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Communicable disease outbreaks can spread rapidly, causing enormous losses to individual health, national economies and social well-being. Therefore, communicable disease surveillance is essential for protecting public health. In Qatar, electronic reporting from primary health centres was proposed as a means of improving disease notification, replacing a paper-based method of reporting (via internal mail, facsimile, email or telephone), which has disadvantages and requires active cooperation and engagement of staff. This study is a predescriptive and postdescriptive analysis, which compared disease notifications received from electronic and paper-based systems during 3-month evaluation periods (quarter 2 in 2016 and quarter 2 in 2018 for paper-based and electronic reporting, respectively) in terms of comprehensiveness, timeliness and completeness. For the 23 notifiable diseases included in this study, approximately twice as many notifications were received through the electronic reporting system as from the paper-based reporting system, demonstrating it is more comprehensive. An overall increase in notifications is likely to have a positive public health impact in Qatar. 100% of electronic notifications were received in a timely manner, compared with 28% for paper-based notifications. Findings of the study show that electronic reporting presents a revolutionary opportunity to advance public health surveillance. It is recommended that electronic reporting be rolled out more widely to improve the completeness, stability and representativeness of the national public health surveillance system in Qatar as well as other countries.

This statement summarises and appraises the evidence on diagnosis, prevention and treatment of the most common lower extremity muscle injuries in sport. We systematically searched electronic databases, and included studies based on the highest available evidence. Subsequently, we evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework, grading the quality of evidence from high to very low. Most clinical tests showed very low to low diagnostic effectiveness. For hamstring injury prevention, programmes that included the Nordic hamstring exercise resulted in a hamstring injury risk reduction when compared with usual care (medium to large effect size; moderate to high quality of evidence). For prevention of groin injuries, both the FIFA 11+programme and the Copenhagen adductor strengthening programme resulted in a groin injury risk reduction compared with usual care (medium effect size; low to moderate quality of evidence). For the treatment of hamstring injuries, lengthening hamstring exercises showed the fastest return to play with a lower reinjury rate compared with conventional hamstring exercises (large effect size; very low to low quality of evidence). Platelet-rich plasma had no effect on time to return-to-play and reinjury risk (trivial effect size; moderate quality of evidence) after a hamstring injury compared with placebo or rehabilitation. At this point, most outcomes for diagnosis, prevention and treatment were graded as very low to moderate quality of evidence, indicating that further high-quality research is likely to have an important impact on the confidence in the effect estimates.

Research is urgently needed to help understand the mental health consequences of the covid-19 pandemic on healthcare workers and the public, researchers have argued in a position paper published in the Lancet Psychiatry .1 The paper, funded by the Academy of Medical Sciences, looks at the psychological, social, and neuroscientific effects of covid-19. It warns of major adverse consequences of the pandemic, including increased social isolation and loneliness, which are “strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan.” The authors suggest a number of immediate and longer term actions to mitigate the mental health consequences of this pandemic and any similar future situations, including better monitoring systems and rapidly rolling out evidence based programmes and treatments that can be accessed remotely. These priorities were informed by two surveys of the public and a panel of 24 experts, including people with lived experience of a mental health issue. The surveys, conducted by Ipsos MORI (1099 people) and the mental health research charity MQ (2198 …

Hepatitis B during pregnancy presents unique management issues for both the mother and fetus. These include the lack of a current cohesive strategy for treatment and follow-up of mothers and their babies; the uncertain risk of postpartum HBV flares; the lack of randomised trial data on the safety and efficacy of antiviral treatment in pregnancy; the lack of head-to-head studies comparing different antivirals in pregnancy; and the lack of epidemiologic information regarding infection across different populations globally. This position paper provides a comprehensive review of the management of women with HBV infection prior to conception, throughout each stage of pregnancy and postpartum, as well as recommendations and clinical approaches for the follow-up of children born to infected mothers, based on available evidence in the literature and recommendations from international experts. Prevention of perinatal transmission is an important component of global efforts to reduce the burden of chronic HBV since vertical transmission is responsible for most of the chronic infection worldwide.

Primary care services in or alongside emergency\ud departments look and function differently and are\ud described using inconsistent terminology. Research to\ud determine effectiveness of these models is hampered by\ud outdated classification systems, limiting the opportunity\ud for data synthesis to draw conclusions and inform\ud decision-making and policy. We used findings from a\ud literature review, a national survey of Type 1 emergency\ud departments in England and Wales, staff interviews,\ud other routine data sources and discussions from\ud two stakeholder events to inform the taxonomy. We\ud categorised the forms inside or outside the emergency\ud department: inside primary care services may be\ud integrated with emergency department patient flow or\ud may run parallel to that activity; outside services may be\ud offered on site or off site. We then describe a conceptual\ud spectrum of integration: identifying constructs that\ud influence how the services function—from being closer\ud to an emergency medicine service or to usual primary\ud care. This taxonomy provides a basis for future evaluation\ud of service models that will comprise the evidence base\ud to inform policy-making in this domain. Commissioners\ud and service providers can consider these constructs in\ud characterising and designing services depending on local\ud circumstances and context.

The aim of this study is to evaluate the current practice of statistical analysis of eye data in clinical science papers published in British Journal of Ophthalmology (BJO) and to determine whether the practice of statistical analysis has improved in the past two decades. All clinical science papers (n=125) published in BJO in January–June 2017 were reviewed for their statistical analysis approaches for analysing primary ocular measure. We compared our findings to the results from a previous paper that reviewed BJO papers in 1995. Of 112 papers eligible for analysis, half of the studies analysed the data at an individual level because of the nature of observation, 16 (14%) studies analysed data from one eye only, 36 (32%) studies analysed data from both eyes at ocular level, one study (1%) analysed the overall summary of ocular finding per individual and three (3%) studies used the paired comparison. Among studies with data available from both eyes, 50 (89%) of 56 papers in 2017 did not analyse data from both eyes or ignored the intereye correlation, as compared with in 60 (90%) of 67 papers in 1995 (P=0.96). Among studies that analysed data from both eyes at an ocular level, 33 (92%) of 36 studies completely ignored the intereye correlation in 2017, as compared with in 16 (89%) of 18 studies in 1995 (P=0.40). A majority of studies did not analyse the data properly when data from both eyes were available. The practice of statistical analysis did not improve in the past two decades. Collaborative efforts should be made in the vision research community to improve the practice of statistical analysis for ocular data.

