraints', 'pharmacists not involved as part of the wider multidisciplinary team', and 'lack of engagement between different services'. Pharmacists noted that their ideal transition service would include specific medication-related transition, for example, adherence, counselling, and supply of medications., Conclusions: These findings support the role of hospital pharmacists as crucial members of the multidisciplinary team required for transition. The skills and knowledge of the hospital pharmacist is under-utilised within the transition service, yet pharmacists are motivated and uniquely skilled healthcare professionals who have the potential to improve medicines transition., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To evaluate the persistence of immunogenicity three months after third dose boosters., Methods: COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of seven COVID-19 vaccines used as a third booster dose. The analysis was conducted using all randomised participants who were SARS-CoV-2 naïve during the study., Results: Amongst the 2883 participants randomised, there were 2422 SARS-CoV-2 naïve participants until D84 visit included in the analysis with median age of 70 (IQR: 30-94) years. In the participants who had two initial doses of ChAdOx1 nCov-19 (Oxford-AstraZeneca; hereafter referred to as ChAd), schedules using mRNA vaccines as third dose have the highest anti-spike IgG at D84 (e.g. geometric mean concentration of 8674 ELU/ml (95% CI: 7461-10,085) following ChAd/ChAd/BNT162b2 (Pfizer-BioNtech, hearafter referred to as BNT)). However, in people who had two initial doses of BNT there was no significant difference at D84 in people given ChAd versus BNT (geometric mean ratio (GMR) of 0.95 (95%CI: 0.78, 1.15). Also, people given Ad26.COV2.S (Janssen; hereafter referred to as Ad26) as a third dose had significantly higher anti-spike IgG at D84 than BNT (GMR of 1.20, 95%CI: 1.01,1.43). Responses at D84 between people who received BNT (15 μg) or BNT (30 μg) after ChAd/ChAd or BNT/BNT were similar, with anti-spike IgG GMRs of half-BNT (15 μg) versus BNT (30 μg) ranging between 0.74-0.86. The decay rate of cellular responses were similar between all the vaccine schedules and doses., Conclusions: 84 days after a third dose of COVID-19 vaccine the decay rates of humoral response were different between vaccines. Adenoviral vector vaccine anti-spike IgG concentrations at D84 following BNT/BNT initial doses were similar to or even higher than for a three dose (BNT/BNT/BNT) schedule. Half dose BNT immune responses were similar to full dose responses. While high antibody tires are desirable in situations of high transmission of new variants of concern, the maintenance of immune responses that confer long-lasting protection against severe disease or death is also of critical importance. Policymakers may also consider adenoviral vector, fractional dose of mRNA, or other non-mRNA vaccines as third doses., Competing Interests: Declaration of Competing Interest KC acts on behalf of University Hospital Southampton as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Janssen, Medimmune, Merck, Pfizer, Sanofi and Valneva. She receives no personal financial payment for this work. SNF acts on behalf of University Hospital Southampton NHS Foundation Trust as an Investigator and/or providing consultative advice on clinical trials and studies of COVID-19 and other vaccines funded or sponsored by vaccine manufacturers including Janssen, Pfizer, AstraZeneca, GlaxoSmithKline, Novavax, Seqirus, Sanofi, Medimmune, Merck and Valneva vaccines and antimicrobials. He receives no personal financial payment for this work. ALG is named as an inventor on a patent covering use of a particular promoter construct that is often used in ChAdOx1-vectored vaccines and is incorporated in the ChAdOx1 nCoV-19 vaccine. ALG may benefit from royalty income paid to the University of Oxford from sales of this vaccine by AstraZeneca and its sublicensees under the University's revenue sharing policy. JH has received payments for presentations for AstraZeneca, Boehringer Ingelheim, Chiesi, Ciple & Teva. VL acts on behalf of University College London Hospitals NHS Foundation Trust as an Investigator on clinical trials of COVID-19 vaccines funded or sponsored by vaccine manufacturers including Pfizer, AstraZeneca and Valneva. He receives no personal financial payment for this work. PM acts on behalf of University Hospital Southampton NHS Foundation Trust and The Adam Practice as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Novavax, Medicago and Sanofi. He received no personal financial payment for this work. JSN-V-T is seconded to the Department of Health and Social Care, England until 31st March 2022. MR has provided post marketing surveillance reports on vaccines for Pfizer and GSK for which a cost recover charge is made. MDS acts on behalf of the University of Oxford as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Pfizer, Novavax. Janssen, Medimmune and MCM vaccines. He received no personal financial payment for this work., (Copyright © 2022. Published by Elsevier Ltd.)

