UK Department Of Health Research Articles

Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials

SummaryBackgroundNeoadjuvant chemotherapy (NACT) for early breast cancer can make breast-conserving surgery more feasible and might be more likely to eradicate micrometastatic disease than might the same chemotherapy given after surgery. We investigated the long-term benefits and risks of NACT and the influence of tumour characteristics on outcome with a collaborative meta-analysis of individual patient data from relevant randomised trials.MethodsWe obtained information about prerandomisation tumour characteristics, clinical tumour response, surgery, recurrence, and mortality for 4756 women in ten randomised trials in early breast cancer that began before 2005 and compared NACT with the same chemotherapy given postoperatively. Primary outcomes were tumour response, extent of local therapy, local and distant recurrence, breast cancer death, and overall mortality. Analyses by intention-to-treat used standard regression (for response and frequency of breast-conserving therapy) and log-rank methods (for recurrence and mortality).FindingsPatients entered the trials from 1983 to 2002 and median follow-up was 9 years (IQR 5–14), with the last follow-up in 2013. Most chemotherapy was anthracycline based (3838 [81%] of 4756 women). More than two thirds (1349 [69%] of 1947) of women allocated NACT had a complete or partial clinical response. Patients allocated NACT had an increased frequency of breast-conserving therapy (1504 [65%] of 2320 treated with NACT vs 1135 [49%] of 2318 treated with adjuvant chemotherapy). NACT was associated with more frequent local recurrence than was adjuvant chemotherapy: the 15 year local recurrence was 21·4% for NACT versus 15·9% for adjuvant chemotherapy (5·5% increase [95% CI 2·4–8·6]; rate ratio 1·37 [95% CI 1·17–1·61]; p=0·0001). No significant difference between NACT and adjuvant chemotherapy was noted for distant recurrence (15 year risk 38·2% for NACT vs 38·0% for adjuvant chemotherapy; rate ratio 1·02 [95% CI 0·92–1·14]; p=0·66), breast cancer mortality (34·4% vs 33·7%; 1·06 [0·95–1·18]; p=0·31), or death from any cause (40·9% vs 41·2%; 1·04 [0·94–1·15]; p=0·45).InterpretationTumours downsized by NACT might have higher local recurrence after breast-conserving therapy than might tumours of the same dimensions in women who have not received NACT. Strategies to mitigate the increased local recurrence after breast-conserving therapy in tumours downsized by NACT should be considered—eg, careful tumour localisation, detailed pathological assessment, and appropriate radiotherapy.FundingCancer Research UK, British Heart Foundation, UK Medical Research Council, and UK Department of Health.

39 Violence intervention and prevention in emergency rooms: the viper study

BackgroundNearly half a million people are killed each year as a consequence of intentional injury and many more seriously injured. Information sharing by Emergency Departments with local government for crime...

Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients

SummaryBackgroundAntifibrinolytics reduce death from bleeding in trauma and post-partum haemorrhage. We examined the effect of treatment delay on the effectiveness of antifibrinolytics.MethodsWe did an individual patient-level data meta-analysis of randomised trials done with more than 1000 patients that assessed antifibrinolytics in acute severe bleeding. We identified trials done between Jan 1, 1946, and April 7, 2017, from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, PubMed, Popline, and the WHO International Clinical Trials Registry Platform. The primary measure of treatment benefit was absence of death from bleeding. We examined the effect of treatment delay on treatment effectiveness using logistic regression models. We investigated the effect of measurement error (misclassification) in sensitivity analyses. This study is registered with PROSPERO, number 42016052155.FindingsWe obtained data for 40 138 patients from two randomised trials of tranexamic acid in acute severe bleeding (traumatic and post-partum haemorrhage). Overall, there were 3558 deaths, of which 1408 (40%) were from bleeding. Most (884 [63%] of 1408) bleeding deaths occurred within 12 h of onset. Deaths from post-partum haemorrhage peaked 2–3 h after childbirth. Tranexamic acid significantly increased overall survival from bleeding (odds ratio [OR] 1·20, 95% CI 1·08–1·33; p=0·001), with no heterogeneity by site of bleeding (interaction p=0·7243). Treatment delay reduced the treatment benefit (p<0·0001). Immediate treatment improved survival by more than 70% (OR 1·72, 95% CI 1·42–2·10; p<0·0001). Thereafter, the survival benefit decreased by 10% for every 15 min of treatment delay until 3 h, after which there was no benefit. There was no increase in vascular occlusive events with tranexamic acid, with no heterogeneity by site of bleeding (p=0·5956). Treatment delay did not modify the effect of tranexamic acid on vascular occlusive events.InterpretationDeath from bleeding occurs soon after onset and even a short delay in treatment reduces the benefit of tranexamic acid administration. Patients must be treated immediately. Further research is needed to deepen our understanding of the mechanism of action of tranexamic acid.FundingUK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation (CRASH-2 trial). London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation (WOMAN trial).