It is 40 years since the seminal description of ‘Munchausen Syndrome by Proxy’ (MSbP) by UK Paediatrician Professor Sir Roy Meadow.1 There have been a number of developments since, which include terminology, definition, prevalence and management. The Royal College of Paediatrics and Child Health (RCPCH) adopted the term ‘Fabricated or Induced Illness by Carers’ (FII) in 2002,2 and updated their guidance in 2009.3 The most recent version of the RCPCH Child Protection Companion extended FII to embrace perplexing presentations with suggestions for management.4 The important evolution in the UK has been towards earlier diagnosis and intervention without the need for proof of deliberate deception. In the USA terms such as ‘Pediatric Condition Falsification’, ‘Medical Child Abuse’ and ‘Caregiver-Fabricated Illness in a Child’ have been introduced although MSbP is still widely used and deception is still implicit.5–7 In adult psychiatry, The Diagnostic and Statistic Manual of Mental Disorders produced by the American Psychiatric Association (DSM-5) replaces Factitious Disorder by Proxy with Factitious Disorder Imposed on Another (FDIoA).8 However, as DSM-5 stipulates that the carer behaviour is associated with identified deception, this excludes many carers involved in paediatric FII. In this paper, FII will be the term used to encompass all of these terms. Paediatricians in the UK have expressed significant concerns about FII, including when and how to recognise it, how to assess risk and how to manage these cases. Even in recent literature, most cases being reported still involve deliberate physical abuse by the carer. There are few descriptions of the earlier presentations and those involving erroneous reporting that form the majority of cases seen by paediatricians. While cases continue to be brought within the umbrella of FII and into the scope of national and local FII procedures for safeguarding children,9 there have …

To investigate if paper-based documentation in the authors' emergency medical service (EMS) satisfies scientific requirements.From 1 July 2007 to 28 February 2008, data from all paper-based protocols of a physician-run EMS in Aachen, Germany, were transferred to a SQL database (n=4815). Database queries were conducted after personal data had been anonymised. Documentation ratios of 11 individual parameters were analysed at two points in time (T1, scene; T2, arrival in emergency department). The calculability of the Mainz Emergency Evaluation Score (MEES, embracing seven vital parameters) was investigated. The calculability of the Revised Trauma Score (RTS) was also determined for all trauma patients (n=408). Fisher's exact test was used to compare differences in ratios at T1 versus T2.The documentation ratios of vital parameters ranged from 99.33% (Glasgow Coma Scale, T1) to 40.31% (respiratory rate, T2). The calculability of the MEES was poor (all missions: 28.31%, T1; 22.40%, T2; p0.001). In missions that required cardiopulmonary resuscitation (n=87), the MEES was calculable in 9.20% of patients at T1 and 29.89% at T2 (p0.001). In trauma missions, the RTS was calculable in 37.26% at T1 and 27.70% at T2 (p=0.004).Documentation of vital parameters is carried out incompletely, and documentation of respiratory rate is particularly poor, making calculation of accepted emergency scores infeasible for a significant fraction of a given test population. The suitability of paper-based documentation is therefore limited. Electronic documentation that includes real-time plausibility checks might improve data quality. Further research is warranted.

ObjectiveTo compare online and paper-based screening for depression and anxiety in adults with cystic fibrosis (CF).Design and settingCross-sectional study in CF clinics in Ireland and through the Cystic Fibrosis Ireland online community.Participants160 adult patients aged 18 or above were recruited. Of these, 147 were included in the analysis; 83 online and 64 paper-based. The remaining 13 were excluded because of incomplete data.MeasuresDepression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS). Data on pulmonary function (forced expiratory volume in 1 s %) and body mass index were self-reported based on clinical assessments. Sociodemographic data were collected.ResultsCompared with the paper-based participants, the online participants were more likely to be female (61.7% vs 48.4%), older (mean 32.2 vs 28.2 years) and were more likely to be married (32.5% vs 15.6%), living with their spouse or partner (42.5% vs 22.6%) and working either full time (33.7% vs 15.9%) or part time (30.1%vs 17.5%). The prevalence rates of elevated anxiety and depression were not significantly different (P=0.71 and P=0.56). HADS anxiety and depression scores were not statistically different between online (P=0.83) and paper-based (P=0.92) participants based on Mann-Whitney U test. A significant negative correlation was found between depression and pulmonary function (r=−0.39, P=0.01) and anxiety and pulmonary function (r=−0.36, P=0.02). Based on Cronbach’s alpha, there were no statistically significant differences between the online and paper-based participants on the internal consistency of the HADS anxiety (P=0.073) and depression (P=0.378) scales.ConclusionsOur findings suggest that online and paper-based screening for depression and anxiety in adult patients with CF yield comparable findings on prevalence rates and scores, associations with health and internal consistency of subscales. This study highlights that online screening offers an alternative method to paper-based screening. Further research with a larger sample and assessment of measurement equivalence between online and paper based screening is needed to confirm our results.

The 100 most-cited papers on age-related macular degeneration (AMD) were analysed using a bibliographic study. The bibliographic databases of the Institute for Scientific Information Web of Knowledge were searched, limited to research articles published between 1965 and 2020 in peer-reviewed journals. The papers were ranked in order of number of citations since publication. Five of the top 10 (and 3 of the top 4) papers reported randomised clinical trial results for either anti-vascular endothelial growth factor agents or nutritional supplements. Four of the top 10 papers reported genotype-phenotype associations between AMD and variants in Complement Factor H. This bibliographic study provides perspective and insight into many of the most influential contributions in the understanding and management of AMD and its evolution over time.

