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This paper assesses the relationship between economic resilience in English regions and the allocation of the UK government’s Community Renewal Fund (CRF). The CRF is part of the government’s ‘Levelling Up’ agenda to address place-based inequalities. Economic resilience is measured using a composite index comprising productivity, skills, unemployment, population density and household income. Data were obtained for the five indicators at local authority (LA) level in England. Regional resilience scores were produced by calculating the weighted mean score of the constituent LAs. Regional resilience values were used to generate an ‘expected share’ funding allocation, which was compared with the actual allocation using differences and correlation. Regional resilience scores ranged from 28.5 (North East) to 66.6 (London). A total of £125.56 million was allocated in the first round of the CRF. All regions in the North received less than their expected share allocation of the CRF, with the least resilient region in England (North East) receiving £13.4 million less. The South West received £9.9 million more than their expected share. All regions in the North of England received less than their expected share allocation of the CRF. There was no significant correlation between resilience values and CRF allocations (r = −0.16, p = 0.68). The current method for CRF allocation may therefore widen existing inequalities rather than ‘level up’.

Over recent decades, the arts have become a popular response to dementia. Amidst wider concerns with accessibility, widening participation and audience diversity, coupled with greater attention to creativity across dementia studies, many arts organisations are now offering dementia friendly initiatives. While dementia friendliness has been well-established for almost a decade, the meaning of friendliness remains vague. This paper reports results from a study of how stakeholders navigate this nebulousness when developing their own dementia friendly cultural events. To assess this, we interviewed stakeholders working for arts organisations in the northwest of England. We found that participants built up local informal networks of knowledge exchange, sharing experiences between stakeholders. The dementia friendliness that characterises this network centres on the crafting of vibes that enable people with dementia to ‘unhide’ themselves. Through this accommodating approach, dementia friendliness converges with stakeholder interests, becoming something of an art form in its own right, typified by active embodied experience, flexible and creative self-expression, and being in-the-moment.

The United Nations (UN) recognises free school meals as critical, yet widely disrupted by COVID-19. We investigate caregiver perceptions and responses to interruptions to the universal infant free school meal programme (UIFSM) in Cambridgeshire, England, using an opt-in online survey. From 586 responses, we find 21 per cent of respondents' schools did not provide UIFSM after lockdown or advised caregivers to prepare packed lunches. Where provided, caregivers perceived a substantial decline in quality and variety of meals, influencing uptake. Direction to bring packed lunches, which caregivers reported to have contained ultra-processed foods of lower nutritional quality, influenced caregiver behaviour rather than safety concerns as claimed by industry. The quality and variety of meals, and school and government policy, had greater impact than concerns for safety. In the UK and at the international level, policymakers, local governments, and schools must act to reverse the trend of ultra-processed foods in packed lunches, while improving the perceived quality of meals provided at schools.

Background Double reading can be used in screening mammography, but it is labor intensive. There is limited evidence on whether trained radiographers (ie, technologists) may be used to provide double reading. Purpose To compare the performance of radiologists and radiographers double reading screening mammograms, considering reader experience level. Materials and Methods In this retrospective study, performance and experience data were obtained for radiologists and radiographer readers of all screening mammograms in England from April 2015 to March 2016. Cancer detection rate (CDR), recall rate (RR), and positive predictive value (PPV) of recall based on biopsy-proven findings were calculated for first readers. Performance metrics were analyzed according to reader professional group and years of reading experience using the analysis of variance test.

A single SARS-CoV-2 vaccine dose reduces onward transmission from case-patients. We assessed the potential effects of receiving 2 doses on household transmission for case-patients in England and their household contacts. We used stratified Cox regression models to calculate hazard ratios (HRs) for contacts becoming secondary case-patients, comparing contacts of 2-dose vaccinated and unvaccinated index case-patients. We controlled for age, sex, and vaccination status of case-patients and contacts, as well as region, household composition, and relative socioeconomic condition based on household location. During the Alpha-dominant period, HRs were 0.19 (0.13-0.28) for contacts of 2-dose BNT162b2-vaccinated case-patients and 0.54 (0.41-0.69) for contacts of 2-dose Ch4dOx1-vaccinated case-patients; during the Delta-dominant period, HRs were higher, 0.74 (0.72-0.76) for BNT162b2 and 1.06 (1.04-1.08) for Ch4dOx1. Reduction of onward transmission was lower for index case-patients who tested positive ≥2 months after the second dose of either vaccine.

Introduction This study aimed to assess the trend of percutaneous and open surgical procedures for peripheral arteriovenous malformations (AVMs) performed in NHS hospitals in England between 2012 and 2018. Methods Hospital Episode Statistics (HES) is a freely available data warehouse that represents the whole population of England served by the NHS. Data from the HES database was obtained and analysed for all hospital episodes between 2012 and 2018 for the total number and trend of ‘primary diagnosis’, and ‘primary procedures and interventions’ identified for peripheral AVMs. Results Over the period studied, there was an increase in the total number of admissions for peripheral AVMs; total primary diagnosis increased from 2242 to 2857 per year. Open surgery remained more commonly performed than percutaneous procedures throughout the studied period. However, the overall percentage of primary procedures and interventions being percutaneous in this period increased from 29.8% to 41.0% per year. The increase in the number of percutaneous procedures per year seemed to occur in both children (from 43 to 124) and adults (from 408 to 492) over the course of the study period. Conclusions This study concluded that open surgery remained the most commonly performed primary procedure for peripheral AVMs, although there was an increasing trend for percutaneous procedures in NHS hospitals in England. The increase in the number and percentage of percutaneous procedures for peripheral AVMs was likely to have significant resource implications for the provision of care for patients with peripheral AVMs in NHS hospitals.

A historiografia neo-republicana de Cambridge estabeleceu uma franca distinção entre republicanismo e liberalismo que merece ser reexaminada. Este artigo busca contribuir para esse debate, propondo um estudo de caso dos commonwealthmen ou republicanos que apoiaram a revolução de 1688 na Inglaterra, mas que se opuseram à nova cultura política e à nova “economia de crédito” do reino de Guilherme III na década de 1690. Ao desviarmos nosso olhar do republicanismo enquanto linguagem para situá-lo sob o republicanismo enquanto cultura, bem como modo de ação política, é possível constatar uma porosidade entre direitos naturais e virtude cívica, mas também entre liberdade negativa e liberdade positiva.

Salad and other fresh produce were collected in England from retail and catering businesses during 2020 to 2021 and were tested for Salmonella, Shiga toxin-producing Escherichia coli (STEC), Listeria, Bacillus cereus, and E. coli. Of the 604 samples collected, 57% were from retail settings and 43% were from catering settings; 61% were either salad leaves or salad leaves mixed with other products. Equal numbers of samples were prepacked or loose, and 50% were refrigerated at the time of sampling. Combining results for all microbiological parameters, 84% were interpreted as satisfactory, 12% were interpreted as borderline, and 4% were interpreted as unsatisfactory. One sample (prepacked leaves, cucumber, and tomato from a caterer) was categorized as unacceptable and potentially injurious because of detection of STEC O76; no STEC from human infections in the United Kingdom matched this isolate. No Salmonella enterica was detected, but Listeria monocytogenes was recovered from 11 samples: 1 at 20 CFU/g and the remainder at20 CFU/g. B. cereus was detected at borderline levels (103 to ≤105 CFU/g) in 9% of samples and at an unsatisfactory level (105 CFU/g) in one sample. E. coli was detected in 3% of samples at borderline levels (20 to ≤102 CFU/g) and in 4% at unsatisfactory levels (102 CFU/g). There was a significant association between detection of L. monocytogenes and borderline or unsatisfactory levels of E. coli. There were no specific risk profiles associated with products with the higher levels of B. cereus, STEC, or Listeria, but elevated levels of E. coli were predominantly confined to loose products from the United Kingdom collected from caterers in summer or autumn 2021 and may have resulted from relaxation of COVID-19 restrictions. Among the L. monocytogenes isolates, only one matched those from human cases and was recovered from a prepacked mixed salad from a catering business in 2021. This isolate was the same strain as that responsible for a multicountry outbreak (2015 to 2018) associated with Hungarian-produced frozen sweet corn; no link to the outbreak food chain was established.