Background & Aims: Diabetes mellitus (DM) is known to be associated with pancreatic ductal adenocarcinoma (PDAC), particularly new-onset DM (NODM). Others have developed polygenic risk scores (PRS) associated with PDAC risk. We aimed to compare the performance of these PRS in an independent cohort to determine if they can discriminate between NODM and long-standing DM patients with PDAC., Methods: Cases (1042) and matched cancer-free controls (10,420) were drawn from the UK Biobank. Five PRS models were calculated using single nucleotide polymorphisms (SNPs) from previous studies (Nakatochi, Galeotti, Molina, Jia, and Rashkin) and a combination of these. Regression models were used to assess the association between PDAC and PRS adjusted for ancestry, smoking, DM, waist circumference, and family history of digestive cancer. Receiver operator characteristic curves and area under the curve metrics (AUC) were used to assess the performance of each PRS for classifying PDAC risk., Results: The combined PRS model achieved the highest AUC (0.605), and significantly improved a clinical risk model in this cohort (AUC = 0.83; P = .0002). Individuals within the fifth quintile have a 2.74-fold increased risk of developing PDAC vs those in the first quintile (P < .001), and have a 3.05-fold increased risk of developing PDAC if they have DM vs those without DM (P < .001). The positive predictive value was 11.9% in participants without DM, 23.9% with long-standing DM, and 86.7% with NODM., Conclusions: The PDAC-related common genetic variants are more strongly associated with DM. This PRS has the potential for targeting individuals with NODM for PDAC secondary screening measures., (Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.)

Background: Few data exist on the comparative safety and immunogenicity of different COVID-19 vaccines given as a third (booster) dose. To generate data to optimise selection of booster vaccines, we investigated the reactogenicity and immunogenicity of seven different COVID-19 vaccines as a third dose after two doses of ChAdOx1 nCov-19 (Oxford-AstraZeneca; hereafter referred to as ChAd) or BNT162b2 (Pfizer-BioNtech, hearafter referred to as BNT)., Methods: COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of third dose booster vaccination against COVID-19. Participants were aged older than 30 years, and were at least 70 days post two doses of ChAd or at least 84 days post two doses of BNT primary COVID-19 immunisation course, with no history of laboratory-confirmed SARS-CoV-2 infection. 18 sites were split into three groups (A, B, and C). Within each site group (A, B, or C), participants were randomly assigned to an experimental vaccine or control. Group A received NVX-CoV2373 (Novavax; hereafter referred to as NVX), a half dose of NVX, ChAd, or quadrivalent meningococcal conjugate vaccine (MenACWY)control (1:1:1:1). Group B received BNT, VLA2001 (Valneva; hereafter referred to as VLA), a half dose of VLA, Ad26.COV2.S (Janssen; hereafter referred to as Ad26) or MenACWY (1:1:1:1:1). Group C received mRNA1273 (Moderna; hereafter referred to as m1273), CVnCov (CureVac; hereafter referred to as CVn), a half dose of BNT, or MenACWY (1:1:1:1). Participants and all investigatory staff were blinded to treatment allocation. Coprimary outcomes were safety and reactogenicity and immunogenicity of anti-spike IgG measured by ELISA. The primary analysis for immunogenicity was on a modified intention-to-treat basis; safety and reactogenicity were assessed in the intention-to-treat population. Secondary outcomes included assessment of viral neutralisation and cellular responses. This trial is registered with ISRCTN, number 73765130., Findings: Between June 1 and June 30, 2021, 3498 people were screened. 2878 participants met eligibility criteria and received COVID-19 vaccine or control. The median ages of ChAd/ChAd-primed participants were 53 years (IQR 44-61) in the younger age group and 76 years (73-78) in the older age group. In the BNT/BNT-primed participants, the median ages were 51 years (41-59) in the younger age group and 78 years (75-82) in the older age group. In the ChAd/ChAD-primed group, 676 (46·7%) participants were female and 1380 (95·4%) were White, and in the BNT/BNT-primed group 770 (53·6%) participants were female and 1321 (91·9%) were White. Three vaccines showed overall increased reactogenicity: m1273 after ChAd/ChAd or BNT/BNT; and ChAd and Ad26 after BNT/BNT. For ChAd/ChAd-primed individuals, spike IgG geometric mean ratios (GMRs) between study vaccines and controls ranged from 1·8 (99% CI 1·5-2·3) in the half VLA group to 32·3 (24·8-42·0) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·1 (95% CI 0·7-1·6) for ChAd to 3·6 (2·4-5·5) for m1273. For BNT/BNT-primed individuals, spike IgG GMRs ranged from 1·3 (99% CI 1·0-1·5) in the half VLA group to 11·5 (9·4-14·1) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·0 (95% CI 0·7-1·6) for half VLA to 4·7 (3·1-7·1) for m1273. The results were similar between those aged 30-69 years and those aged 70 years and older. Fatigue and pain were the most common solicited local and systemic adverse events, experienced more in people aged 30-69 years than those aged 70 years or older. Serious adverse events were uncommon, similar in active vaccine and control groups. In total, there were 24 serious adverse events: five in the control group (two in control group A, three in control group B, and zero in control group C), two in Ad26, five in VLA, one in VLA-half, one in BNT, two in BNT-half, two in ChAd, one in CVn, two in NVX, two in NVX-half, and one in m1273., Interpretation: All study vaccines boosted antibody and neutralising responses after ChAd/ChAd initial course and all except one after BNT/BNT, with no safety concerns. Substantial differences in humoral and cellular responses, and vaccine availability will influence policy choices for booster vaccination., Funding: UK Vaccine Taskforce and National Institute for Health Research., Competing Interests: Declaration of interests KCa acts on behalf of University Hospital Southampton as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Janssen, Medimmune, Merck, Pfizer, Sanofi, and Valneva. She receives no personal financial payment for this work. SNF acts on behalf of University Hospital Southampton National Health Service (NHS) Foundation Trust as an investigator or providing consultative advice, or both, on clinical trials and studies of COVID-19 and other vaccines funded or sponsored by vaccine manufacturers including Janssen, Pfizer, AstraZeneca, GlaxoSmithKline, Novavax, Seqirus, Sanofi, Medimmune, Merck, and Valneva. He receives no personal financial payment for this work. ALG is named as an inventor on a patent covering use of a particular promoter construct that is often used in ChAdOx1-vectored vaccines and is incorporated in the ChAdOx1 nCoV-19 vaccine. ALG might benefit from royalty income paid to the University of Oxford from sales of this vaccine by AstraZeneca and its sublicensees under the University's revenue sharing policy. JH has received payments for presentations for AstraZeneca, Boehringer Ingelheim, Chiesi, Ciple, and Teva. VL acts on behalf of University College London Hospitals NHS Foundation Trust as an investigator on clinical trials of COVID-19 vaccines funded or sponsored by vaccine manufacturers including Pfizer, AstraZeneca, and Valneva. He receives no personal financial payment for this work. PM acts on behalf of University Hospital Southampton NHS Foundation Trust and The Adam Practice as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Novavax, Medicago, and Sanofi. He received no personal financial payment for this work. JSN-V-T is seconded to the Department of Health and Social Care, England. MR has provided post marketing surveillance reports on vaccines for Pfizer and GlaxoSmithKline for which a cost recover charge is made. MDS acts on behalf of the University of Oxford as an investigator on studies funded or sponsored by vaccine manufacturers including AstraZeneca, GlaxoSmithKline, Pfizer, Novavax, Janssen, Medimmune, and MCM vaccines. He received no personal financial payment for this work. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. Published by Elsevier Ltd.. All rights reserved.)