Researchers whose rapid investigations into possible covid treatments that helped to save over a million lives worldwide have won a top prize in this year’s BMJ Awards. The Recovery collaborative group’s trial, which was the first to show that the inexpensive steroid dexamethasone improved survival among patients with covid-19 who had severe respiratory complications, was awarded The BMJ ’s research paper of the year.1 It found that dexamethasone reduced the risk of death by a third among patients on ventilators and by almost a fifth among those on oxygen. The award judges praised the “landmark” NHS study. They said, “The setup of …

IntroductionHormone replacement therapy (HRT) can help women experiencing menopausal symptoms, but usage has declined due to uncertainty around risks of cancer and some cardiovascular diseases (CVD). Moreover, improved cancer survival rates mean that more women who survive cancer go on to experience menopausal symptoms. Understanding these relationships is important so that women and their clinicians can make informed decisions around the risks and benefits of HRT. This study’s primary aim is to determine the association between HRT use after cancer diagnosis and the risk of cancer-specific mortality. The secondary aims are to investigate the risks of HRT on subsequent cancer, all-cause mortality and CVD.Methods and analysisWe will conduct a population-based longitudinal cohort study of 18–79 year-old women diagnosed with cancer between 1998 and 2020, using the QResearch database. The main exposure is HRT use, categorised based on compound, dose and route of administration, and modelled as a time-varying covariate. Analysis of HRT use precancer and postcancer diagnosis will be conducted separately. The primary outcome is cancer-specific mortality, which will be stratified by cancer site. Secondary outcomes include subsequent cancer diagnosis, CVD (including venous thrombo-embolism) and all-cause mortality. Adjustment will be made for key confounders such as age, body mass index, ethnicity, deprivation index, comorbidities, and cancer grade, stage and treatment. Statistical analysis will include descriptive statistics and Cox proportional hazards models to calculate HRs and 95% CIs.Ethics and disseminationEthical approval for this project was obtained from the QResearch Scientific Committee (Ref: OX24, project title ‘Use of hormone replacement therapy and survival from cancer’). This project has been, and will continue to be, supported by patient and public involvement panels. We intend to the submit the findings for peer-reviewed publication in an academic journal and disseminate them to the public through Cancer Research UK.

Perplexing medical presentations encompass many situations encountered by paediatricians, where a child is reported to have symptoms or disabilities that impact significantly on their everyday functioning, and yet thorough medical evaluation has not revealed an adequate and realistic medical explanation. Unlike in other medically unexplained symptoms (MUS), the parent(s) are reluctant to support a rehabilitative approach to the child and insist on continued investigations. The clinicians dealing with the child are, in addition, alert to the possibility that there may be an unusual and potentially harmful parent-child interaction that is causing or perpetuating the presentation.1 If any of the professionals involved with the child becomes concerned that the child may be suffering (or at risk of) significant harm, and if that concern cannot be quickly and easily resolved, then under current safeguarding procedures a referral should be made to Children’s Social Care. These will be managed under existing fabricated or induced illness (FII) guidelines and procedures. However, paediatricians recognise that there are many cases just below that threshold, where safeguarding does not provide a suitable framework for managing the child, and where there is room for a rehabilitative approach to be attempted before considering a safeguarding approach. These are cases where harm to the child is predominantly iatrogenic and avoidable. There may be a potential for some of these cases to progress to ‘True’ FII over time but they are not at that stage. We propose that the essence of the management of perplexing presentations (PP)/FII is to recognise these PP at an early stage. We suggest that early intervention may reduce the potential for iatrogenic harm, help to restore normal functioning and may reduce the need for safeguarding interventions. We also propose that current procedures may need to be revised to take account of the wider spectrum of …

Hepatocellular carcinoma (HCC) ranks number three among the most frequent causes of death from solid tumors worldwide. With obesity and fatty liver diseases as risk factors on the rise, HCC represents an ever increasing challenge. While there is still no curative treatment for most patients numerous novel drugs have been proposed, but most ultimately failed in phase III trials. This manuscript targets therapeutic advances and most burning issues. Expert key point summaries and urgent research agenda are provided regarding risk factors, including microbiota, need for prognostic and predictive biomarkers and the equivocal role of liver biopsy. Therapeutic topics highlighted are locoregional techniques, combination therapies and the potential of immunotherapy. Finally the manuscript provides a critical evaluation of novel targets and strategies for personalized treatment of HCC.

An elevated risk of ovarian cancer has been observed in Norwegian pulp and paper workers who were possibly occupationally exposed to asbestos. The present study was initiated to investigate if the increased risk could be associated with asbestos fibers in ovarian tissue from workers in this industry. Normal ovarian tissue specimens from three groups of women were included in the study. The case group included specimens from 46 women diagnosed with ovarian cancer in the period 1953–2000, and who had been working in one or more pulp and paper mills between 1920 and 1993. Normal ovarian tissue specimens from two control groups without occupational history from pulp and paper work were selected from the Cancer Registry database. Tissue blocks were digested and prepared for transmission electron microscopy. Number of fibers per gram wet weight was calculated. Asbestos fibers were found in normal ovarian tissue from two subjects in the case group, while no fibers were found in the control groups. The two asbestos positive cases had been working as paper sorter/packer and chlorine plant worker, respectively. Both were possibly secondary exposed to asbestos from family members working as insulators. We conclude that the findings in this study did not allow drawing any firm conclusion about an association between occupational exposure to asbestos and ovarian cancer in Norwegian pulp and paper workers. Our study confirms that asbestos fibers may reach the ovaries and demonstrates that the applied method is appropriate for identification of the fibers

Objectives: The objective of the present study was to investigate the risk of death from non-malignant diseases in female pulp and paper workers in Norway. Methods: A total of 3143 women first employed between 1920–93 were included in the study cohort. Information about each cohort member was obtained from personnel record files in the mills in order to identify employment periods and job categories. Data on cause and date of death were added by linkage to the Cause of Death Register using unique personal identification numbers. The follow up period was 1951–2000. Standardised mortality ratios (SMRs) with 95% confidence intervals (95% CIs) were calculated using the national female mortality rates as reference. Poisson regression analysis was used to examine internal relations between the duration of employment in paper departments and the risk of death from selected causes. Relative risks (RRs) and 95% CIs were calculated. Results: The study showed a significantly increased risk for total non-malignant mortality (SMR = 1.14, 95% CI 1.05 to 1.24), mainly due to increased mortality from ischaemic heart disease (SMR = 1.22, 95% CI 1.03 to 1.43) and cerebrovascular diseases (SMR = 1.16, 95% CI 0.94 to 1.42). Analysis by department showed the highest risk of death in paper department workers with short term employment. Internal analyses showed a 5% and 9% increase in risk of dying from ischaemic heart disease and respiratory diseases, respectively, among paper department workers exposed to paper dust. The risk decreased with increasing duration of employment. Conclusion: The increased risk of ischaemic heart diseases and respiratory diseases seen among employees of paper departments may be related to exposure to paper dust.