To obtain in-depth perspectives from carers concerning their relationships with paediatric epilepsy services with and without an Epilepsy Specialist Nurse (ESN).Semi-structured interviews with 58 carers, 37 from service areas with an ESN, and 21 from areas without an ESN in the North-West of England, were conducted and analysed using Thematic Analysis adopting a realist epistemological position.Four themes relating to different aspects of carers' needs were identified. These were needs for understanding the condition, ongoing condition management support, educational liaison support, and emotional support. The ESNs were able to meet these diverse support needs of families proactively and sensitively, whereas in services without ESNs, carers were left to attempt to fulfil needs across different contexts in an ad hoc manner.Paediatric ESNs provide an essential resource for both CWE, carers and other professionals involved in the care of CWE that helps to mitigate carer burden.

This article explores the theory and utility of a syndemic approach for the study of disease in the past. Syndemic principles are examined alongside other theoretical developments within bioarchaeology. Two case studies are provided to illustrate the efficacy of this approach: Tuberculosis and vitamin D deficiency in 18th and 19th century England, and malaria and helminth infections in Early Medieval England.Public health studies of present syndemics, in addition to published bioarchaeological, clinical and social information relating to the chosen case studies.The data from these two historical examples are revisited within a syndemic framework to draw deeper conclusions about disease clustering and heterogeneity in the past.A syndemic framework can be applied to past contexts using clinical studies of diseases in a modern context and relevant paleopathological, archaeological, and historical data.This approach provides a means for providing a deeper, contextualised understanding ancient diseases, and integrates well with extant theoretical tools in bioarchaeology SIGNIFICANCE: Syndemics provides scholars a deep-time perspective on diseases that still impact modern populations.Many of the variables essential for a truly syndemic approach cannot be obtained from current archaeological, bioarchaeological, or historical methods.More detailed and in-depth analysis of specific disease clusters within the past and the present, which draws on a comprehensive analysis of the social determinants of health.

The French, English, and Spanish wrote poems about the “New World” to represent it as known rather than unknown in the interpoetics of epistemic incorporation—to take the unknown of the Americas between and among these European cultures to make them known in terms of earlier knowledge. This article focuses on prefatory poems (paratext) and the main poem (text), and espe­cially the threshold between these poets, their interpoetics. It also focuses on beginnings as another threshold and moving across and on. To recognize the recognizable, anagnorisis within the known framework—that is what the texts of exploration and encounter, including poetry, tend to do—can involve misrecognition. Examining dedicatory poems, lyric, pageant, and epic, and how the known and the unknown work in the poetics of representation, this article argues that the interpoetics is between poems, between paratext and text, work and world, a mimesis that involves poems begetting other poems and representing reality., Les Français, les Anglais et les Espagnols ont écrit des poèmes sur le « Nouveau Monde » pour le représenter comme connu plutôt qu’inconnu dans l’interpoétique de l’incorporation épistémique – soit prendre l’inconnu des Amériques entre et parmi ces cultures européennes pour les faire con­naître en termes de connaissances antérieures. Cet article se concentre sur les poèmes liminaires (le paratexte) et le poème central (le texte), et plus particulièrement sur le seuil entre ces poètes, leur interpoétique. Il porte également sur les commencements comme un autre seuil et les déplacements à travers ce seuil et au-delà, pour reconnaître le reconnaissable, une sorte d’anagnorisis dans le cadre connu – ce que les textes d’exploration et de rencontre, y compris la poésie, tendent à faire (et ceci peut impliquer une méconnaissance). Cet article examine différents genres poétiques (poèmes dédica­toires, lyriques, épiques et entrées royales) et les relations entre le connu et l’inconnu dans la poétique de la représentation pour montrer que cette interpoétique se situe entre les poèmes, entre le paratexte et le texte, l’oeuvre et le monde – une mimèsis impliquant des poèmes qui engendrent d’autres poèmes et qui représentent la réalité.

Why does Falstaff travel to York via Gloucestershire in Henry the Fourth, part two? And why does Shakespeare interrupt his second tetralogy of history plays to take his most famous comic character to Windsor in the Merry Wives? This article uses Falstaff's tour of England in these two plays to explore an idea of the country founded upon local identities rather than on the overarching appeal of nationhood. Drawing upon chorography and social history, it focusses on the association of people and place and offers a view of England from the ground up rather than through the more imposing structures of political narrative and symbolic form. Publisher PDF

Introduction High-quality research into surgical disease will benefit surgical patients. Whereas nearly one-fifth of National Health Service (NHS) England consultants are surgeons, less than 5% of the government’s health research funding supports surgical research. Methods Using an observational study, we identified surgeons in active research fellowships and on selection panels for the three largest pan-specialty medical funding bodies in the UK. We quantified the proportion of editorial board members that are surgeons, and the proportion of surgical research published over a 1-year period in the New England Journal of Medicine, The Lancet and the British Medical Journal. Results Some 185/1,579 (12%) of research fellowships held by clinicians were awarded to surgeons, with relatively fewer surgeons holding senior fellowships compared with predoctoral fellowships. Across the three research funding bodies, 9/165 (5%) of the clinical panel members were surgeons, whereas for the three pan-specialty journals, 5/84 (6%) of the clinical editorial board members were surgeons. Of the 541 original articles published by the same three journals, only 45 (8%) were classified as surgical. Conclusions We show that surgeons were underrepresented across differing domains of clinical academia. The causes of this are likely multifactorial; there are fewer senior surgeons occupying decision-making positions, fewer role models in senior fellowship positions and surgical training may leave less time to engage in research. We propose further qualitative research within the surgical community, funding bodies and journals to understand the origins of the problem and begin to form evidence-based solutions.

Austrian archival documents, reflecting the views of Austrian diplomats on the direct and indirect developments regarding the Mosul issue, consist of the articles written by three Austrian ambassadors working in Türkiye, the Soviet Union and Switzerland, addressing their foreign ministers. In their writings, these Austrian diplomats not only included the experiences and views on the Mosul issue, but also tried to reveal the connections of England, France, Italy and Russia on the subject. In the first of five different dated articles consisting of thirty-four archival documents, Prime Minister Rauf Bey himself explained why Türkiye took a step back against Britain in the Mosul issue. In other articles, it is stated how Mosul was left to Iraq by England and its contribution to the creation of a wall between Türkiye and Azerbaijan. In addition, the role played by the Americans in Mosul and why Britain cannot risk a war with Türkiye are explained. In addition, the anxiety caused by Russia in securing the Indian land route and its relationship with Mosul are revealed. Subsequently, while France was on the side of England regarding Mosul, its foresight regarding an important problem that Türkiye still has to grapple with is declared. At the same time, it is revealed how Italy tried to gain an advantage by taking sides with England in the Mosul issue and its relation with its expansionist ambitions towards Türkiye. Finally, it is also mentioned how Italy tried to benefit from the Balkan states in this direction and why it had to take a step back against Türkiye.The aim of our research is to reveal the extent to which the information and analyzes of the Austrian diplomats working in three different countries on the Mosul issue, based on the Austrian archival documents, overlap with the facts., Musul meselesi ile ilgili doğrudan ve dolaylı gelişmelere dair Avusturyalı diplomatların görüşlerini yansıtan Avusturya arşiv belgeleri; Türkiye, Sovyetler Birliği ve İsviçre’de görevli üç Avusturya elçisinin kendi dışişleri bakanlarına hitaben kaleme aldıkları yazılardan oluşmaktadır. Söz konusu Avusturyalı diplomatlar yazılarında, sadece Musul meselesine dair yaşananlara ve görüşlerine yer vermekle kalmamış aynı zamanda İngiltere, Fransa, İtalya ve Rusya’nın konuyla ilgili bağlantılarını da ortaya koymaya çalışmıştır. Otuz dört arşiv belgesinden oluşan beş farklı tarihli yazının ilkinde Türkiye’nin Musul meselesinde İngiltere karşısında neden geri adım attığı bizzat Başbakan Rauf Bey tarafında açıklanmıştır. Diğer yazılarda ise Musul’un İngiltere tarafından Irak’a nasıl bırakıldığı ve Türkiye ile Azerbaycan arasında bir duvar oluşturulmasındaki katkısı belirtilmektedir. Ayrıca Musul hususunda Amerikalıların oynadığı rol ve İngiltere’nin Türkiye ile niçin bir savaşı göze alamayacağı izah edilmektedir. Bunun yanı sıra İngiltere açısından Hindistan kara yolunun emniyete alınmasında Rusya’nın yarattığı kaygı ve bunun Musul ile ilişkisi ortaya konulmaktadır. Akabinde de Fransa’nın Musul konusunda İngiltere safında yer alırken Türkiye’nin bugün de boğuşmak zorunda kaldığı önemli bir soruna dair öngörüsü deklere edilmektedir. Aynı zamanda İtalya’nın Musul meselesinde İngiltere’nin yanında yer almakla nasıl bir menfaat sağlamaya çalıştığı ve bunun Türkiye’ye yönelik yayılmacı emelleri ile ilişkisi gözler önüne serilmektedir. Nihayetinde ise İtalya’nın bu doğrultuda Balkan devletlerinden nasıl yararlanmaya çalıştığı ve Türkiye karşısında neden geri adım atmak zorunda kaldığı da dile getirilmektedir.Araştırmamızın amacı, Avusturya arşiv belgelerine dayanarak Musul meselesine dair üç farklı ülkede görevli Avusturyalı diplomatların bilgi ve analizlerinin gerçeklerle ne derece örtüştüğünü ortaya koymaktır.