SemEHR: surfacing semantic data from clinical notes in electronic health records for tailored care, trial recruitment, and clinical research

BackgroundDeriving structured data from unstructured clinical notes in electronic health records (EHRs) requires natural language processing and clinical expertise, which is often costly, and frequently a one-off investment. We implemented SemEHR, a semantic search system that reduces the expertise and effort required in this context. We aimed to use it to characterise and select patients for projects such as the UK Department of Health 100,000 Genome Project. MethodsBuilt upon the off-the-shelf toolkits, Bio-YODIE and CogStack, SemEHR integrates heterogeneous EHR documents and identifies contextualised (negation, temporality, and experiencer) mentions of a wide range of biomedical concepts including SNOMED CT, ICD-10, LOINC, and Drug Ontology. Text mining and semantics techniques are incorporated to derive a longitudinal patient panorama, combining structured profiles and unstructured records, available through semantic search interfaces. FindingsWe deployed SemEHR in various UK hospital EHRs, including the South London and Maudsley NHS Foundation Trust, where 46 million concept mentions were identified from 18 million documents. In a liver disease study, SemEHR identified 94 of 100 hepatitis C positive manually annotated patients. In a HIV study, SemEHR identified 21 of 23 true positives in a 1000-patient cohort. At King's College Hospital, SemEHR is being used to recruit patients into the 100,000 Genomes Project, where ontological associations are integrated to match recruitment criteria and populate complex phenotype models. A preliminary evaluation suggests that the tool is able to validate previously submitted cases and is very fast in searching phenotypes. InterpretationUsing SemEHR, a query such as “find patients with a family history of hepatitis C”, which previously might have required the user to have natural language processing expertise, becomes a simple search, for which SemEHR retrieves a relevant patient cohort, populates patient-level summaries, and provides a link to each mention in the original source. Results and feedback from the multiple studies have proven its efficiency: previously weeks or months of work can be done within minutes in some cases. FundingMedical Research Council (MC_PC_14089); NIHR Biomedical Research Centre for Mental Health, Biomedical Research Unit for Dementia; the European Union's Horizon 2020 (No 644753 KConnect); Wellcome Trust Seed Award in Science (109823/Z/15/Z); National Institute for Health Research University College London Hospital's Biomedical Research Centre; Arthritis Research UK; British Heart Foundation; Cancer Research UK; Chief Scientist Office; Economic and Social Research Council; Engineering and Physical Sciences Research Council; National Institute for Social Care and Health Research; Wellcome Trust (grant MR/K006584/1).

Ethnic variations in sexual behaviours and sexual health markers: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