This year’s winner was a landmark trial that changed practice worldwide in the treatment of covid-19, writes Matthew Limb

The government has bought some time to find a sustainable solution The spring budget delivered £2bn of new funding for social care over three years from 2017‑18 and a commitment to publish a green paper outlining options for future funding. The government’s decision to find additional resources reflects the huge pressures facing social care in England, which the Care Quality Commission described as near “tipping point,”1 and the effect of these pressures on the NHS. These resources will go some way towards stabilising social care, even though they fall short of the sums independent commentators have argued are needed to bridge the expected funding gap by the end of this parliament.2 The announcement of a green paper, planned for the autumn, fulfils the prime minister’s commitment to explore ways of making the funding of social care sustainable. Several options are likely to be considered, including compulsory social insurance as used in countries such as Germany and Japan; acting on the recommendations of the Dilnot report to introduce a cap on care costs, which was included in the Care Act …

IntroductionHealth Data Research UK designated seven UK-based Hubs to facilitate health data use for research. PIONEER is the Hub in Acute Care. PIONEER delivered workshops where patients/public citizens agreed key principles to guide access to unconsented, anonymised, routinely collected health data. These were used to inform the protocol.MethodsThis paper describes the PIONEER infrastructure and data access processes. PIONEER is a research database and analytical environment that links routinely collected health data across community, ambulance and hospital healthcare providers. PIONEER aims ultimately to improve patient health and care, by making health data discoverable and accessible for research by National Health Service, academic and commercial organisations. The PIONEER protocol incorporates principles identified in the public/patient workshops. This includes all data access requests being reviewed by the Data Trust Committee, a group of public citizens who advise on whether requests should be supported prior to licensed access.Ethics and disseminationEast Midlands–Derby REC (20/EM/0158): Confidentiality Advisory Group (20/CAG/0084). www.PIONEERdatahub.co.uk

IntroductionPeople of Ashkenazi Jewish (AJ) ancestry are more likely than unselected populations to have a BRCA1/2 pathogenic variant, which cause a significantly increased risk of breast, ovarian and prostate cancer. Three specific BRCA1/2 pathogenic variants, referred to as BRCA-Jewish founder mutations (B-JFM), account for >90% of BRCA1/2 pathogenic variants in people of AJ ancestry. Current practice of identifying eligible individuals for BRCA testing based on personal and/or family history has been shown to miss at least 50% of people who have one of these variants. Here we describe the protocol of the JeneScreen study—a study established to develop and evaluate two different population-based B-JFM screening programmes, offered to people of Jewish ancestry in Sydney and Melbourne, Australia.Methods and analysisTo rmeasure the acceptability of population-based B-JFM screening in Australia, two screening programmes using different methodologies have been developed. The Sydney JeneScreen programme provides information and obtains informed consent by way of an online tool. The Melbourne JeneScreen programme does this by way of community sessions attended in person. Participants complete questionnaires to measure clinical and psychosocial outcomes at baseline, and for those who have testing, 2 weeks postresult. Participants who decline testing are sent a questionnaire regarding reasons for declining. Participants with a B-JFM are sent questionnaires 12-month and 24-month post-testing. The questionnaires incorporate validated scales, which measure anxiety, decisional conflict and regret, and test-related distress and positive experiences, and other items specifically developed or adapted for the study. These measures will be assessed for each programme and the two population-based B-JFM screening methods will be compared.Ethics and disseminationInstitutional Human Research Ethics Committee approval was obtained from the South Eastern Area Health Service Human Research Ethics Committee: HREC Ref 16/125.Following the analysis of the study results, the findings will be disseminated widely through conferences and publications, and directly to participants in writing.

IntroductionMen who have sex with men (MSM) are one of the most at-risk group for contracting HIV in the USA. However, the HIV epidemic impacts some groups of MSM disproportionately. Latino MSM comprise 25.1% of new HIV infections among MSM between the ages of 13 and 29 years. The daily medication tenofovir/emtricitabine was approved by the Food and Drug Administration for pre-exposure prophylaxis (PrEP) in 2012 and has demonstrated strong efficacy in reducing HIV acquisition.Methods and analysisThrough extensive formative research, this study uses a pilot randomised controlled trial design and will examine the feasibility and acceptability of a patient navigation intervention designed to address multiple barriers to improve engagement in the PrEP continuum among 60 Latino MSM between the ages of 18 and 29 years. The patient navigation intervention will be compared with usual care plus written information to evaluate the feasibility and acceptability of the intervention and study methods and the intervention’s potential in improving PrEP continuum behaviours. The results will be reviewed for preparation for a future full-scale efficacy trial.Ethics and disseminationThis study was approved by the institutional review board at San Diego State University and is registered at ClinicalTrials.gov. The intervention development process, plan and the results of this study will be shared through peer-reviewed journal publications, conference presentations and healthcare system and community presentations.Registration detailsRegistered under the National Institutes of Health’s ClinicalTrials.gov (NCT04048382) on 7 August 2019 and approved by the San Diego State University (HS-2017–0187) institutional review board. This study began on 5 August 2019 and is estimated to continue through 31 March 2021. The clinical trial is in the pre-results stage.

BackgroundInjury prevention programmes (IPPs) are effective in reducing injuries among adolescent team sports. However, there is no validated cricket-specific IPP despite the high incidence of musculoskeletal injuries among amateur cricketers.ObjectivesTo evaluate whether a cricket injury prevention programme (CIPP) as a pretraining warm-up or post-training cool-down can reduce injury rates in amateur cricket players.MethodsCIPP is a cluster randomised controlled trial which includes 36 male amateur club teams having cricket players aged 14–40 years to be randomly assigned to three study arms: warm-up, cool-down and control (n=12 teams, 136 players in each arm). The intervention groups will perform 15 min CIPP either as a pretraining warm-up or a post-training cool-down.Outcome measuresThe primary outcome measure will be injury incidence per 1000 player hours and the secondary outcome measures will be whether IPP as a warm-up is better than IPP as a cool-down, and the adherence to the intervention.Trial registration numberACTRN 1261700047039.