Closer integration of health and social care is a policy priority in many countries. The Covid-19 pandemic has reinforced the necessity of joining up health and social care systems, especially in care home settings. However, the meaning and perceived importance of integration for residents’ and carers’ experience is unclear and we do not know whether it has changed during the pandemic.Using unique data from on-line care home service reviews, we combined multiple methods. We used Natural Language Processing with supervised machine learning to construct a measure of sentiment for care home residents' and their relatives’ (measured by AFINN score). Difference-in-difference analysis was used to examine whether experiencing integrated care altered these sentiments by comparing changes in sentiment in reviews related to integration (containing specific terms) to those which were not. Finally, we used network analysis on post-estimation results to assess which specific attributes stakeholders focus on most when detailing their most/least positive experiences of health and care integration in care homes, and whether these attributes changed over the pandemic.Reviews containing integration words were more positive than reviews unrelated to integration in the pre-pandemic period (about 2.3 points on the AFINN score) and remained so during the first year of the pandemic. Overall positive sentiment increased during the Covid-19 period (average by +1.1 points), mainly in reviews mentioning integration terms at the beginning of the first (+2.17, p-value 0.175) and second waves (+3.678, p-value 0.027). The role of care home staff was pivotal in both positive and negative reviews, with a shift from aspects related to care in pre-pandemic to information services during the pandemic, signalling their importance in translating integrated needs-based paradigms into policy and practice.

Choosing hypodontia treatment requires young people and parents to consider a large amount of information, identify what is important to them, and make trade-offs between options. This study aimed to examine young people and parents’ preferences for hypodontia treatment using discrete choice experiment (DCE). This was a cross-sectional survey of young people (12–16 y) with hypodontia of any severity, at any stage of treatment, and their parents. Participants were recruited from NHS Hospitals in England and Wales. A bespoke DCE questionnaire was developed to measure preferences for 6 attributes of hypodontia treatment (waiting time, treatment time, problems during treatment, discomfort during treatment, bite, appearance). The questionnaire was completed 1) online by young people and parents, individually or together, and 2) by child–parent dyads under observation. Preferences were analyzed using regression models. In total, 204 participants (122 young people, 56 parents, 26 dyads) completed the online questionnaire and 15 child–parent dyads completed the questionnaire under observation. The most important attribute in hypodontia treatment was improvement in appearance, but significant heterogeneity was found in preferences. Four distinct groups of participants were found: group 1 (39%): severe discomfort and problems were most important; group 2 (31%): most concerned about improvement in appearance of teeth and improvement in bite; group 3 (22%): appearance 3 times more important than any other attribute; and group 4 (9%): preferences difficult to interpret. There was variation in how child–parent dyads approached decision-making, with some negotiating joint preferences, while for others, one individual dominated. Making trade-offs in DCE tasks helped some people think about treatment and identify their preferences. Appearance is an important outcome from hypodontia treatment, but preferences vary and potential risks and functional outcome are also important to some people. There is a notable level of uncertainty in decision-making, which suggests further shared decision support would be valuable.

The recovery of elective waiting lists represents a major challenge and priority for the health services of many countries. In England's National Health Service (NHS), the waiting list has increased by 45% in the two years since the COVID-19 pandemic was declared in March 2020. Long waits associate with worse patient outcomes and can deepen inequalities and lead to additional demands on healthcare resources. Modelling the waiting list can be valuable for both estimating future trajectories and considering alternative capacity allocation strategies. However, there is a deficit within the current literature of scalable solutions that can provide managers and clinicians with hospital and specialty level projections on a routine basis. In this paper, a model representing the key dynamics of the waiting list problem is presented alongside its differential equation based solution. Versatility of the model is demonstrated through its calibration to routine publicly available NHS data. The model has since been used to produce regular monthly projections of the waiting list for every hospital trust and specialty in England.

BackgroundIntensive home visiting for adolescent mothers may help reduce health disparities. Given limited resources, such interventions need to be effectively targeted. We evaluated which mothers were enrolled in the Family Nurse Partnership (FNP), an intensive home-visiting service for first-time young mothers commissioned in >130 local authorities in England since 2007.MethodsWe created a population-based cohort of first-time mothers aged 13–19 years giving birth in English National Health Service hospitals between 1 April 2010 and 31 March 2017, using administrative hospital data linked with FNP programme, educational and social care data. Mothers living in a local authority with an active FNP site were eligible. We described variation in enrolment rates across sites, and identified maternal and FNP site characteristics associated with enrolment.ResultsOf 110 520 eligible mothers, 25 680 (23.2% (95% CI: 23.0% to 23.5%)) were enrolled. Enrolment rates varied substantially across 122 sites (range: 11%–68%), and areas with greater numbers of first-time adolescent mothers achieved lower enrolment rates. Mothers aged 13–15 years were most likely to be enrolled (52%). However, only 26% of adolescent mothers with markers of vulnerability (including living in the most deprived areas and ever having been looked after as a child) were enrolled.ConclusionA substantial proportion of first-time adolescent mothers with vulnerability markers were not enrolled in FNP. Variation in enrolment across sites indicates insufficient commissioning of places that is not proportional to level of need, with mothers in areas with large numbers of other adolescent mothers least likely to receive support.