Background: Bell's palsy is a lower motor neurone facial weakness of unknown aetiology, although reactivation of a virus within the facial nerve has been proposed., Methods: A prospective study was conducted of Bell's palsy cases presenting to our paediatric ENT unit over a 19-week period, from February to June 2020. Patients were invited for severe acute respiratory syndrome coronavirus-2 antibody testing. A text-message questionnaire was sent to other ENT centres to determine their observational experience., Results: During the study period, 17 children presented with Bell's palsy, compared with only 3 children in the same time period in the previous year (p < 0.0001). Five patients underwent severe acute respiratory syndrome coronavirus-2 antibody testing, the results of which were all negative. Four out of 15 centres questioned perceived an increased incidence in paediatric Bell's palsy., Conclusion: Clinicians are encouraged to be vigilant to the increase in paediatric Bell's palsy seen during the coronavirus disease 2019 pandemic, which may represent a post-viral sequela of coronavirus disease 2019.

Objectives : Severe Acute Respiratory Syndrome coronavirus-2 (SARS-CoV-2) has caused enormous strain on health-care systems worldwide. Early recognition of prognostic markers and appropriate management of patients with coronavirus disease 2019 (Covid-19) remains a major global health concern, particularly when resources are limited. We undertook a study to see if basic tests can inform frontline clinicians of disease trajectory in individual patients with COVID-19. Methods : We retrospectively assessed characteristics of the first 50 consecutive patients admitted to district general hospital in the United Kingdom with positive SARS-Cov-2 RNA swabs. Results : Our patient cohort shared broad similarities with previously published data on comorbidities and presenting features. We have found that chest radiographic assessment differed between survivors and non-survivors. Air space shadowing in middle zones were more prevalent in non-survivors (73.3% vs. 35.5% [p = 0.027]). Chest radiograph severity score was also found to be higher in non-survivors compared to survivors (3 vs. 1.5 [p = 0.007]). Conclusions : In this small retrospective study, our results suggest features of chest radiographs at presentation may provide a helpful tool for prognostication. In environments with constrained computed tomography (CT) imaging with serial chest radiographs could be a cost-effective tool in the assessment of Covid-19 patients.