The National Health Service (NHS) has become unaffordable through no fault of its own. Advances in medical technology, increased availability of better treatments, and disease epidemiology have all contributed to this challenging situation. People are living longer and putting a strain upon the NHS with an increasing burden of chronic illness. Will the new White Paper, Equity and Excellence: Liberating the NHS ,1 prove to be the salvation of the NHS? We have grown accustomed to NHS restructuring every 3 years or so, but the current proposals suggest the biggest change in strategic direction since the inception of the NHS. Many of us have lived through general practitioner (GP) fundholding, followed by primary care groups (PCGs), only for these to be scrapped and replaced with primary care trusts (PCTs). Historically, the provision of reproductive and sexual health has been poorly funded, and viewed as a ‘Cinderella service’. Despite this we understand only too well that the relatively small amounts of money spent in primary care to provide contraception and genitourinary medicine services have a significant impact upon the sexual health of those who receive the service and that this is regarded as an efficient use of scarce NHS resources. Community contraceptive services play a pivotal role in preventing unwanted pregnancies, the need for terminations or antenatal care and, in many instances, significant social support. Chlamydia screening and treatment reduces the number of women developing complications such as pelvic infection and ectopic pregnancy. The cervical screening programme with its army of primary care nurses has contributed to a significant reduction from 1433 to 960 cervical cancer deaths annually over the last 30 years.2 We have, however, struggled with equity of access to NHS-funded assisted reproductive technologies (ART), with PCTs using clinical and/or social criteria (e.g. child in a previous …

Objective: We evaluated the feasibility of electronic data capture of self-administered patient questionnaires using a Tablet PC for integration in routine patient management; we also compared these data with results received from corresponding paper–pencil versions. Methods: Standardised patient questionnaires (FFbH/HAQ, BASDAI, SF-36) were implemented in our documentation software. 153 outpatients (rheumatoid arthritis, systemic lupus erythematosus, spondyloarthritis) completed sets of questionnaires as paper–pencil and electronic versions using a Tablet PC. The quality and validity of data obtained using a Tablet PC and the capability of disabled patients to handle it were assigned; patients’ experiences, preferences and computer/internet use were also assessed. Results: Scores obtained by direct data entry on the Tablet PC did not differ from the scores obtained by the paper–pencil questionnaires in the complete group and disease subgroups. No major difficulties using the Tablet PC occurred. 62.1% preferred remote data entry in the future. Seven (4.6%) patients felt uncomfortable with the Tablet PC due to their rheumatic disease. Conclusions: Self-administered questionnaires via Tablet PC are a facile and capable option in patients with rheumatic diseases to monitor disease activity, efficacy and safety assessments continuously. Tablet PC applications offers directly available data for clinical decision-making improves quality of care by effective patient monitoring, and contributes to patients’ empowerment.

The British government views its new 10 year plan, outlined this week, as a turning point for the NHS. The white paper The New NHS gives control of most of the NHS budget to GPs and community nurses, writes John Warden The new NHS, foreshadowed in the white paper, will build on what has worked and discard what has failed. It is the basis of a 10 year programme of “evolutionary change rather than organisational upheaval.” There will be no return to Labour's old command and control system. But there will be an end to the competitive internal market, introduced by the Conservatives; in its place will be a system of “integrated care” based on partnership driven by performance. The government believes that “what counts is what works.” Many features of the internal market will survive. For example, the separation between the purchase and provision of hospital care will be retained; cooperation, however, will replace competition. Local doctors, nurses, and health authorities will have new powers to commission services and ensure that the local NHS is built around the needs of patients. Health authorities will have a powerful supervisory role with greater input …

IntroductionGynaecological cancers collectively account for almost 10% of cancer diagnoses made in Australian women. The extent of variation in gynaecological cancer survival rates and treatment outcomes across Australia is not well documented. The purpose of the clinical quality registry described in this paper is to systematically monitor and improve quality of care provided to these women, and facilitate clinical process improvements to ensure better patient outcomes and greater adherence to best practice care. The registry infrastructure has been developed in conjunction alongside the inaugural ovarian, tubal and peritoneal (OTP) module, allowing for concurrent piloting of the methodology and one module. Additional tumour modules will be developed in time to cover the other gynaecological tumour types.Method and analysisThe National Gynae-Oncology Registry (NGOR) aims to capture clinical data on all newly diagnosed cancers of the uterus, ovary, fallopian tubes, peritoneum, cervix, vulva and vagina in Australia with a view to using these data to support improved clinical care and increased adherence to ‘best practice’. Data are sourced from existing clinical databases maintained by clinicians and/or hospital gynaecological cancer units. A pilot phase incorporating only OTP cancers has recently been conducted to assess the feasibility of the registry methodology and assess the support of a quality initiative of this nature among clinicians and other key stakeholders.Ethics and disseminationThe NGOR has received National Mutual Acceptance (NMA) ethics approval from Monash Health Human Research Ethics Committee (HREC), NMA HREC Reference Number: HREC/17/MonH/198. We also have approval from Mercy Health HREC and University of Tasmania HREC. Data will be routinely reported back to participating sites illustrating their performance against measures of agreed best practice. It is through this feedback system that the registry will support changes to quality of care and improved patient outcomes.

Background Paediatric Early Warning Scores (PEWS) are advocated to assist healthcare professionals to identify early signs of serious illness or deterioration in hospitalised children. A weighting is applied to score components reflecting deviation from a pre-determined ‘norm’. Higher aggregate scores trigger an escalation in care-delivery aiming to prevent adverse events. Knowledge to improve PEWS performance is evolving. Most published studies are from single sites using paper-based documentation, which limits the quantity and quality of data that can be collected and subsequently modelled. Process errors in documentation including missing data, illegible recording, plotting or calculation errors have potential to impede the reliability of the PEWS assessment. Aim To determine the reliability of the PEWS assessment, we measured the accuracy of data recording, PEWS calculation and time to complete documentation for five clinical vignettes, using a hand-held electronic physiological surveillance system (VitalPAC®Paediatric) compared to traditional paper-based methods. We also explored the user acceptability of both methods. Method A mixed method controlled exercise of documenting paediatrics vital signs and clinical observations, and calculating the PEWS score was undertaken. A web based survey was also conducted to determine user acceptability. Results Twenty-three clinical staff participated in the controlled exercise. Using VitalPAC®Paediatric the accuracy of documentation improved from 85.6% to 98.5%, p Conclusion In a controlled exercise, the VitalPAC®Paediatric prototype reduced human factor error in vital signs documentation and PEWS score calculation, and saved time.