Randomised controlled trials (RCTs) inform prescription guidelines, but stringent eligibility criteria exclude individuals with vulnerable characteristics, which we define as comorbidities, concomitant medication use, and vulnerabilities due to age. Poor external validity can result in inadequate treatment decision information. Our first aim was to quantify the extent of exclusion of individuals with vulnerable characteristics from RCTs for all prescription drugs. Our second aim was to quantify the prevalence of individuals with vulnerable characteristics from population electronic health records who are actively prescribed such drugs. In tandem, these two aims will allow us to assess the representativeness between RCT and real-world populations and identify vulnerable populations potentially at risk of inadequate treatment decision information. When a vulnerable population is highly excluded from RCTs but has a high prevalence of individuals actively being prescribed the same medication, there is likely to be a gap in treatment decision information. Our third aim was to investigate the use of real-world evidence in contributing towards quantifying missing treatment risk or benefit through an observational study.We extracted RCTs from ClinicalTrials.gov from its inception to April 28, 2021, and primary care records from the Clinical Practice Research Datalink Gold database from Jan 1, 1998, to Dec 31, 2020. We referred to the British National Formulary to classify prescription drugs into drug categories. We conducted descriptive analyses and quantified RCT exclusion and prevalence of individuals with vulnerable characteristics for comparison to identify populations without treatment decision information. Exclusion and prevalence were assessed separately for different age groups, individual clinical specialities, and for quantities of concomitant conditions by clinical specialities, where multimorbidity was defined as having two or more clinical specialties, and medications prescribed, where polypharmacy was defined as having five or more medications prescribed. Population trends of individuals with multimorbidity or polypharmacy were assessed separately by age group. We conducted an observational cohort study to validate the use of real-world evidence in contributing towards quantifying treatment risk or benefit for patients with dementia on anti-dementia drugs with and without a contraindicated clinical speciality. To do so, we identified the clinical specialities that anti-dementia drug RCTs highly excluded yet had corresponding high prevalence in the real-world population, forming the groups with highest risk of having scarce treatment decision information. Cox regression was used to assess if the risk of mortality outcomes differs between both groups.43 895 RCTs from ClinicalTrials.gov and 5 685 738 million individuals from primary care records were used. We considered 989 unique drugs and 286 conditions across 13 drug-category cohorts. For the descriptive analyses, the median RCT exclusion proportion across 13 drug categories was 81·5% (IQR 76·7-85·5) for adolescents (aged18 years), 26·3% (IQR 21·0-29·5) for individuals older than 60 years, 40·5% (IQR 33·7-43·0) for individuals older than 70 years, and 52·9% (IQR 47·1-56·0) for individuals older than 80 years. Multimorbidity had a median exclusion proportion of 91·1% (IQR 88·9-91·8) and median prevalence of 41·0% (IQR 34·9-46·0). Concomitant medication use had a median exclusion proportion of 52·5% (IQR 50·0-53·7) and a median prevalence of 94·3% (IQR 84·3-97·2), and polypharmacy had a median prevalence of 47·7% (IQR 38·0-56·1). Population trends show increasing multimorbidity with age and consistently high polypharmacy across age groups. Populations with cardiovascular or otorhinolaryngological comorbidities had the highest risk of having scarce treatment decision information. For the observational study, populations with cardiovascular or psychiatric comorbidities had highest risk of having scarce treatment decision information. Patients with dementia with an anti-dementia prescription and contraindicated cardiovascular condition had a higher risk of mortality (hazard ratio [HR] 1·20 [95% CI 1·13-1·28 ; p0·0001]) compared with patients with dementia without a contraindicated cardiovascular condition. Patients with dementia with comorbid delirium (HR 1·25 [95% CI 1·06-1·48]; p0·0088), intellectual disability (HR 2·72 [95% CI 1·53-4·81]; p=0·0006), and schizophrenia and schizotypal delusional disorders (HR 1·36 [95% CI 1·02-1·82]; p=0·036) had a higher risk of mortality compared with patients with dementia without these conditions.Overly stringent RCT exclusion criteria do not appropriately account for the heterogeneity of vulnerable characteristics observed in real-world populations. Treatment decision information is scarce for such individuals, which might affect health outcomes. We discuss the challenges facing the inclusivity of such individuals and highlight the strength of real-world evidence as an integrative solution in complementing RCTs and increasing the completeness of evidence-based medicine assessments in evaluating the effectiveness of treatment decisions.Wellcome Trust, National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, Academy of Medical Sciences, and the University College London Overseas Research Scholarship.

Academic health centres (AHCs) are organisations that aim to mobilise knowledge into practice by improving the responsiveness of health systems to emerging evidence. This study aims to explore the population health role of AHCs in Australia and England, where AHCs represent novel organisational forms.A multiple-case study design using qualitative methods was used to explore population health goals and activities in four discrete AHCs in both countries during 2017 and 2018. Data from 85 interviews with AHC leaders, clinicians and researchers, direct observation, and documentation were analysed within and across the cases.Comparison across cases produced four cross-case themes: health care rather than population health; incremental rather than major health system change; different conceptions of "translation" and "innovation"; and unclear pathways to impact. The ability of the AHCs to define and enact a population health role was hindered during the study period by gaps in knowledge mobilisation strategies at a health system and policy level, the biomedical orientation of government designation schemes for AHCs in Australia and England, and competing expectations of the sovereign partner organisations in AHCs against a backdrop of limited operational resources.The study identifies several institutional elements that are likely to be needed for AHCs in Australia and England to deliver on both internal and external expectations of their population health role.

The devolution of public services from central to local government can increase sensitivity to local population needs but might also reduce the expertise and resources available. Little evidence is available on the impact of devolution on population health. We evaluated the effect of devolution affecting health services and wider determinants of health on life expectancy in Greater Manchester, England.We estimated changes in life expectancy in Greater Manchester relative to a control group from the rest of England (excluding London), using a generalised synthetic control method. Using local district-level data collected between Jan 1, 2006 and Dec 31, 2019, we estimated the effect of devolution on the whole population and stratified by sex, district, income deprivation, and baseline life expectancy.After devolution, from November, 2014, life expectancy in Greater Manchester was 0·196 years (95% CI 0·182-0·210) higher than expected when compared with the synthetic control group with similar pre-devolution trends. Life expectancy was protected from the decline observed in comparable areas in the 2 years after devolution and increased in the longer term. Increases in life expectancy were observed in eight of ten local authorities, were larger among men than women (0·338 years [0·315-0·362] for men; 0·057 years [0·040-0·074] for women), and were larger in areas with high income deprivation (0·390 years [0·369-0·412]) and lower life expectancy before devolution (0·291 years [0·271-0·311]).Greater Manchester had better life expectancy than expected after devolution. The benefits of devolution were apparent in the areas with the highest income deprivation and lowest life expectancy, suggesting a narrowing of inequalities. Improvements were likely to be due to a coordinated devolution across sectors, affecting wider determinants of health and the organisation of care services.The Health Foundation and the National Institute for Health and Care Research.

Aim: To identify drug-related death trends associated with synthetic cannabinoid receptor agonists (SCRAs) reported to the National Programme on Substance Abuse Deaths (NPSAD) from England. Design:...

Funder: Obstetric Anaesthetists' Association; Id: http://dx.doi.org/10.13039/501100000667, There is evidence that ethnic inequalities exist in maternity care in the UK, but those specifically in relation to UK obstetric anaesthetic care have not been investigated before. Using routine national maternity data for England (Hospital Episode Statistics Admitted Patient Care) collected between March 2011 and February 2021, we investigated ethnic differences in obstetric anaesthetic care. Anaesthetic care was identified using OPCS classification of interventions and procedures codes. Ethnic groups were coded according to the hospital episode statistics classifications. Multivariable negative binominal regression was used to model the relationship between ethnicity and obstetric anaesthesia (general and neuraxial anaesthesia) by calculating adjusted incidence ratios for the following: differences in maternal age; geographical residence; deprivation; admission year; number of previous deliveries; and comorbidities. Women giving birth vaginally and by caesarean section were considered separately. For women undergoing elective caesarean births, after adjustment for available confounders, general anaesthesia was 58% more common in Caribbean (black or black British) women (adjusted incidence ratio [95%CI] 1.58 [1.26-1.97]) and 35% more common in African (black or black British) women (1.35 [1.19-1.52]). For women who had emergency caesarean births, general anaesthesia was 10% more common in Caribbean (black or black British) women (1.10 [1.00-1.21]) than British (white) women. For women giving birth vaginally (excluding assisted vaginal births), Bangladeshi (Asian or Asian British), Pakistani (Asian or Asian British) and Caribbean (black or black British) women were, respectively, 24% (0.76 [0.74-0.78]), 15% (0.85 [0.84-0.87]) and 8% (0.92 [0.89-0.94]) less likely than British (white) women to receive neuraxial anaesthesia. This observational study cannot determine the causes for these disparities, which may include unaccounted confounders. Our findings merit further research to investigate potentially remediable factors such as inequality of access to appropriate obstetric anaesthetic care.