SummaryBackgroundSexual health entails the absence of disease and the ability to lead a pleasurable and safe sex life. In Britain, ethnic inequalities in diagnoses of sexually transmitted infections (STI) persist; however, the reasons for these inequalities, and ethnic variations in other markers of sexual health, remain poorly understood. We investigated ethnic differences in hypothesised explanatory factors such as socioeconomic factors, substance use, depression, and sexual behaviours, and whether they explained ethnic variations in sexual health markers (reported STI diagnoses, attendance at sexual health clinics, use of emergency contraception, and sexual function).MethodsWe analysed probability survey data from Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3; n=15 162, conducted in 2010–12). Reflecting Britain's current ethnic composition, we included in our analysis participants who identified in 2011 as belonging to one of the following seven largest ethnic groups: white British, black Caribbean, black African, Indian, Pakistani, white other, and mixed ethnicity. We calculated age-standardised estimates and age-adjusted odds ratios for all explanatory factors and sexual health markers for all these ethnic groups with white British as the reference category. We used multivariable regression to examine the extent to which adjusting for explanatory factors explained ethnic variations in sexual health markers.FindingsWe included 14 563 (96·0%) of the 15 162 participants surveyed in Natsal-3. Greater proportions of black Caribbean, black African, and Pakistani people lived in deprived areas than those of other ethnic groups (36·9–55·3% vs 16·4–29·4%). Recreational drug use was highest among white other and mixed ethnicity groups (25·6–27·7% in men and 10·3–12·9% in women in the white other and mixed ethnicity groups vs 4·1–15·6% in men and 1·0–11·2% in women of other ethnicities). Compared with white British men, the proportions of black Caribbean and black African men reporting being sexually competent at sexual debut were lower (32·9% for black Caribbean and 21·9% for black African vs 47·4% for white British) and the number of partners in the past 5 years was greater (median 2 [IQR 1–4] for black Caribbean and 2 [1–5] for black African vs 1 [1–2] for white British), and although black Caribbean and black African men reported greater proportions of concurrent partnerships (26·5% for black Caribbean and 38·9% for black African vs 14·8% for white British), these differences were not significant after adjusting for age. Compared with white British women, the proportions of black African and mixed ethnicity women reporting being sexually competent were lower (18·0% for black African and 35·3% for mixed ethnicity vs 47·9% for white British), and mixed ethnicity women reported larger numbers of partners in the past 5 years (median 1 [IQR 1–4] vs 1 [1–2]) and greater concurrency (14·3% vs 8·0%). Reporting STI diagnoses was higher in black Caribbean men (8·7%) and mixed ethnicity women (6·7%) than white British participants (3·6% in men and 3·2% in women). Use of emergency contraception was most commonly reported among black Caribbean women (30·7%). Low sexual function was most common among women of white other ethnicity (30·1%). Adjustment for explanatory factors only partly explained inequalities among some ethnic groups relative to white British ethnicity but did not eliminate ethnic differences in these markers.InterpretationEthnic inequalities in sexual health markers exist, and they were not fully explained by differences in their broader determinants. Holistic interventions addressing modifiable risk factors and targeting ethnic groups at risk of poor sexual health are needed.FundingMedical Research Council, the Wellcome Trust, the Economic and Social Research Council, UK Department of Health, and The National Institute for Health Research.

Cost-effectiveness of screening for HIV in primary care: a health economics modelling analysis

SummaryBackgroundEarly HIV diagnosis reduces morbidity, mortality, the probability of onward transmission, and their associated costs, but might increase cost because of earlier initiation of antiretroviral treatment (ART). We investigated this trade-off by estimating the cost-effectiveness of HIV screening in primary care.MethodsWe modelled the effect of the four-times higher diagnosis rate observed in the intervention arm of the RHIVA2 randomised controlled trial done in Hackney, London (UK), a borough with high HIV prevalence (≥0·2% adult prevalence). We constructed a dynamic, compartmental model representing incidence of infection and the effect of screening for HIV in general practices in Hackney. We assessed cost-effectiveness of the RHIVA2 trial by fitting model diagnosis rates to the trial data, parameterising with epidemiological and behavioural data from the literature when required, using trial testing costs and projecting future costs of treatment.FindingsOver a 40 year time horizon, incremental cost-effectiveness ratios were £22 201 (95% credible interval 12 662–132 452) per quality-adjusted life-year (QALY) gained, £372 207 (268 162–1 903 385) per death averted, and £628 874 (434 902–4 740 724) per HIV transmission averted. Under this model scenario, with UK cost data, RHIVA2 would reach the upper National Institute for Health and Care Excellence cost-effectiveness threshold (about £30 000 per QALY gained) after 33 years. Scenarios using cost data from Canada (which indicate prolonged and even higher health-care costs for patients diagnosed late) suggest this threshold could be reached in as little as 13 years.InterpretationScreening for HIV in primary care has important public health benefits as well as clinical benefits. We predict it to be cost-effective in the UK in the medium term. However, this intervention might be cost-effective far sooner, and even cost-saving, in settings where long-term health-care costs of late-diagnosed patients in high-prevalence regions are much higher (≥60%) than those of patients diagnosed earlier. Screening for HIV in primary care is cost-effective and should be promoted.FundingNHS City and Hackney, UK Department of Health, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care.