Background Many maternal, newborn and child health (MNCH) programmes have paired community health workers with mobile technologies to strengthen the ability of health information systems (HIS) to track women and children across time and beyond the clinical setting. However, little is known regarding the comparative effectiveness of using mobile technologies to enhance HIS data in resource-poor settings. Methods Focus group discussions were conducted with community health workers called Health Activists (HAs; n=30), Community Organisation Leaders (n=28), HA Trainers (n=21), district and tribal area officials (n=3) and State Officials (n=4). We analysed user perceptions along seven key HIS processes: data collection, transmission, processing, analysis, display, quality checking and feedback. Results The mobile-based health information system (mHIS) was found to be supportive of the MNCH continuum of care by improving the regularity and timeliness of access to robust data. Respondents noted that data errors were reduced in real time through automated error checking and data processing, which also reduced users’ workloads. The mHIS additionally enabled users to analyse both individual and aggregate data, allowing them to identify specific individuals in need of services or training as well as to identify general trends in service delivery. The system9s data display and feedback mechanisms were viewed as improving data use for decision-making. The remaining challenges of the mHIS versus the paper-based HIS included resource, infrastructural and technological barriers that hindered efficient use over time. Conclusions As compared to paper-based HIS systems, mobile technologies can improve health information processes in resource-poor settings. More efforts are needed to ensure sufficient financial investment, training and use of mHIS data at all levels of the HIS.

This is a response to Barutta and Vollmann's article 'Physician-assisted death with limited access to palliative care.' I show how they misconstrue a key empirical statement made by the European Association for Palliative Care regarding legalisation of euthanasia and physician-assisted suicide. Additionally, I include some further remarks on the relationship between euthanasia and palliative care. I read with interest the article, which delineate well several positions and gives a nice overview of arguments presented on either side. I also found the line of argument unprejudiced and clear, and am sure people working within palliative care would benefit from reading it.

A study of antibiotics and maternal infections after childbirth had an “amazing” impact, reports Matthew Limb

Background There is a lack of consensus regarding the definition of advance care planning (ACP), the people for whom it is most beneficial, how and by whom it should be conducted, its integration in health care, and what appropriate outcomes measures are. Further, there are considerable differences worldwide in the willingness of health care providers, patients and relatives to discuss issues related to disease progression and end-of-life care, and the integration of these discussions in the health care system. Aim To draft a white paper about ACP that is based on scientific evidence and transcultural consensus building that describes a common understanding of the definition the key elements of ACP. This white paper is commissioned by the European Association for Palliative Care (EAPC). Methods and expected results A three-round Delphi study will be conducted by a core group of 14 experts from 8 countries. The first round took place in June 2014 in a 2-day expert meeting. Five core domains were established: concept, content, system, measurements, and challenges/concerns. Subsequently, based on literature, a set of 50 recommendations related to these domains were drafted. These will be assessed in two rounds on its importance by a multidisciplinary expert panel (n = 100 from 16 countries). In addition, a research agenda for future ACP research will be constructed. Conclusion The ACP white paper will provide a comprehensive overview of ACP based on evidence and consensus. It can serve as a framework for clinical practice, policy and research.

Objectives Study the relationship between inhalation of airborne particles in a pulp and paper mill and markers of inflammation and coagulation in blood. Method Personal sampling of inhalable dust was performed for 72 subjects working in a Swedish pulp and paper mill. Stationary measurements were used to study different particle size fractions including respirable dust, PM10 , PM2.5, the particle surface area and particle number concentrations of ultrafine particles. Markers of inflammation such as interleukins (IL-1b, IL-6, IL-8, and IL-10), C-reactive protein (CRP), serum amyloid A (SAA), and fibrinogen and markers of coagulation such as factor VIII, von Willebrand factor vWF), plasminogen activator inhibitor (PAI-1), and D-dimer were determined before the first shift after a work free period of normally five days and after the first, second and third shift Results The average 8hr-TWA level of inhalable dust in was 0.30 mg/m3, range 0.005–3.3 mg/m3.The proxies for 8hr-TWAs of respirable dust was 0.045 mg/m3, PM10 0.17 mg/m3 and PM2.5 0.08 mg/m3. No significant increase of markers of inflammation or coagulation in blood during the working week was noted after a non-exposure period of five days. In a multiple regression analysis adjustments were made for sex, age, smoking, BMI, and blood group. Significant positive correlations were found between several particle exposure metrics and CRP, SAA and fibrinogen taken pre- and post-shift day 1, suggesting a dose-effect relationship. Conclusions These relations between particle exposure and inflammatory markers may indicate an increased risk of cardiovascular disease.

The use of filter paper four point 24 hour cortisol profiles in the diagnosis and management of secondary adrenocortical deficiency was examined. Eighteen children with familial short stature and isolated growth hormone deficiency had normal 24 hour and morning plasma cortisol concentrations measured. Eight of 11 children with multiple pituitary hormone deficiencies had evidence of hypocorticalism despite previously normal baseline cortisols or responses to insulin hypoglycaemia or tetracosactrin. Nine of 11 children with hypopituitarism on replacement treatment (4.9-12.5 mg/m2/day) had satisfactory concentrations of cortisol, though morning cortisols were often low. Filter paper profiles are a simple, inexpensive, and relatively non-invasive way of managing children with suspected hypocorticalism and of monitoring their treatment.

Objective Although paediatric-onset IBD is becoming more common, few medications have a registered paediatric indication. There are multiple hurdles to performing clinical trials in children, emphasising the importance of choosing an appropriate outcome measure, which can facilitate enrolment, and thereby also drug approval. The aim of this consensus statement is to highlight paediatric specific issues and key factors critical for the optimal conduct of paediatric IBD trials. Design The Paediatric European Crohn9s and Colitis Organisation (ECCO) committee has established an international expert panel to determine the best outcome measures in paediatric IBD, following a literature search and a modified Delphi process. All recommendations were endorsed by at least 80% agreement. Results Recognising the importance of mucosal healing (MH), the panel defined steroid-free MH as primary outcome measure for all drugs of new category with one or two postintervention endoscopies per trial (at 8–12 weeks and/or 54 weeks). Since endoscopic evaluation is a barrier for recruitment in children, trials with medications already shown to induce MH in children or adults, could use paediatric-specific disease activity scores as primary outcome, including a modified Paediatric Crohn9s Disease Activity Index in Crohn9s disease and the Paediatric Ulcerative Colitis Activity Index in UC. Secondary outcomes should include safety issues, MR enterography-based damage and inflammatory scores (in Crohn9s disease), faecal calprotectin, quality of life scales, and a patient-reported outcome. Conclusions It is crucial to perform paediatric trials early in the development of new drugs in order to reduce off-label use of IBD medication in children. The thoughtful choice of feasible and standardised outcome measures can help move us towards this goal.