Background and Hypothesis Children exposed to socioenvironmental adversities (eg, urbanicity, pollution, neighborhood deprivation, crime, and family disadvantage) are more likely to subsequently develop subclinical psychotic experiences during adolescence (eg, hearing voices, paranoia). However, the pathways through which this occurs have not been previously investigated. We hypothesized that cognitive ability and inflammation would partly explain this association. Study Design Data were utilized from the Environmental-Risk Longitudinal Twin Study, a cohort of 2232 children born in 1994–1995 in England and Wales and followed to age 18. Socioenvironmental adversities were measured from birth to age 10 and classified into physical risk (defined by high urbanicity and air pollution) and socioeconomic risk (defined by high neighborhood deprivation, neighborhood disorder, and family disadvantage). Cognitive abilities (overall, crystallized, fluid, and working memory) were assessed at age 12; and inflammatory markers (C-reactive protein, interleukin-6, soluble urokinase plasminogen activator receptor) were measured at age 18 from blood samples. Participants were interviewed at age 18 regarding psychotic experiences. Study Results Higher physical risk and socioeconomic risk were associated with increased odds of psychotic experiences in adolescence. The largest mediation pathways were from socioeconomic risk via overall cognitive ability and crystallized ability, which accounted for ~11% and ~19% of the association with psychotic experiences, respectively. No statistically significant pathways were found via inflammatory markers in exploratory (partially cross-sectional) analyses. Conclusions Cognitive ability, especially crystallized ability, may partly explain the association between childhood socioenvironmental adversity and adolescent psychotic experiences. Interventions to support cognitive development among children living in disadvantaged settings could buffer them against developing subclinical psychotic phenomena.

This best practice guide is written with the aim of providing an overview of current hybrid closed-loop (HCL) systems in use within the United Kingdom's (UK) National Health Service (NHS) and to provide education and advice for their management on both an individual and clinical service level. The environment of diabetes technology, and particularly HCL systems, is rapidly evolving. The past decade has seen unprecedented advances in the development of HCL systems. These systems improve glycaemic outcomes and reduce the burden of treatment for people with type 1 diabetes (pwT1D). It is anticipated that access to these systems will increase in England as a result of updates in National Institute of Health and Care Excellence (NICE) guidance providing broader support for the use of real-time continuous glucose monitoring (CGM) for pwT1D. NICE is currently undertaking multiple-technology appraisal into HCL systems. Based on experience from centres involved in supporting advanced technologies as well as from the recent NHS England HCL pilot, this guide is intended to provide healthcare professionals with UK expert consensus on the best practice for initiation, optimisation and ongoing management of HCL therapy.

Familial British dementia (FBD) and familial Danish dementia (FDD) are autosomal dominant forms of dementia caused by mutations in the integral membrane protein 2B (ITM2B, also known as BRI2) gene. Secretase processing of mutant BRI2 leads to secretion and deposition of BRI2-derived amyloidogenic peptides, ABri and ADan that resemble APP/β-amyloid (Aβ) pathology, which is characteristic of Alzheimer's disease (AD). Amyloid pathology in FBD/FDD manifests itself predominantly in the microvasculature by ABri/ADan containing cerebral amyloid angiopathy (CAA). While ABri and ADan peptide sequences differ only in a few C-terminal amino acids, CAA in FDD is characterized by co-aggregation of ADan with Aβ, while in contrast no Aβ deposition is observed in FBD. The fact that FDD patients display an earlier and more severe disease onset than FBD suggests a potential role of ADan and Aβ co-aggregation that promotes a more rapid disease progression in FDD compared to FBD. It is therefore critical to delineate the chemical signatures of amyloid aggregation in these two vascular dementias. This in turn will increase the knowledge on the pathophysiology of these diseases and the pathogenic role of heterogenous amyloid peptide interactions and deposition, respectively. Herein, we used matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI-MSI) in combination with hyperspectral, confocal microscopy based on luminescent conjugated oligothiophene probes (LCO) to delineate the structural traits and associated amyloid peptide patterns of single CAA in postmortem brain tissue of patients with FBD, FDD as well as sporadic CAA without AD (CAA+) that show pronounced CAA without parenchymal plaques. The results show that CAA in both FBD and FDD consist of N-terminally truncated- and pyroglutamate-modified amyloid peptide species (ADan and ABri), but that ADan peptides in FDD are also extensively C-terminally truncated as compared to ABri in FBD, which contributes to hydrophobicity of ADan species. Further, CAA in FDD showed co-deposition with Aβ x-42 and Aβ x-40 species. CAA+ vessels were structurally more mature than FDD/FBD CAA and contained significant amounts of pyroglutamated Aβ. When compared with FDD, Aβ in CAA+ showed more C-terminal and less N-terminally truncations. In FDD, ADan showed spatial co-localization with Aβ3pE-40 and Aβ3-40 but not with Aβx-42 species. This suggests an increased aggregation propensity of Aβ in FDD that promotes co-aggregation of both Aβ and ADan. Further, CAA maturity appears to be mainly governed by Aβ content based on the significantly higher 500/580 patterns observed in CAA+ than in FDD and FBD, respectively. Together this is the first study of its kind on comprehensive delineation of Bri2 and APP-derived amyloid peptides in single vascular plaques in both FDD/FBD and sporadic CAA that provides new insight in non-AD-related vascular amyloid pathology. Cover Image for this issue: https://doi.org/10.1111/jnc.15424.

The defence or second postmortem examination is instructed by the defence legal team, per defendant, following an initial postmortem examination performed by a Home Office registered forensic pathologist. The obscure origin of this practice has allowed it to proceed as a matter of routine in English and Welsh culture, in stark contrast to international jurisdictions. The Chief Coroner's Guidance (2019) describes a change in perspective from the Home Office Circular 30 (1999) in which a presumed right to request a second postmortem examination is replaced by a process of heavy scrutiny, favouring a paper-based desktop review of the evidence. The reasons for supporting this seismic change in practice are numerous, from the limited evidential value attained to undue distress experienced by the decedent's family. Whilst it remains imperative for accused persons to examine and test the evidence, this can often be objectively and robustly enacted without a second invasive examination. Any paradigm shift takes time, and may be met with resistance, particularly when the culture is established at all levels of the legal system in which it exists. We discuss the reasons why this shift in practice is necessary to best serve both the defendant and the decedent.

Treating patients in psychiatric intensive care units (PICUs) is costly for the English National Health Service (NHS), requiring significant staff time. Oxevision, a non-contact system, providing vision-based patient monitoring and management (VBPMM) has been introduced in some NHS mental health trusts which aims to help clinicians to deliver safer and more efficient care. The objective of this early economic evaluation was to explore the impact of introducing VBPMM with standard care, versus standard care alone on health and economic outcomes in PICUs across England. The model uses a cost calculator approach to evaluate the potential benefits of introducing VBPMM, capturing differences in observation hours and critical events such as assaults. Effectiveness data were primarily based on a 24-month observational before and after study undertaken in an NHS mental health trust using VBPMM. Outcomes reported in this study are incremental costs and reduction in clinical events presented as per occupied bed days, per patient, per average ward, and for the English NHS overall. Scenario analysis was conducted to test the uncertainty of results using statistical significance of key inputs. The analysis indicates that introducing VBPMM may be cost saving compared with standard care alone. The biggest driver of estimated cost savings was from the potential reduction in one to one observation hours, which may have significant impact in PICUs. Limitations of the analysis include the single center data underpinning the analysis and assumptions made about transferability of clinical data to different sized wards. Scenario analysis was conducted, and the results were robust to statistically significant changes in input parameters. This study suggests that introducing VBPMM on PICUs has the potential to reduce costs and improve efficiency of resource allocation, but results should be confirmed with additional clinical study evidence.