Department of Health must stop sharing patient details with immigration enforcers, says BMA

The BMA will call on the UK Department of Health to stop sharing patient details with the Home Office for immigration enforcement. Delegates at the BMA’s annual representative meeting in Bournemouth on 28 June voted in favour of a motion opposing the practice of sharing patients’ administrative details, including their address, with the Home Office. The motion said, “This meeting notes and deplores the recently signed memorandum of understanding between the UK Department of Health, NHS Digital and the Home Office, which agrees to the transfer of patient administrative details . . . without the consent of the patient and the knowledge of the GP.” It said that this agreement was a …

UK Donation Ethics Committee Response to the New South Wales Consultation on Ante-Mortem Interventions for Organ Donation

This is a response to the New South Wales consultation on ante-mortem interventions for organ donation submitted on behalf of the former members of the UK Donation Ethics Committee (UKDEC), UKDEC was an independent body, hosted by the Academy of Medical Royal Colleges, and funded by all four UK Health Departments. UKDEC’s role was to consider ethical issues relating to the field of organ donation and transplantation and to provide independent advice to clinicians, policy leads and others. The NSW Discussion Paper assumes that ante-mortem interventions cannot be authorised using the Guardianship Act 1987, s.32 standard for decision-making, i.e. promoting and maintaining the patient’s health and well-being. In the response we argue that provisions in the Guardianship Act and their judicial interpretation appear to leave room for arguments that non-therapeutic medical interventions such as ante-mortem interventions to optimise donor organ quality and improve transplant outcomes could be permitted under the Act if they are in the patient’s best interests, interpreted broadly to include emotional, psychological and social interests, although an amendment to s.46 of the Act would make this clearer. In our view, the use of the Guardianship Act 1987 to make a best interests decision for the patient is to be preferred to the proposed amendment of the Human Tissue Act 1983 to permit the senior next of kin to consent to ante-mortem interventions. The latter proposal contains no standard of decision-making (for example, best interests), so senior next of kin could consent to ante-mortem interventions which are not in the patient’s best interests. The retention of ante-mortem decision-making under the Guardianship Act 1987 would achieve greater consistency and protect the patient from abuse or exploitation, as required by s.4(g). Moreover, it would avoid the use of ‘special rules’ for decisions at the end of potential organ donors’ lives, and the risk of damaging public confidence in organ donation and discouraging the registration of consent to donation.

Causes of death up to 10 years after admissions to hospitals for self-inflicted, drug-related or alcohol-related, or violent injury during adolescence: a retrospective, nationwide, cohort study