Objectives: To describe the characteristics and outcomes of hospitalised patients with COVID-19 from UK in the highest decile of health and gross regional products per capita., Design: Prospective cohort study., Setting: Recruited all adult inpatients with laboratory-confirmed COVID-19 symptoms admitted to a single Surrey centre between March and April 2020. Extensive demographic details were documented., Outcome Measure: COVID-19 status of alive/dead and intensive care unit (ICU) status of yes/no., Participants: Patients with COVID-19 from Surrey centre UK (n=429)., Results: 429 adult inpatients (mean age 70±18 years; men 56.4%) were included in this study, of whom, 19.1% required admission to ICU and 31.9% died. Adverse outcomes were associated with age (OR with each decade of years: 1.78, 95% CI 1.53 to 2.11, p<0.001 for mortality); male gender (OR=1.08, 95% CI 0.72 to 1.63, p=0.72, present in 70.7%, of admissions to ICU versus 53% of other cases, p=0.004); cardiac disease (OR=3.43, 95% CI 2.10 to 5.63, p<0.001), diabetes mellitus (OR=2.37, 95% CI 1.09 to 5.17, p=0.028) and dementia (OR=5.06, 95% CI 2.79 to 9.44, p<0.001). There was no significant impact of ethnicity or body mass index on disease outcome., Conclusions: Despite reports of worse outcomes in deprived regions, we show similar complication and mortality rates due to COVID-19 in an affluent and high life expectancy region., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background Extensive literature covers the relationship between psychiatric and dental health, but little research explores the ability of dental practitioners to confidently address patient mental health. This paper explored self-reported confidence of dental students when addressing patient mental health in a university setting.Methods Mixed-method approach involving a quantitative scenario-based survey and focus groups. Research participants were from years three, four and five of the Bachelor of Dental Surgery (BDS) degree.Results Survey data showed low confidence among dental students. Focus group themes included lack of education, prejudice and rejecting responsibility. Participants suggested communication skills workshops to help improve confidence.Discussion Self-reported confidence among dental students when addressing patient mental health was low, echoing wider literature findings. Focus groups highlighted an absence of patient mental health from the curriculum. Systematic reviews have recommended greater education around screening tools for 'assessing psychological comorbidity'. Using best practice, focus group data and psychologist guidance, we developed a communication skills case-based workshop for service improvement.Conclusion Low student confidence likely originates from limited focus within the BDS curriculum. The research will be expanded into other UK dental schools to explore the confidence of dental students nationally and to evaluate and trial the developed workshop.

Background: The lay public often conceptualise mental disorders in a different way to mental health professionals, and this can negatively impact on outcomes when in treatment., Aims: This study explored which disorders the lay public are familiar with, which theoretical models they understand, which they endorse and how they compared to a sample of psychiatrists., Methods: The Maudsley Attitude Questionnaire (MAQ), typically used to assess mental health professional's concepts of mental disorders, was adapted for use by a lay community sample ( N  = 160). The results were compared with a sample of psychiatrists ( N  = 76)., Results: The MAQ appeared to be accessible to the lay public, providing some interesting preliminary findings: in order, the lay sample reported having the best understanding of depression followed by generalised anxiety, schizophrenia and finally antisocial personality disorder. They best understood spiritualist, nihilist and social realist theoretical models of these disorders, but were most likely to endorse biological, behavioural and cognitive models. The lay public were significantly more likely to endorse some models for certain disorders suggesting a nuanced understanding of the cause and likely cure, of various disorders. Ratings often differed significantly from the sample of psychiatrists who were relatively steadfast in their endorsement of the biological model., Conclusion: The adapted MAQ appeared accessible to the lay sample. Results suggest that the lay public are generally aligned with evidence-driven concepts of common disorders, but may not always understand or agree with how mental health professionals conceptualise them. The possible causes of these differences, future avenues for research and the implications for more collaborative, patient-clinician conceptualisations are discussed.

Objectives: The National Institute of Health and Clinical Excellence and The Royal College of Physicians recommend transferring thrombolysed patients with stroke to a hyperacute stroke unit (HASU) within 4 h from hospital arrival (T Arrival-HASU ), but there is paucity of evidence to support this cut-off. We assessed if a shorter interval within this target threshold conferred a significant improvement in patient mortality., Design: We conducted a retrospective analysis of prospectively collected data from the Sentinel Stroke National Audit Programme., Setting: Four major UK hyperacute stroke centres between 2014 and 2016., Participants: A total of 183 men (median age = 75 years, IQR = 66-83) and 169 women (median age = 81 years, IQR = 72.5-88) admitted with acute ischaemic stroke., Main Outcome Measures: We evaluated T Arrival-HASU in relation to inpatient mortality, adjusted for age, sex, co-morbidities, stroke severity, time between procedures, time and day on arrival., Results: There were 51 (14.5%) inpatient deaths. On ROC analysis, the AUC (area under the curve) was 61.1% (52.9-69.4%, p = 0.01) and the cut-off of T Arrival-HASU where sensitivity equalled specificity was 2 h/15 min (intermediate range = 30 min to 3 h/15 min) for predicting mortality. On logistic regression, compared with the fastest T Arrival-HASU group within 2 h/15 min, the slowest T Arrival-HASU group beyond upper limit of intermediate range (≥ 3 h/15 min) had an increased risk of mortality: 5.6% vs. 19.6%, adjusted OR = 5.6 (95%CI:1.5-20.6, p = 0.010)., Conclusions: We propose three new alarm time zones (A1, A2 and A3) to improve stroke survival: "A1 Zone" (T Arrival-HASU  < 2 h/15 min) indicates that a desirable target, "A2 Zone" (T Arrival-HASU  = 2 h/15 min to 3 h/15 min), indicates increasing risk and should not delay any further, and "A3 Zone" (T Arrival-HASU  ≥ 3 h/15 min) indicates high risk and should be avoided.