Background: This article is part one of a series presenting the findings of stakeholder surveys with ostomates and stoma care nurses for stoma services in England. Due to the volume of data and publication limits this article focuses on the views and experiences of 2504 people living with a stoma (ostomates). Aim: To understand the experience of ostomates in relation to the current services provided in hospital and at home, the delivery of care and views on areas that work well and areas that require improvement. Methods: Ostomates were asked to share their experiences in a national online survey, promoted via multiple organisations. The survey included sections for respondent demographics, interactions with the stoma care nurse (SCN), products and dispensing services, as well as patients' experiences relating to both hospital-based care and home-based care. Free-text responses relating to service delivery in hospital and at home were coded and thematically analysed. Findings: Results are presented, and verbatim quotes used to demonstrate themes. These include care provision and access to visits from the SCN, physical and psychological care, information sharing, specialist knowledge and products. Conclusion: Overall, the survey respondents praised the care given, however, the experiences and views shared via the survey show significant variation in the care and services received. This article presents the findings of a survey of ostomates living in England. A second article, presenting the findings about the experiences of stoma care nurses will be published in a forthcoming issue.

Peer reviewed: True, Funder: National Institute for Health Research (NIHR) Applied Research Collaboration East of England (ARC EoE), OBJECTIVES: In the context of a growing number of dementia friendly communities (DFCs) globally, a need remains for robust evaluation, and for tools to capture relevant evidence. This paper reports the development of a suite of evaluation resources for DFCs through a national study in England. METHODS: Fieldwork took place in six diverse case study sites across England. A mixed methods design was adopted that entailed documentary analysis, focus groups, interviews, observations, and a survey. Participants were people affected by dementia and practice-based stakeholders. A national stakeholder workshop was held to obtain input beyond the research sites. A workshop at the end of the study served to check the resonance of the findings and emerging outputs with stakeholders from the case study DFCs. RESULTS: The study had three key outputs for the evaluation of DFCs: First, an evaluation framework that highlights thematic areas to be considered in evaluating DFCs. Second, a Theory of Change that presents inputs into a DFC and short, medium and longer term outcomes. Third, a matrix for assessing a DFC's degree of maturity, which enables a sense of the kinds of outcomes a DFC might realistically aspire to. These three outputs form a suite of interlinking and complementary evaluation resources for DFCs. CONCLUSIONS: The study has contributed evidence-based resources for monitoring and evaluation that complement existing frameworks. They can be applied to arrive at a detailed assessment of how well a DFC works for people affected by dementia, and at insights into the underlying factors that can guide future policy and practice.

The use of artificial playing surfaces in professional rugby union is growing, but their effect on the injury risk profile remains unclear. The aim of this study was to examine the effect of playing surface on match injury risk in men's professional rugby in England. Six seasons of injury data (2013/14–2018/19) were collected from 15 professional English, men's rugby teams participating in domestic and European competition. The incidence, severity, and burden of match injuries were compared across playing surfaces. The dataset included 3351 injuries from a combined European and domestic data set (separated in to 2 categories; artificial and natural/hybrid surfaces) and 2675 injuries from a domestic only dataset (separated into 3 categories; artificial, hybrid, and natural surfaces). There were no differences in incidence rates between surface types on combined European and domestic match data, but injury burden was significantly greater on artificial (3082 days/1000 h, 95% CI 2847-3337) in comparison with natural/hybrid surfaces (2364 days/1000 h, 95% CI 2277–2454, p < 0.001). These differences were primarily driven by a significantly greater mean severity of hip/groin, and foot/toe injuries on artificial surfaces. This is the largest study to date to examine the relationship between surface type and injury risk in rugby union. The average severity and burden of injuries sustained on artificial surfaces was significantly greater compared with those sustained on hybrid/natural grass surfaces. This study can inform those involved in selection of surface for elite sport, weighing up the positive and negative elements of the varying surface types.

Introduction The COVID-19 pandemic has changed the presentation of many medical and surgical conditions, including major trauma. We aimed to assess how lockdown changed the presentation, severity and management of major trauma patients at our level 1 trauma centre in England. Methods Data were collected retrospectively from the Trauma Audit and Research Network’s database between 23 March and 28 April 2020 and compared with the same period in 2019. Collected data included patient demographics, and the mechanism, severity and management of injuries. Results We experienced a 56.4% reduction in major trauma admissions during the lockdown period when compared with 2019. In 2020, more patients arrived in haemodynamic shock (25.3% vs 12.2%, p=0.02); however, Glasgow Coma Scale and Injury Severity Score were unchanged. A higher proportion of incidents occurred at home (37.2% vs 53.5%, p=0.018), with no difference in trauma secondary to substance abuse or assault. During lockdown, patients had a significantly shorter hospital (17 vs 10 days, p=0.029) and critical care stay (2 vs 1 day, p=0.033). A higher proportion of major trauma patients were assessed by specialty trainees in the emergency department in 2020 (12.8% vs 53.1%, p=0.0001) with a lower proportion assessed by a consultant (69.8% vs 46.7%, p=0.001). Conclusions The COVID-19 pandemic and lockdown drastically changed human behaviour, as reflected in the change in presentation of major trauma. Changes in the management of these patients reflect adaptive measures to manage the pressures generated by the worldwide pandemic.

The abolition of Public Health England (PHE) during the COVID-19 pandemic has raised concerns about the future of the public health system in the UK, particularly in England. The two new bodies established in haste to replace PHE prompt reflection on the executive agency's fate and the need to identify any lessons to ensure that a public health system is put in place that is fit for purpose. The UK COVID-19 Inquiry provides an opportunity to make recommendations, but it will need to act quickly to avoid recommendations being ignored. Two areas of concern are highlighted in this Viewpoint: the respective remits of the new bodies and their governance arrangements. Both issues demand urgent attention if the new structures are to succeed and avoid a similar fate to that which befell PHE. But underlying these concerns is a much larger challenge arising from the UK's broken political system. The political system in the UK suffers from several systemic weaknesses, including departmentalism, poor implementation, an inability or unwillingness of those in power to listen to the truth, and chronic short-termism at the expense of long-term planning. Overhauling the UK's dysfunctional political system is a prerequisite for successfully improving the public health system.

This research introduces 'The Bioarchaeology of Disability' (BoD), a population-scale approach which allows for a comprehensive understanding of physical impairment and disability in past communities through a combination of palaeopathological, funerary, and documentary analyses.The BoD consists of three phases: 1) Contextualisation includes period-specific literature review; 2) Data collection consists of palaeopathological re-analysis of all individuals with physical impairment and collation of mortuary treatment data; and 3) Analysis integrates the gathered data, literature review, and theoretical frameworks to explore contemporary perceptions of disability.The BoD is demonstrated through an investigation of physical impairment and disability in later Anglo-Saxon England (c.8th-11th centuries AD) which includes four burial populations (NIndividuals with physical impairment could be buried with normative or non-normative treatment (e.g., stone/clay inclusions, non-normative body positioning), and in marginal, non-marginal, and central locations.The overall funerary variation for individuals with physical impairment was relatively slight, which may suggest that religious factors were influencing normative funerary treatment of impaired and potentially disabled individuals. The funerary variability that was observed for individuals with physical impairment was probably influenced by individual and community-specific beliefs.This research describes a population-scale approach to archaeological disability studies that can be replicated in other archaeological contexts.Individuals with non-skeletal physical impairment (e.g., soft tissue, mental) are not considered by the BoD.The BoD should be applied to different archaeological communities around the world to better understand disability and physical impairment in the past.

Although seemingly benign, the presence of a patent foramen ovale (PFO) may play an important role in the pathophysiology of disease, specifically a paradoxical embolism leading to cryptogenic stroke. The European Society of Cardiology recently published guidelines detailing how PFOs are associated with paradoxical embolism and how they are diagnosed and managed. This review guides physicians in the diagnostic and referral process to a multidisciplinary team involved in PFO closure. It reviews the clinical trials comparing device closure with medical therapy and highlights the current NHS England commissioning process on PFO management. Finally, we give an overview of other conditions where PFO device closure may need to be considered.