Emergency hospital admission with adversity-related injury (ie, self-inflicted, drug-related or alcohol-related, or violent injury) affects 4% of 10-19-year-olds. Their risk of death in the decade after hospital discharge is twice as high as that of adolescents admitted to hospitals for accident-related injury. We established how cause of death varied between these groups. We did a retrospective, nationwide, cohort study comparing risks of death in five causal groups (suicide, drug-related or alcohol-related, homicide, accidental, and other causes of death) up to 10 years after hospital discharge following adversity-related (self-inflicted, drug-related or alcohol-related, or violent injury) or accident-related (for which there was no recorded adversity) injury. We included adolescents (aged 10-19 years) who were admitted as an emergency for adversity-related or accident-related injury between April 1, 1997, and March 31, 2012. We excluded adolescents who did not have their sex recorded, died during the index admission, had no valid discharge date, or were admitted with injury related to neither adversity nor accidents. We identified admissions for adversity-related or accident-related injury to the National Health Service in England with the International Classification of Diseases-10 codes in Hospital Episode Statistics data, linked to the Office for National Statistics mortality data for England, to establish cause-specific risks of death between the first day and 10 years after discharge, and to compare risks between adversity-related and accident-related index injury after adjustment for age group, socioeconomic status, and chronic conditions. We identified 1 080 368 adolescents (388 937 [36·0%] girls, 690 546 [63·9%] boys, and 885 [0·1%] adolescents who did not have their sex recorded). Of these adolescents, we excluded 40 549 (10·4%) girls, 56 107 (8·1%) boys, and all 885 without their sex recorded. Of the 333 009 (30·8%) adolescents admitted with adversity-related injury (181 926 [54·6%] girls and 151 083 [45·4%] boys) and 649 818 (60·2%) admitted with accident-related injury (166 462 [25·6%] girls and 483 356 [74·4%] boys), 4782 (0·5%) died in the 10 years after discharge (1312 [27·4%] girls and 3470 [72·6%] boys). Adolescents discharged after adversity-related injury had higher risks of suicide (adjusted subhazard ratio 4·54 [95% CI 3·25-6·36] for girls, and 3·15 [2·73-3·63] for boys) and of drug-related or alcohol-related death (4·71 [3·28-6·76] for girls, and 3·53 [3·04-4·09] for boys) in the next decade than they did after accident-related injury. Although we included homicides in our estimates of 10-year risks of adversity-related deaths, we did not explicitly present these risks because of small numbers and risks of statistical disclosure. There was insufficient evidence that girls discharged after adversity-related injury had increased risks of accidental deaths compared with those discharged after accident-related injury (adjusted subhazard ratio 1·21 [95% CI 0·90-1·63]), but there was evidence that this risk was increased for boys (1·26 [1·09-1·47]). There was evidence of decreased risks of other causes of death in girls (0·64 [0·53-0·77]), but not in boys (0·99 [0·84-1·17]). Risks of suicide were increased following self-inflicted injury (adjusted subhazard ratio 5·11 [95% CI 3·61-7·23] for girls, and 6·20 [5·27-7·30] for boys), drug-related or alcohol-related injury (4·55 [3·23-6·39] for girls, and 4·51 [3·89-5·24] for boys), and violent injury in boys (1·43 [1·15-1·78]) versus accident-related injury. However, the increased risk of suicide in girls following violent injury versus accident-related injury was not significantly increased (adjusted subhazard ratio 1·48 [95% CI 0·73-2·98]). Following each type of index injury, risks of suicide and risks of drug-related or alcohol-related death were increased by similar magnitudes. Risks of suicide were significantly increased after all types of adversity-related injury except for girls who had violent injury. Risks of drug-related or alcohol-related death increased by a similar magnitude. Current practice to reduce risks of harm after self-inflicted injury should be extended to drug-related or alcohol-related and violent injury in adolescence. Prevention should address the substantial risks of drug-related or alcohol-related death alongside risks of suicide. UK Department of Health.

Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial

SummaryBackgroundPost-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.MethodsIn this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.FindingsBetween March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group.InterpretationTranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.FundingLondon School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation.

Government recognises contribution of EU workers to the NHS, says health minister

NHS workers from the EU are valued by the government, the minister of state for health has said

P707 Paediatric IBD patients do not meet the daily recommendations of vitamin D and calcium intake: survey based analysis in a tertiary centre