Distinct clinical syndromes have been associated with pathogenic MT-ATP6 variants. In this cohort study, we identified 125 individuals (60 families) including 88 clinically affected individuals and 37 asymptomatic carriers. Thirty-one individuals presented with Leigh syndrome and 7 with neuropathy ataxia retinitis pigmentosa. The remaining 50 patients presented with variable nonsyndromic features including ataxia, neuropathy, and learning disability. We confirmed maternal inheritance in 39 families and demonstrated that tissue segregation patterns and phenotypic threshold are variant dependent. Our findings suggest that MT-ATP6-related mitochondrial DNA disease is best conceptualized as a mitochondrial disease spectrum disorder and should be routinely included in genetic ataxia and neuropathy gene panels. ANN NEUROL 2019;86:310-315., (© 2019 The Authors. Annals of Neurology published by Wiley Periodicals, Inc. on behalf of American Neurological Association.)

Objectives: Bedside ultrasound is increasingly being used to guide fluid management in shocked patients. Little data exist on the inter-rater reliability of techniques used, especially when performed by nonexpert trainee doctors. The primary aim of this study is to measure the inter-rater reliability of five ultrasound techniques commonly used to guide fluid management: inferior vena cava collapsibility index (IVCCI), transthoracic echocardiography (TTE)-derived stroke volumes, ultrasound cardiac output monitor (USCOM) derived stroke volume and carotid artery blood flow and corrected flow time measurements., Methods: Two Royal College of Emergency Medicine level one ultrasound-certified emergency medicine trainees performed paired ultrasound measurements on 31 healthy nonpatient volunteers. Inter-rater reliability was assessed through three indices: interclass correlation coefficient (ICC), limits of agreements (LOAs) derived from Band-Altman plots and the proportion of paired scans with absolute differences of less that 15% (defined as agreement)., Results: TTE-derived measurements performed the best overall, with an LOA of 22%, an ICC of 0.55 and an agreement of 80%. USCOM also performed well, with an LOA of 33%, an ICC of 0.68 and an agreement of 58%. IVCCI and carotid artery-derived measurements performed poorly across all indices., Conclusion: TTE-derived measurements showed the highest level of inter-rater reliability and can thus be expected to provide reliable measures over time with different sonographer clinicians. USCOM interobserver reliability was also adequate for clinical use. However, on the basis of inter-reliability measures, IVCCI and carotid artery measurements were found to be inadequate for clinical use.

Objectives: End-stage kidney disease disproportionately affects people of South Asian origin. This study aimed to uncover the lived experiences of this group of patients on centre-based haemodialysis (HD), the most prevalent dialysis modality., Design: The study utilised a qualitative focus group methodology. Seven focus groups were conducted across four NHS Trusts in the UK including three in Gujarati and two each in Punjabi and Urdu. This provided an inclusive opportunity for South Asian patients to contribute in their language of origin. A total of 24 patients participated. Focus groups were facilitated by bilingual project workers and data were forward translated and analysed using thematic analysis., Results: Four themes were identified. This included (1) 'treatment imposition', which comprised of the restrictive nature of HD, the effects of treatment and the feeling of being trapped in an endless process. (2) The 'patient-clinician relationship' centred around the impact of a perceived lack of staff time, and inadequacies in the quality of interactions. (3) 'Coping strategies' highlighted the role of cognitive reappraisal, living in the moment and family support networks in facilitating adjustment. (4) 'Pursuit of transplantation' included equating this form of treatment with restoring normality, alongside cultural factors limiting hopefulness for receiving an organ., Conclusions: In general, the experiences of South Asian patients receiving HD were not unique to this ethnic group. We did find distinct issues in relation to interactions with healthcare professionals, views on access to transplantation and the importance of family support networks. The study provides useful insights which may help enhance culturally tailored renal care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Significance: Mobile devices such as tablet computers have become widely available as mainstream devices and are also used in some schools, but there is an absence of robust information regarding the efficacy of any optical/electronic low vision device or tablet computer in supporting education of young people with low vision., Purpose: A randomized controlled trial (RCT) is needed to measure the impact of tablet computers on education, specifically on independent access to educational material, in children and young people with low vision. We conducted a pilot RCT to determine the feasibility of conducting a full-scale trial., Methods: This was a randomized multicenter pilot trial across two sites in the United Kingdom and one site in India. Forty children and young people aged 10 to 18 years with low vision (best-corrected visual acuity for distance between <20/60 [0.48 logMAR] and 20/400 [1.30 logMAR] in the better eye) in the United Kingdom (n = 20) and India (n = 20) were randomized to two parallel arms, with a 1:1 allocation ratio, to control (n = 20) or intervention (n = 20). Control group participants received standard low vision care. The intervention group received a tablet computer (iPad) with low vision applications and instruction in its use, including accessibility features. Four primary outcomes included (1) 6-month recruitment rate, (2) retention of participants for 3 months, (3) acceptance/usage of device, and (4) accessibility of device., Results: Nineteen participants (95%) enrolled within 6 months in the United Kingdom, and 20 participants (100%), in India. Retention at 3 months was 85% (n = 17) in the United Kingdom and 95% (n = 19) in India. More than one half of participants reported using a tablet computer at school at least once every day. The majority (90%) found it easily accessible., Conclusions: This study demonstrated that it is feasible to recruit children and young people with low vision into an international multicenter RCT of electronic assistive technology. Regardless of geographical location, children and young people with low vision reported using tablet computers at least once a day at school and accessed them easily.