The increasing prevalence of malignant disease has been associated with shifts in environmental, socioeconomic, and lifestyle risk factors as well as increased adult lifespan. We examine the relationship between malignant neoplasms affecting bone, age and industrialization.Pre-existing skeletal data from 11 medieval (1066-1547, n = 8973) and 14 industrial (1700-1890, n = 4748) cemeteries (N = 13,721) from England.Context number, sex, age-at-death, evidence of skeletal malignancy, and diagnosis were collated. The data were compared using chi square, Kolmogorov-Smirnov tests and logistic regression (α = 0.01).There was a statistically significant increase in skeletal malignancy from 0.06 % in the medieval sample to 0.36 in the industrial sample (p 0.001). Age had a strong relationship with malignancy (p = 0.003), sex did not (p = 0.464). Logistic regression revealed that time-period (p 0.001) was a stronger predictor of skeletal malignancy than age-at-death (p = 0.002).Our results confirm that even with the temporal increase in adult human lifespan the increase of malignant neoplasms of bone between the medieval and industrial time periods is still statistically significant.The augmented exposure to carcinogens and pollution during the Industrial Revolution had a strong effect on an individual's susceptibility to developing malignant disease of bone.This meta-analysis relies upon previously gathered data and diagnosis from a large number of researchers and did not include radiographic or CT screening. Only malignant neoplasms that affected bone could be included.Increasing excavation and analysis of post-medieval cemeteries will provide more data. Multimethod approaches (radiography, CT, Micro-CT and histology) are encouraged.

Neste artigo iremos analisar os caminhos da educação escolar indígena (EEI) em três países colonizados pela Inglaterra. Objetiva-se usar a EEI como pano de fundo para analisarmos as discrepâncias na condução da educação escolar, contando eventos históricos marcantes para a EEI. Foi realizado um estudo bibliográfico sobre a EEI nos países Estados Unidos da América; Austrália e Nova Zelândia e criada uma cronologia dos marcos temporais. O enfrentamento do apartheid e do racismo provocou atrasos na condução da EEI e o protagonismo dos nativos na condução da EEI., En este artículo analizaremos los camiños de la educación escolar indígena (EEI) en tres países colonizados por Inglaterra. Tuvo como objetivo utilizar la EEI como antecedente para analizar las discrepancias en la conducta de la educación escolar, relatando hechos históricos importantes para la EEI. Se realizó un estudio bibliográfico sobre la EEI en los países de estudio y se elaboró una cronología de tiempos. El enfrentamiento al apartheid y al racismo provocó retrasos en la gestión de la EEI y el protagonismo de los indígenas en la gestión de la EEI., In this article we will analyze the paths of indigenous school education (ISE) in three countries colonized by England. It aimed to use the ISE as a background to analyze the discrepancies in the conduct of school education, telling important historical events for the ISE. A bibliographic study was carried out on the ISE in the United States of America; Australia and New Zealand and a chronology of time milestones created. The confrontation of apartheid and racism caused delays in the conduction of the ISE and the protagonism of the natives in the conduction of the ISE.

Despite use of 23-valent pneumococcal polysaccharide vaccine (PPV23) in England, disease burden among at-risk adults remains high. We evaluated the public health and budgetary impact of 20-valent pneumococcal conjugate vaccine (PCV20) compared to the current adult pneumococcal vaccination program.Five-year outcomes and costs of invasive pneumococcal disease (IPD) and community-acquired pneumonia (CAP) among adults aged 65-99 years and adults aged 18-64 years with underlying conditions in England were projected using a deterministic cohort model. Hypothetical vaccination with PCV20 versus PPV23 was compared from the National Health Service (NHS) perspective.Replacing PPV23 with PCV20 would prevent 785 IPD hospitalizations, 11,751 CAP hospitalizations, and 1,414 deaths over 5 years, and would reduce medical care costs by £48.5 M. With vaccination costs higher by £107.2 M, projected net budgetary impact is £58.7 M. The budgetary impact would be greatest in year 1 (£26.3 M), and would decrease over time (to £1.6 M by year 5). The average budget increase (£11.7 M/year) represents0.01% of the Department of Health and Social Care total budget and3% of the vaccine budget.Use of PCV20 among adults currently eligible for PPV23 in England would substantially reduce the burden of pneumococcal disease, with modest budgetary impact.

3D printing has rapidly developed and been applied in forensic science due to its use in creating demonstrations for courts of law. Much of the literature on this specific topic has focused on the use of 3D printed models in academia, the potential influence on a jury, and its use as a long-term documentation process, but with few actual forensic case examples. This paper offers an insight into the development of 3D printing in forensic practice and how 3D printing is currently being used in the criminal justice system in England and Wales.A series of case reports were gathered from multiple police forces and forensic practitioners in the UK to identify how 3D printing was being used. These discussions established who was requesting 3D printed exhibits, what type of technologies were being utilised, what type of exhibits were being printed, and resulting feedback for the use of 3D printed material within a criminal case. As a result, this research demonstrates the current use of 3D printing in England and Wales, discussing the associated cases that have been known to incorporate 3D prints. Likewise, this work explores the limitations that have been encountered by forensic practitioners and identifies a series of research questions that should be considered in future investigations.

Meeting goals for ‘net zero’ emissions may require the removal of previously emitted carbon dioxide from the atmosphere. One proposal, enhanced rock weathering, aims to speed up the weathering processes of rocks by crushing them finely and spreading them on agricultural land. Public perceptions of enhanced rock weathering and its wider social and environmental implications will be a critical factor determining its potential; we use six 2-day deliberative workshops in England, Wales and Illinois to understand public views. Consideration of enhanced rock weathering deployment in tropical countries led participants to frame it from a social justice perspective, which had been much less prevalent when considering Western agricultural contexts, and generated assumptions of increased scale, which heightened concerns about detrimental social and environmental impacts. Risk perceptions relating to ‘messing with nature’ became amplified when participants considered enhanced rock weathering in relation to ‘iconic’ environments such as the oceans and rainforest.

Background Emollients are a mainstay of treatment for dry skin conditions. In the UK, prescribers are usually expected to follow local National Health Service (NHS) formularies. A previous study in 2018 showed that the recommended emollients across England and Wales varied widely. Evidence has since emerged that bath additives provide no additional clinical benefit in eczema. Aim To compare emollient formularies and guidelines in England. Methods Clinical Commissioning Group (CCG) formularies and guidelines were identified in April–May 2021, compiled and then analysed descriptively. Results In total, 105 CCGs, 72 emollient formularies and 47 emollient prescribing guidelines were identified. There were internal inconsistencies between formularies and their accompanying guidelines in 19% of cases. The majority (68%) of formularies/guidelines were organized using a ranking system. In total, 126 different leave-on emollients were named. Creams and ointments were universally available and were the most recommended first-line types. Cost was more likely than patient choice to be recommended as a criterion for selecting which emollient to prescribe. Aqueous cream was the leave-on emollient most commonly not recommended. Nearly three-quarters (74%) of formularies stated that bath additives should not be prescribed. Conclusion All CCGs in England have an emollient formulary/guideline, but there is still great variability between them in their recommendations. Although the number of formularies/guidelines has reduced since 2017, there has been an increase in the total number of unique recommended leave-on emollients. Most CCGs are no longer recommending bath emollients for eczema.