Background: Achieving optimal levels of vitamin D (VitD) and calcium (Ca) is essential for developing children, especially in patients with inflammatory bowel disease (IBD). VitD and Ca play a major role in bone health and recently VitD has shown to potentiate the effect of anti-inflammatory treatments. However, achieving a sufficient oral intake is difficult in this group taking into account young age, modern eating habits and the nature of IBD itself. The purpose of this study was to evaluate if children with IBD seen in our centre achieve optimal Vit D and Ca intake according to recommendations made by the British Scientific Advisory Committee on Nutrition and the UK Department of Health. Methods: A prospective dietetic survey was conducted among sequential IBD children seen in clinics over a 12 month period. Ca and VitD intakes were assessed through a 24-hour recall of dietary intake questionnaire. Children who had been placed on restricted diets for allergic disease were excluded as well as children under 4 years. Included patients were classified according to age into 2 groups: 4–10 and 11–18 years. Sources of VitD were divided into dairy, oily fish, fortified cereals and egg. Analysis was performed using absolute values, percentages and means in Microsoft Excel. Results: Survey was conducted in 151 patients, this represents 68.3% of all IBD patients under follow-up. 94 patients were included for analysis and 57 were excluded. 43/94 (45.7%) were females. Overall, only 26.6% and 21.3% of the surveyed population achieved the current recommended intake for Ca and VitD respectively. In the younger group, only 7/31 (22.6%) met the current VitD recommendations, the same figure repeats with regards Ca intake. In the older group, only 13/63 (20.6%) and 18/63 (28.6%) met the Ca and VitD recommendations respectively. In both groups dairy was the main source of vitamin D (61.3% young ones and 58.7% older ones). Less than 1/3 of the patients have an optimal intake of oily fish and egg (sufficient intake 19%, 9% for children and 30%, 26% for adolescents). Conclusions: Paediatric IBD patients living in the UK do not meet the minimum requirements of VitD and Ca intake and therefore are at risk of having poor bone health, calcium homeostasis imbalance and VitD deficiency. In the great majority, Ca and VitD sources come from diary whereas the contribution of oily fish and egg as a VitD source is minimal. We recommend that paediatric IBD patients receive frequent counseling on healthy eating habits and proactive intake monitoring. Routine VitD supplementation recommended by local authorities must be followed as there is an insufficient vitD oral intake among these population.

The Experimental Computer Programme: The First Computing Initiative for the National Health Service in England

The Experimental Computer Programme (1967-1979) was the first central government intervention for hospital computing in the English National Health Service. Influenced by developments in the United States, the UK Department of Health envisioned integrated medical and management information systems, operating in real time. The approach to implementation was experimental and piecemeal. The program was overambitious for the computer technology available, but social, economic, and political barriers were equally significant. Despite positioning as a research program, evaluation was poorly managed. Although the program was judged to be a failure at the time, some projects were partially successful. The history of the program remains relevant to the question of how governments might best support hospital computing initiatives in relatively centralized, publicly funded health systems.

Event coverage: ESMO Asia Congress returns to Singapore

Event coverage: ESMO Asia Congress returns to Singapore

A built environment response to the rising costs of dementia

Purpose This paper aims to identify costs related to dementia care provision and explore how purpose-built environment investments can help control these costs and improve quality of life and clinical outcomes. Design/methodology/approach This research adopts a multi-method approach where the findings of a literature review drove the analysis of data obtained from the 115 pilot projects funded by the Department of Health England’s National Dementia Capital Investment Programme. Findings Under the UK Government’s new productivity challenge, it is fundamental to identify actions that provide value for money to prioritise policy and practice. This paper identifies healthcare spaces (e.g. bathroom) where the impact of the built environment on healthcare costs are most evident and building elements (e.g. lighting) to which these costs can be directly associated. The paper advocates the development of evidence and decision support tools capable of: linking built environment interventions to the healthcare costs; and helping the healthcare and social care sectors to develop effective and efficient capital investment strategies. Research Limitations/implications Further work needs to develop more systematic ways of rationalising proactive and timely built environment interventions capable of mitigating dementia (and older people) care cost escalation. Originality/value This research takes an innovative view on capital investment for care environments and suggests that appropriate built environment interventions can have a profound impact on costs associated with dementia care provision.

Clinical effectiveness and cost-effectiveness of physiotherapy and occupational therapy versus no therapy in mild to moderate Parkinson's disease: a large pragmatic randomised controlled trial (PD REHAB).