Introduction: Because of their high risk of stroke, anticoagulation therapy is recommended for most patients with atrial fibrillation (AF). The present study evaluated the use of anticoagulants in the community and in a hospital setting for patients with AF and its associations with stroke., Methods: Patients admitted with stroke to four major hospitals in County of Surrey, England were surveyed in the 2014-2016 Sentinel Stroke National Audit Programme. Descriptive statistics was used to summarise subject characteristics and χ² test to assess differences between categorical variables., Results: A total of 3309 patients, 1656 men (mean age: 73.1 years±SD 13.2) and 1653 women (79.3 years±13.0) were admitted with stroke (83.3% with ischaemic, 15.7% haemorrhagic stroke and 1% unspecified). AF occurred more frequently (χ 2 =62.4; p<0.001) among patients admitted with recurrent (30.2%) rather than with first stroke (17.1%). There were 666 (20.1%) patients admitted with a history of AF, among whom 304 (45.3%) were anticoagulated, 279 (41.9%) were untreated and 85 (12.8%) deemed unsuitable for anticoagulation. Of the 453 patients with history of AF admitted with a first ischaemic stroke, 138 (37.2%) were on anticoagulation and 41 (49.6%) were not (χ 2 = 6.3; p<0.043) and thrombolysis was given more frequently for those without prior anticoagulation treatment (16.1%) or unsuitable for anticoagulation (23.6%) compared with those already on anticoagulation treatment (8.3%; χ 2 =10.0; p=0.007). Of 2643 patients without a previous history of AF, 171 (6.5%) were identified with AF during hospitalisation. Of patients with AF who presented with ischaemic stroke who were not anticoagulated or deemed unsuitable for anticoagulation prior to admission, 91.8% and 75.0%, respectively, were anticoagulated on discharge., Conclusions: The study highlights an existing burden for patients with stroke and reflects inadequate treatment of AF which results in an increased stroke burden. There is significant scope to improve the rates of anticoagulation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Familial evaluation after a sudden death with negative autopsy (sudden arrhythmic death syndrome; SADS) may identify relatives at risk of fatal arrhythmias., Objectives: This study aimed to assess the impact of systematic ajmaline provocation testing using high right precordial leads (RPLs) on the diagnostic yield of Brugada syndrome (BrS) in a large cohort of SADS families., Methods: Three hundred three SADS families (911 relatives) underwent evaluation with resting electrocardiogram using conventional and high RPLs, echocardiography, exercise, and 24-h electrocardiogram monitor. An ajmaline test with conventional and high RPLs was undertaken in 670 (74%) relatives without a familial diagnosis after initial evaluation. Further investigations were guided by clinical suspicion., Results: An inherited cardiac disease was diagnosed in 128 (42%) families and 201 (22%) relatives. BrS was the most prevalent diagnosis (n = 85, 28% of families; n = 140, 15% of relatives). Ajmaline testing was required to unmask the BrS in 97% of diagnosed individuals. The use of high RPLs showed a 16% incremental diagnostic yield of ajmaline testing by diagnosing BrS in an additional 49 families. There were no differences of the characteristics between individuals and families with a diagnostic pattern in the conventional and the high RPLs. On follow-up, a spontaneous type 1 Brugada pattern and/or clinically significant arrhythmic events developed in 17% (n = 25) of the concealed BrS cohort., Conclusions: Systematic use of ajmaline testing with high RPLs increases substantially the yield of BrS in SADS families. Assessment should be performed in expert centers where patients are counseled appropriately for the potential implications of provocation testing., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the impact of the introduction of a dedicated management protocol of necrotizing otitis externa patients with joint care between otorhinolaryngology and infectious diseases., Materials and Methods: Retrospective review of case notes and the otorhinolaryngology department database of all adults admitted with necrotizing otitis externa at our teaching hospital over a 5-year period. The patients were split into two groups (first group of 10 patients prior to the introduction of the dedicated management protocol, and a second group of 33 patients managed after the introduction of this protocol)., Results: Of the 43 patients included in the study, diabetes mellitus was present in 83.7%. Pseudomonas aeruginosa was grown in 67.4% of patients. All 43 patients underwent computed tomography and magnetic resonance imaging (with contrast) scans. Surgical intervention was undertaken in 25.6% of patients. Mean follow-up was 10 months (SD, ±7 months). Of the 43 patients, 79.1% made a full recovery and were discharged. Relapse occurred in 9.3% of patients. One patient died because of a myocardial infarction 4 months after treatment. The mean length of stay was significantly lower after the protocol was introduced (25.6±5.3 vs. 14.2±3.8 days, p=0.001), and the duration of treatment was also significantly lower after the protocol (21.2±6.8 vs. 14.3±4.3 weeks, p=0.01)., Conclusion: The introduction of a dedicated management protocol and joint care with otorhinolaryngology and infectious diseases resulted in improved care and decreased length of stay in patients. Early diagnosis and involvement with the relevant teams as well as prompt intervention are the key factors that reduce morbidity and mortality.