In the present work, the top 20 cited papers published in Tobacco Control between 1998 and 15 September 2011, the top 10 cited papers published after 2008 and the 50 authors whose papers have been most cited in the journal are reported. US authors dominated the most cited papers and the most cited authors, with Australian authors in second place. Papers on youth and secondhand smoke dominated the top 20 papers, although harm reduction and packaging papers appeared in the post 2008 leading cited papers.

ObjectiveAnalyses of the impact of a body of clinical trial reports subject to research misconduct have been few. Our objective was to examine the impact on clinically relevant research of a group of researchers’ trial reports (‘affected trial reports’) affected by research misconduct, and whether identification of misconduct invoked a reappraisal.DesignIn 2016, we used five databases and search engines to identify ‘citing publications’, that is, guidelines, systematic and other reviews, and clinical trials citing any of 12 affected trial reports, published 1998–2011, eventually retracted for research misconduct. The affected trial reports were assessed more likely to have had impact because they had hip fracture outcomes and were in journals with impact factor >4. Two authors assessed whether findings of the citing publications would change if the affected trial reports were removed. In 2018, we searched for evidence that the citing publications had undertaken a reassessment as a result of the potential influence of the affected trial reports.ResultsBy 2016 the affected trial reports were cited in 1158 publications, including 68 systematic reviews, meta-analyses, narrative reviews, guidelines and clinical trials. We judged that 13 guidelines, systematic or other reviews would likely change their findings if the affected trial reports were removed, and in another eight it was unclear if findings would change. By 2018, only one of the 68 citing publications, a systematic review, appeared to have undertaken a reassessment, which led to a correction.ConclusionsWe found evidence that this group of affected trial reports distorted the evidence base. Correction of these distortions is slow, uncoordinated and inconsistent. Unless there is a rapid, systematic, coordinated approach by bibliographic databases, authors, journals and publishers to mitigate the impact of known cases of research misconduct, patients, other researchers and their funders may continue to be adversely affected.

This paper published in 1989 comes number 8 in the most cited papers in the Journal of Clinical Pathology in this 70th anniversary of the Journal and cited some 631 times in the 27 years since it was published. In this paper, the French–American–British (FAB) group studied specimens from 110 patients who were well characterised with clinical and laboratory studies including electron microscopy.1 They looked at peripheral blood films, bone aspirate and trephine specimens and some lymph node biopsy specimens. On the basis of cytology and membrane phenotype, the disorders were defined. Immunological techniques used included distinguishing between B and T lymphocytes using membrane (SMIg) and cytoplasmic (CyIg) immunoglobulin and rosette tests with sheep erythrocytes and monoclonals against cell surface epitopes. In a series of meetings over 18 months, the group met and reviewed and discussed the cases and agreed on the classification. The technologies used were the state-of-the-art methods of the time. Morphology, the long-standing foundation of haematology, is the initial technique used. However, it is recognised that morphological appearances in certain entities can be highly variable. In this paper, the experts agree and define the appearances of the different types of chronic leukaemias and in the illustrations give clear examples of the morphology. However, at the time of …

A researcher who made headlines with a paper that claimed to have found a genetic test to measure ageing and diagnose Alzheimer’s disease tried to suppress scientific discussion about his data by threatening legal action. Jamie Timmons and colleagues published their research in Genome Biology ,1 with widespread pick-up in UK newspapers. The story was also listed by the BBC among its 10 scientific breakthroughs of 2015. The researchers claimed that they had identified a 150 gene expression signature in blood for healthy ageing, which was also “diagnostic for” Alzheimer’s disease. The claim seemed surprising to some others in the field. The data presented on healthy ageing were based on muscle samples from 108 men, all aged around 70. But David Melzer, professor of epidemiology and public health at the University of Exeter, said that the blood sample results reported showed limited ability to distinguish Alzheimer’s from healthy control participants and failed to identify mild cognitive impairment samples correctly. Melzer and his group were part of an international collaboration on gene expression and ageing that studied 15 000 participants from 14 cohorts. That study found 1497 genes in blood associated with age,2 but only 10 overlapped with the 150 gene signature in Timmons’s paper. Melzer and colleagues posted results for …

ObjectivesDysfunction after transient ischaemic attack (TIA) and minor stroke is often underestimated by clinical measures. Patient-reported outcome measures used in value-based healthcare may help in detecting these problems. The Patient-Reported Outcomes Measurement Information System 10-Question Short Form (PROMIS-10 Global Health) is a concise patient-centred outcome measuring tool proposed for assessing health status in patients who had stroke. This study aims to address the validity of the Dutch PROMIS-10 in patients who had stroke in the Netherlands and also aims to compare telephone versus on-paper assessment.DesignObservational cohort study.SettingSingle-centre hospital in the Netherlands.Participants75 patients who were diagnosed with TIA or minor stroke and discharged without rehabilitation treatment 1 year ago (between December 2014 and January 2016) completed the study.Primary and secondary outcome measuresPROMIS-10 physical (PH) and mental health (MH) scores assessed 1 year poststroke on paper (n=37) and by telephone (n=38) was compared with RAND-36 physical and mental component scores assessed on paper.ResultsPROMIS-10 and RAND-36 correlated significantly in PH, r=0.81 (95% CI 0.69 to 0.88), and MH, r=0.76 (95% CI 0.64 to 0.85). Paper-and-pencil assessed correlations were r=0.87 and 0.79 for PH and MH, respectively. Telephone assessed correlations were r=0.76 and 0.73 for PH and MH, respectively. Internal consistency analysis indicated high reliabilities for both health components of the PROMIS-10, all Cronbach’s α>0.70.ConclusionsThe Dutch PROMIS-10 was found to strongly correlate with the RAND-36. Paper-and-pencil assessment was found to have a higher correlation than telephone assessment. This study provides support for the use of the Dutch PROMIS-10 in assessing health status in patients after TIA and minor stroke.