Cochrane reviews of physiotherapy (PT) and occupational therapy (OT) for Parkinson's disease found insufficient evidence of effectiveness, but previous trials were methodologically flawed with small sample size and short-term follow-up. To evaluate the clinical effectiveness and cost-effectiveness of individualised PT and OT in Parkinson's disease. Large pragmatic randomised controlled trial. Thirty-eight neurology and geriatric medicine outpatient clinics in the UK. Seven hundred and sixty-two patients with mild to moderate Parkinson's disease reporting limitations in activities of daily living (ADL). Patients were randomised online to either both PT and OT NHS services (n = 381) or no therapy (n = 381). Therapy incorporated a patient-centred approach with individual assessment and goal setting. The primary outcome was instrumental ADL measured by the patient-completed Nottingham Extended Activities of Daily Living (NEADL) scale at 3 months after randomisation. Secondary outcomes were health-related quality of life [Parkinson's Disease Questionnaire-39 (PDQ-39); European Quality of Life-5 Dimensions (EQ-5D)], adverse events, resource use and carer quality of life (Short Form questionnaire-12 items). Outcomes were assessed before randomisation and at 3, 9 and 15 months after randomisation. Data from 92% of the participants in each group were available at the primary time point of 3 months, but there was no difference in NEADL total score [difference 0.5 points, 95% confidence interval (CI) -0.7 to 1.7; p = 0.4] or PDQ-39 summary index (0.007 points, 95% CI -1.5 to 1.5; p = 1.0) between groups. The EQ-5D quotient was of borderline significance in favour of therapy (-0.03, 95% CI -0.07 to -0.002; p = 0.04). Contact time with therapists was for a median of four visits of 58 minutes each over 8 weeks (mean dose 232 minutes). Repeated measures analysis including all time points showed no difference in NEADL total score, but PDQ-39 summary index (curves diverging at 1.6 points per annum, 95% CI 0.47 to 2.62; p = 0.005) and EQ-5D quotient (0.02, 95% CI 0.00007 to 0.03; p = 0.04) showed significant but small differences in favour of the therapy arm. Cost-effective analysis showed that therapy was associated with a slight but not significant gain in quality-adjusted life-years (0.027, 95% CI -0.010 to 0.065) at a small incremental cost (£164, 95% CI -£141 to £468), resulting in an incremental cost-effectiveness ratio of under £4000 (£3493, 95% -£169,371 to £176,358). There was no difference in adverse events or serious adverse events. NHS PT and OT did not produce immediate or long-term clinically meaningful improvements in ADL or quality of life in patients with mild to moderate Parkinson's disease. This evidence does not support the use of low-dose, patient-centred, goal-directed PT and OT in patients in the early stages of Parkinson's disease. Future research should include the development and testing of more structured and intensive PT and OT programmes in patients with all stages of Parkinson's disease. Current Controlled Trials ISRCTN17452402. This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 63. See the NIHR Journals Library website for further project information. The Birmingham Clinical Trials Unit, University of Birmingham, received support from the UK Department of Health up to March 2012. Catherine Sackley was supported by a NIHR senior investigator award, Collaboration for Leadership in Applied Health Research and Care East of England and West Midlands Strategic Health Authority Clinical Academic Training award.

Polonium-210 poisoning: a first-hand account

Polonium-210 ((210)Po) gained widespread notoriety after the poisoning and subsequent death of Mr Alexander Litvinenko in London, UK, in 2006. Exposure to (210)Po resulted initially in a clinical course that was indistinguishable from infection or exposure to chemical toxins, such as thallium. A 43-year-old man presented to his local hospital with acute abdominal pain, diarrhoea, and vomiting, and was admitted to the hospital because of dehydration and persistent gastrointestinal symptoms. He was initially diagnosed with gastroenteritis and treated with antibiotics. Clostridium difficile toxin was subsequently detected in his stools, which is when he first raised the possibility of being poisoned and revealed his background and former identity, having been admitted under a new identity with which he had been provided on being granted asylum in the UK. Within 6 days, the patient had developed thrombocytopenia and neutropenia, which was initially thought to be drug induced. By 2 weeks, in addition to bone marrow failure, he had evidence of alopecia and mucositis. Thallium poisoning was suspected and investigated but ultimately dismissed because blood levels of thallium, although raised, were lower than toxic concentrations. The patient continued to deteriorate and within 3 weeks had developed multiple organ failure requiring ventilation, haemofiltration, and cardiac support, associated with a drop in consciousness. On the 23rd day after he first became ill, he suffered a pulseless electrical activity cardiorespiratory arrest from which he could not be resuscitated and was pronounced dead. Urine analysis using gamma-ray spectroscopy on day 22 showed a characteristic 803 keV photon emission, raising the possibility of (210)Po poisoning. Results of confirmatory analysis that became available after the patient's death established the presence of (210)Po at concentrations about 10(9)-times higher than normal background levels. Post-mortem tissue analyses showed autolysis and retention of (210)Po at lethal doses in several organs. On the basis of the measured amounts and tissue distribution of (210)Po, it was estimated that the patient had ingested several 1000 million becquerels (a few GBq), probably as a soluble salt (eg, chloride), which delivered very high and fatal radiation doses over a period of a few days. Early symptoms of (210)Po poisoning are indistinguishable from those of a wide range of chemical toxins. Hence, the diagnosis can be delayed and even missed without a high degree of suspicion. Although body surface scanning with a standard Geiger counter was unable to detect the radiation emitted by (210)Po, an atypical clinical course prompted active consideration of poisoning with radioactive material, with the diagnosis ultimately being made with gamma-ray spectroscopy of a urine sample. UK NHS, Public Health England, and the UK Department of Health.