Background: The incidence of cardiovascular disease is considerably disparate among different racial and ethnic populations. While dobutamine stress echocardiography (DSE) has been shown to be useful in Caucasian patients, its role among ethnic minority groups remains unclear. This study aimed to investigate the prognostic importance of DSE in three ethnic groups in the UK., Methods: DSE was performed on 6231 consecutive patients. After exclusions, 5329 patients formed the study (2676 [50.2%] Indian Asian, 2219 [41.6%] European white and 434 [8.1%] Afro-Caribbean). Study outcome measures were non-fatal cardiac events (NFCE) and all-cause mortality., Results: There were 849 (15.9%) NFCE and 1365 (25.6%) deaths over a median follow-up period of 4.6 years. In total 1174 (22%) patients had inducible myocardial ischaemia during DSE, 859 (16.1%) had fixed wall motion abnormalities and 3645 (68.4%) patients had a normal study. Ethnicity did not predict events. Among the three ethnic groups, ischaemia on DSE was associated with 2 to 2.5 times the risk of non-fatal cardiac events and 1.2 to 1.4 times the risk of all-cause mortality. Peak wall motion score index was the strongest independent predictor of non-fatal cardiac events and all-cause mortality in all groups. The C statistic for the prediction of NFCE and all-cause mortality were significantly higher when DSE parameters were added to the standard risk factors for all ethnic groups., Conclusions: DSE is a strong predictor of NFCE and all-cause mortality and provides predictive information beyond that provided by standard risk factors in three major racial and ethnic groups. No major differences among racial and ethnic groups in the predictive value of DSE was detected.

Aim: To determine whether diurnal temporal variations in hypoglycaemic frequency occur in hospitalized patients., Methods: Hypoglycaemic events were identified in a snapshot bedside audit of capillary blood glucose results from diabetes charts of all inpatients receiving insulin or a sulphonylurea (with or without insulin) on 2 days separated by 6 weeks. Additionally, capillary blood glucose measurements were remotely captured over 2 months, in the same category of patients, and analysed for temporal patterns. Hypoglycaemia was defined as 'severe' when the capillary blood glucose was < 3.0 mmol/l and 'mild' when the capillary blood glucose was between 3.0 and 3.9 mmol/l., Results: The bedside audit found that 74% of those audited experienced a hypoglycaemia event. Eighty-three per cent of all hypoglycaemic events and 70% of severe events were recorded between 21.00 and 09.00 h. This was confirmed in the longer duration remote monitoring study where 70% of all hypoglycaemic events and 66% of severe events occurred between 21.00 and 09.00 h., Conclusion: Hypoglycaemia occurs more frequently between 21.00 and 09.00 h in hospitalized patients receiving treatments that can cause hypoglycaemia. This may be related to insufficient carbohydrate intake during this period, and is potentially preventable by changes in catering practice., (© 2013 The Authors. Diabetic Medicine © 2013 Diabetes UK.)

Objective: A cognitive interpersonal maintenance model of anorexia nervosa (AN) was first proposed in 2006 and updated in 2013 (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006; Treasure and Schmidt, J Eat Disorders, in press.). The aim of this study was to test the interpersonal component of this model in people with AN requiring intensive hospital treatment (inpatient/day patient)., Method: On admission to hospital women with AN or eating disorder not otherwise specified (AN subtype; n = 152; P) and their primary carers (n = 152; C) completed questionnaires on eating symptoms (P), depression and anxiety (P, C), accommodation and enabling (C), and psychological control (C). Structural equation modeling was used to examine relationships among these components., Results: Carers' expressed emotion and level of psychological control were significantly related to carers' distress, which in turn, was related to patients' distress. This pathway significantly predicted eating symptoms in patients., Discussion: The cognitive interpersonal maintenance model of eating disorders (EDs) was confirmed in part and suggests that interventions targeting interpersonal maintaining factors such as carer distress might impact on patient outcomes., (Copyright © 2013 Wiley Periodicals, Inc.)