In celebration of the Platinum Jubilee, the current Editor-in-Chief, Professor Tahir Pillay, has reflected on the past 70 years, especially the best cited papers that have appeared in the Journal of Clinical Pathology ( JCP ).1 For the journal to have endured and remained relevant for this length of time, clearly it must have published good work consistently. The second most cited paper in the Journal is a superb review by Bosch and colleagues on human papillomavirus (HPV) and uterine cervical cancer.2 Data measurement on impact and relevance in publishing is now de rigueur and the yardstick by which a piece of work is judged. There are several repositories and search engines such as Google Scholar …

Sweden’s top ethical review board has called for six papers published by the disgraced surgeon Paolo Macchiarini to be retracted. They include a key 2011 paper published in the Lancet in which Macchiarini and colleagues claimed success in transplanting an artificial trachea seeded with the patient’s own cells into a 36 year old man.1 The operation took place at the Karolinska University Hospital in Stockholm. Since doubts first emerged about Macchiarini’s work, a series of reviews has been carried out.23 At first the Karolinska Institute, which employed him, declined to accept that there was evidence of misconduct but was …

Choosing Health’ a Public Health White Paper was published in November 2004 with its Implementation Paper expected in Spring 2005. Sexual and reproductive health plays an important role in this White Paper which heralds the Government’s desire to move from a disease-orientated medical approach to a clinical style of supporting people to make better choices more in line with traditional community family planning and reproductive health services. This represents an opportunity to raise community contraceptive and sexual health service profiles develop new sexual health approaches and secure funding to implement service development. However to make the most of these opportunities traditional community contraceptive services need to demonstrate that they are already delivering health-promoting clinical services with potential to do more. (excerpt)

Chavkin W, Leitman L, Polin K; for Global Doctors for Choice. Int J Gynecol Obstet 2013;123:S41–S56. This is a comprehensive analysis of conscientious objection/refusal by doctors, nurses, midwives and pharmacists in five areas of reproductive healthcare: abortion, assisted reproductive technologies (ART), contraception, unavoidable pregnancy loss due to maternal illness and prenatal diagnosis. The rights of objecting providers are balanced against those of patients. A systematic search for data from quantitative, qualitative and ethnographic studies in the last 15 years was done. Objection varied enormously with some objectors being absolute and others making exceptions. The overall impression is that objection is widespread and increasing globally. Because of lack of empirical data on the impact of …

Evaluation of published medical research remains a challenge. Two classic yardsticks are the citation count (the number of times a given paper is cited by others)1 2 and the impact factor of the journal that published the paper (which reflects the average number of citations per article).2 3 However, the citation count can be assessed only several years after publication, and the impact factor is not paper specific and is thus virtually meaningless in assessing any given paper.3 Another measure, which can be obtained rapidly and is paper specific, is the “hit count” (the number of times a paper is accessed online). Whether this count predicts citations is unknown. I examined this issue prospectively in a cohort of papers published in the BMJ . The study used articles published in volume 318 of the BMJ (1999) in sections titled Papers, General Practice, and Information in Practice. The hit counts (full text articles, HTML version) for the main body of each article within a week of publication were provided by a …

Before changing your practice in the light of a published research paper, you should decide whether the methods used were valid. This article considers five essential questions that should form the basis of your decision. Only a tiny proportion of medical research breaks entirely new ground, and an equally tiny proportion repeats exactly the steps of previous workers. The vast majority of research studies will tell us, at best, that a particular hypothesis is slightly more or less likely to be correct than it was before we added our piece to the wider jigsaw. Hence, it may be perfectly valid to do a study which is, on the face of it, “unoriginal.” Indeed, the whole science of meta-analysis depends on the literature containing more than one study that has addressed a question in much the same way. The practical question to ask, then, about a new piece of research is not “Has anyone ever done a similar study?” but “Does this new research add to the literature in any way?” For example: Before assuming that the results of a paper are applicable to your own practice, ask yourself …

It usually comes as a surprise to students to learn that some (perhaps most) published articles belong in the bin, and should certainly not be used to inform practice.1 The first box shows some common reasons why papers are rejected by peer reviewed journals. #### Why were papers rejected for publication? RETURN TO TEXT Most papers now appearing in medical journals are presented more or less in standard IMRAD format: Introduction (why the authors decided to do this research), Methods (how they did it, and how they analysed their results), Results (what they found), and Discussion (what the results mean). If you are deciding whether a paper is worth reading, you should do so on the design of the methods section and not on the interest of the hypothesis, the nature or potential impact of the results, or the speculation in the discussion. The assessment of methodological quality (critical appraisal) has been covered in detail in many textbooks on evidence based medicine,2 3 4 5 6 and in Sackett and colleagues' Users' Guides to …

IntroductionEvidence suggests bowel scope screening (BSS) can significantly reduce an individual’s risk of developing colorectal cancer (CRC). BSS for 55 year olds was therefore introduced to the English Bowel Cancer Screening Programme (BCSP) in 2013. However, the benefits are only gained from test completion and uptake is low (43%). Primary care involvement has consistently shown benefits to cancer screening uptake and so this study aims to build on this knowledge and evaluate general practitioner (GP) practice led interventions designed to increase BSS attendance.Methods and analysisA three-arm randomised controlled trial will be conducted to evaluate three interventions: one intervention for prospective BSS invitees (primer letter with locally tailored leaflet sent by an individual’s GP practice) and two interventions for those who do not attend their BSS appointment (a self-referral letter sent by an individual’s GP practice and a patient navigation call made on behalf of an individual’s GP practice). The trial will be set in Yorkshire. Individuals soon to receive their invitation to attend BSS at one of the Hull and East Yorkshire Bowel Cancer Screening centre sites, will be randomly assigned to one of three groups: control (usual care; no input from GP practice), Intervention group A (primer letter/leaflet and a self-referral letter), Intervention group B (primer letter/leaflet and a patient navigation call). Attendance data will be obtained from the BCSP database (via National Health Service (NHS) Digital) 3 months after the last intervention. Regression analysis will compare uptake, and additional clinical outcomes, across the three groups. The analysis will be multivariate and adjust for several covariates including gender and area-level deprivation.Ethics and disseminationNHS ethical approval has been obtained from London-Harrow Research Ethics Committee. The results will be submitted for publication in a peer-reviewed journal and presented at conferences.Trial registration numberISRCTN16252122; Pre-results.