Preventing catheter-related bloodstream infections

British Journal of Healthcare ManagementVol. 22, No. 6 Infection PreventionPreventing catheter-related bloodstream infectionsJennie WilsonJennie WilsonSearch for more papers by this authorJennie WilsonPublished Online:21 Jun 2016https://doi.org/10.12968/bjhc.2016.22.6.304AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Bion J, Richardson A, Hibbert P et al. (2012) Matching Michigan: a 2-year stepped wedge interventional programme to minimise central venous catheters infections in intensive care units in England. BMJ Qual Saf 22: 110–23 Crossref, Google ScholarCurran ET (2011) Intravenous drug preparation: the infection risks. Br J Nurs 20: S4, S6–8 Link, Google ScholarHalton KA, Cook D, Paterson DL et al. (2010) Cost-effectiveness of a central venous catheter care bundle. PLoS One 5: e12815 Crossref, Google ScholarHealth Protection Agency (2012) English national point prevalence survey on healthcare associated infections and antimicrobial use, 2011: preliminary data. Health Protection Agency, London. www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317134305239 (accessed 1 June 2016) Google ScholarLoveday HP, Wilson JA, Pratt RP et al.; UK Department of Health (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 86: S1 S1–70 Crossref, Google ScholarPronovost P, Needham D, Berenholtz S et al. (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355: 2725–32 Crossref, Google ScholarO'Grady NP, Alexander M, Burns LA et al. (2011) Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 52: e162–93 Crossref, Google ScholarLipitz-Snyderman A, Steinwachs D, Needham DM et al. (2011) Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 342: d219 Crossref, Google ScholarRupp ME, Sholtz LA, Jourdan DR et al. (2007) Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis 44: 1408–14 Crossref, Google ScholarWebster J, Osborne S, Rickard C, New K (2013) Clinically-indicated replacement versus routine replacement of peripheral venous catheters. Cochrane Database Syst Rev 4: CD007798 Google ScholarWilson J (2006) Infection Control in Clinical Practice. Elsevier, London Google ScholarZhang L, Cao S, Marsh N et al. (2016) Infection risks associated with peripheral catheters. J Infect Prevent (in press) Crossref, Google Scholar FiguresReferencesRelatedDetails 2 June 2016Volume 22Issue 6ISSN (print): 1358-0574ISSN (online): 1759-7382 Metrics History Published online 21 June 2016 Published in print 2 June 2016 Information© MA Healthcare LimitedPDF download

Preventing foot complications in diabetes: the St Vincent Declaration 26 years on

Preventing foot complications in diabetes: the St Vincent Declaration 26 years on

Oxidative stability of purified common kilka (clupeonella cultiventris caspia) triacylglycerols as affected by the bene kernel and hull oils and their unsaponifiable matters.

Oxidative stability of purified common kilka (clupeonella cultiventris caspia) triacylglycerols as affected by the bene kernel and hull oils and their unsaponifiable matters.