Aims: Athletic training in male black athletes (BAs) is associated with marked ECG repolarization changes that overlap with hypertrophic cardiomyopathy (HCM). Differentiating between the two entities is prudent since BAs exhibit a higher prevalence of exercise-related sudden death from HCM compared with white athletes (WAs)., Methods and Results: Between 1996 and 2010, 904 BAs underwent serial cardiac evaluations including ECG and echocardiography. Athletes exhibiting T-wave inversions were investigated further for HCM. Results were compared with 1819 WAs, 119 black controls (BCs), and 52 black HCM patients. Athletes were followed up for 69.7 ± 29.6 months. T-wave inversions were present in 82.7% HCM patients, 22.8% BAs, 10.1% BCs, and 3.7% WAs. In athletes, the major determinant of T-wave inversions was black ethnicity. T-wave inversions in BAs (12.7%) were predominantly confined to contiguous anterior leads (V1-V4). Only 4.1% of BAs exhibited T-wave inversions in the lateral leads. In contrast, both BCs and HCM patients exhibited lower prevalence of T-wave inversions in leads V1-V4 (4.2 and 3.8%, respectively) with most T-wave inversions in HCM patients (76.9%) involving the lateral leads. During follow-up one BA survived cardiac arrest and two athletes (one BA, one WA) were diagnosed with HCM. All three exhibited T-wave inversions in the lateral leads., Conclusions: T-wave inversions in leads V1-V4 appear to represent an ethnic variant of 'athlete's heart'. Conversely, T-wave inversions in the lateral leads may represent the initial expression of underlying cardiomyopathy and merit further evaluation and regular surveillance.

Background: Ethnicity is an important determinant of cardiovascular adaptation in athletes. Studies in black male athletes reveal a higher prevalence of electric repolarization and left ventricular hypertrophy than observed in white males; these frequently overlap with those observed in cardiomyopathy and have important implications in the preparticipation cardiac screening era. There are no reports on cardiac adaptation in highly trained black females, who comprise an increasing population of elite competitors., Methods and Results: Between 2004 and 2009, 240 nationally ranked black female athletes (mean age 21+/-4.6 years old) underwent 12-lead ECG and 2-dimensional echocardiography. The results were compared with 200 white female athletes of similar age and size participating in similar sports. Black athletes demonstrated greater left ventricular wall thickness (9.2+/-1.2 versus 8.6+/-1.2 mm, P<0.001) and left ventricular mass (187.2+/-42 versus 172.3+/-42 g, P=0.008) than white athletes. Eight black athletes (3%) exhibited a left ventricular wall thickness >11 mm (12 to 13 mm) compared with none of the white athletes. All athletes revealed normal indices of systolic and diastolic function. Black athletes exhibited a higher prevalence of T-wave inversions (14% versus 2%, P<0.001) and ST-segment elevation (11% versus 1%, P<0.001) than white athletes. Deep T-wave inversions (-0.2 mV) were observed only in black athletes and were confined to the anterior leads (V(1) through V(3))., Conclusions: Systematic physical exercise in black female athletes is associated with greater left ventricular hypertrophy and higher prevalence of repolarization changes than in white female athletes of similar age and size participating in identical sporting disciplines. However, a maximal left ventricular wall thickness >13 mm or deep T-wave inversions in the inferior and lateral leads are rare and warrant further investigation.

Aims: Athletic activity is associated with electrocardiographic T-wave inversions in some adults, resembling those observed in cardiomyopathy. The prevalence and significance of T-wave inversions in adolescent athletes, the group most vulnerable to exercise-related sudden death from cardiomyopathy, is unknown., Methods and Results: This study evaluated 1710 adolescent athletes and 400 healthy controls. Subjects with T-wave inversions underwent intensive cardiac investigations to identify a potential cause. There was no significant difference in the overall prevalence of T-wave inversions between athletes and controls (4 vs. 3%; P = 0.46). T-wave inversions in leads V1-V3 were largely confined to athletes and controls aged <16 years. Only 0.1% of athletes aged >or=16 years exhibited T-wave inversions beyond V2. T-wave inversions in the inferior and/or lateral leads and deep T-wave inversions occurred infrequently in athletes (1.5 and 0.8%, respectively) and were associated with a high prevalence of left ventricular hypertrophy or congenital cardiac anomalies. Despite intensive investigations, no athlete was diagnosed with a cardiomyopathy., Conclusions: T-wave inversions in V1-V3 are relatively common in athletes <16 years and probably represent the juvenile electrocardiogram pattern. In adolescent athletes, T-wave inversions beyond V2 if >or=16 years, T-wave inversions in the inferior/lateral leads and deep T-wave inversions in any lead are unusual, warranting further investigations for underlying cardiomyopathy.