Background: Older people are at the greatest risk of poor outcomes after serious injury. Evidence is limited for the benefit of assessment by a geriatrician in trauma care. We aimed to determine the effect of geriatrician assessment on clinical outcomes for older people admitted to hospital with serious injury. Methods: In this multicentre observational study (FiTR 2), we extracted prospectively collected data on older people (aged ≥65 years) admitted to the 23 major trauma centres in England over a 2·5 year period from the Trauma Audit and Research Network (TARN) database. We examined the effect of a geriatrician assessment within 72 h of admission on the primary outcome of inpatient mortality in older people admitted to hospital with serious injury, with patients censored at discharge. We analysed data using a multi-level Cox regression model and estimated adjusted hazard ratios (aHRs). Findings: Between March 31, 2019, and Oct 31, 2021, 193 156 patients had records held by TARN, of whom 35 490 were included in these analyses. Median age was 81·4 years (IQR 74·1–87·6), 19 468 (54·9%) were female, and 16 022 (45·1%) were male. 28 208 (79·5%) patients had experienced a fall from less than 2 m. 16 504 (46·5%) people received a geriatrician assessment. 4419 (12·5%) patients died during hospital stay, with a median time from admission to death of 6 days (IQR 2–14). Of those who died, 1660 (37·6%) had received a geriatrician assessment and 2759 (62·4%) had not (aHR 0·43 [95% CI 0·40–0·46]; p

Background The governance for introducing innovative surgical procedures/devices differs from the research requirements needed for new drugs. New invasive procedures/devices may be offered to patients outside of research protocols with local organization oversight alone. Such institutional arrangements exist in many countries and written policies provide guidance for their use, but little is known about their scope or standards. Methods One hundred and fifty acute NHS trusts in England and seven health boards in Wales were systematically approached for information about their policies. A modified framework approach was used to analyse when policies considered new procedures/devices to be within local organization remit and/or requiring research ethics committee (REC) approval. Results Of 113 policies obtained, 109 and 34 described when local organization and REC approval was required, respectively. Procedures/devices being used for the first time in the organization (n = 69) or by a clinician (n = 67) were commonly within local remit, and only 36 stated that evidence was required. Others stated limited evidence as a rationale for needing REC approval (n = 13). External guidance categorizing procedures as ‘research only’ was the most common reason for gaining REC approval (n = 15). Procedures/devices with uncertain outcomes (n = 28), requiring additional training (n = 26), and not previously used (n = 6) were within the remit of policies, while others recommended REC application in these situations (n = 5, 2 and 7, respectively). Conclusion This study on NHS policies for surgical innovation shows variability in the introduction of procedures/devices in terms of local oversight and/or need for REC approval. Current NHS standards allow untested innovations to occur without the safety of research oversight and thus a standard approach is urgently needed.

Background This study assessed the impact of the first COVID-19 wave in England on outcomes for acute appendicitis, gallstone disease, intestinal obstruction, diverticular disease, and abdominal wall hernia. Methods Emergency surgical admissions for patients aged 18 years and older to 124 NHS Trust hospitals between January and June in 2019 and 2020 were extracted from Hospital Episode Statistics. The risk of 90-day mortality after admission during weeks 11–19 in 2020 (national lockdown) and 2019 (pre-COVID-19) was estimated using multilevel logistic regression with case-mix adjustment. The primary outcome was all-cause mortality at 90 days. Results There were 12 231 emergency admissions and 564 deaths within 90 days during weeks 11–19 in 2020, compared with 18 428 admissions and 542 deaths in the same interval in 2019. Overall, 90-day mortality was higher in 2020 versus 2019, with an adjusted OR of 1.95 (95 per cent c.i. 0.78 to 4.89) for appendicitis, 2.66 (1.81 to 3.92) for gallstone disease, 1.99 (1.44 to 2.74) for diverticular disease, 1.70 (1.13 to 2.55) for hernia, and 1.22 (1.01 to 1.47) for intestinal obstruction. After emergency surgery, 90-day mortality was higher in 2020 versus 2019 for gallstone disease (OR 3.37, 1.26 to 9.02), diverticular disease (OR 2.35, 1.16 to 4.73), and hernia (OR 2.34, 1.23 to 4.45). For intestinal obstruction, the corresponding OR was 0.91 (0.59 to 1.41). For admissions not leading to emergency surgery, mortality was higher in 2020 versus 2019 for gallstone disease (OR 2.55, 1.67 to 3.88), diverticular disease (1.90, 1.32 to 2.73), and intestinal obstruction (OR 1.30, 1.06 to 1.60). Conclusion Emergency admission was reduced during the first lockdown in England and this was associated with higher 90-day mortality.

The National Health Service was established in the United Kingdom in 1948 as a universal, comprehensive service free at the point of delivery, which is publicly provided, funded, and accountable. Market incrementalism in England has eroded this system over three decades. The recently enacted Health and Care Act will erode it further. This article first explains briefly how legislation and policy initiatives in 1990, 2003, and 2012 furthered development of the market and private provision of health services, and then describes the main structural changes in the new Act and their implications. England is now moving decisively toward a marketized, two-tier, mixed-funding system with several similarities to the United States.

Never a monarch nor head of state, Queen Caroline of Ansbach (1683-1737) is among the legendary women rulers of England and Great Britain alongside Queens Elizabeth I and II, Queen Victoria, and Lady Margaret Thatcher. As queen consort, she was the acknowledged power behind the throne of her husband, King George II (1683-1760), working with Robert Walpole, the first Prime Minister of England. George accepted her intellectual superiority and backstage dominance even before he acceded to the throne in 1727. “[He had] no pretensions toward intellect and [was] basically interested in little more than military glory, political power, and a wife who would do her duty by providing him with male heirs,” wrote popular historian John Van de Kiste. After they were wed in 1705, Caroline carried out her task with a remarkable fecundity: a male heir, Frederick Louis, in 1707, followed by Anne (1709), Amelia (1711), Caroline (1713), George William (1717), William (1721), Mary (1723), and Louise (1724). With good reason she believed that her influence over George came from his sexual attraction to her. It was a conceit that proved to be her undoing as she strove to hide from common knowledge an unsightly umbilical hernia. The rupture caused her death in 1737 at age 54. It strangulated, perforated, and spilled feculent succus entericus and fetid fluid onto the royal bed, a vivid example of the consequences of an untreated surgical condition.

ObjectiveThis study assessed the transfer of patients from paediatric cardiac to adult congenital heart disease (ACHD) services in England and the factors impacting on this process.MethodsThis retrospective cohort study used a population-based linked data set (LAUNCHES QI data set: ‘Linking Audit and National datasets in Congenital Heart Services for Quality Improvement’) including all patients born between 1987 and 2000, recorded as having a congenital heart disease (CHD) procedure in childhood. Hospital Episode Statistics data identified transfer from paediatric to ACHD services between the ages of 16 and 22 years.ResultsOverall, 63.8% of a cohort of 10 298 patients transferred by their 22nd birthday. The estimated probability of transfer by age 22 was 96.5% (95% CI 95.3 to 97.7), 86.7% (95% CI 85.6 to 87.9) and 41.0% (95% CI 39.4 to 42.6) for severe, moderate and mild CHD, respectively. 166 patients (1.6%) died between 16 and 22 years; 42 of these (0.4%) died after age 16 but prior to transfer. Multivariable ORs in the moderate and severe CHD groups up to age 20 showed significantly lower likelihood of transfer among female patients (0.87, 95% CI 0.78 to 0.97), those with missing ethnicity data (0.31, 95% CI 0.18 to 0.52), those from deprived areas (0.84, 95% CI 0.72 to 0.98) and those with moderate (compared with severe) CHD (0.30, 95% CI 0.26 to 0.35). The odds of transfer were lower for the horizontal compared with the vertical care model (0.44, 95% CI 0.27 to 0.72). Patients who did not transfer had a lower probability of a further National Congenital Heart Disease Audit procedure between ages 20 and 30 compared with those who did transfer: 12.3% (95% CI 5.1 to 19.6) vs 32.5% (95% CI 28.7 to 36.3).ConclusionsMajority of patients with moderate or severe CHD in England transfer to adult services. Patients who do not transfer undergo fewer elective CHD procedures over the following decade.

Objectives. To examine the impact of US restrictions implemented in February 2020 prohibiting flavors other than menthol and tobacco in cartridge-based e-cigarettes. Methods. We analyzed 5 cross-sectional waves of the International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Surveys, conducted online with youths aged 16 to 19 years in the United States, Canada, and England, for differences in usual e-cigarette flavor, device, and brand reported by past-30-day vapers (n = 9512) before (2017, 2018, 2019), during (February 2020), and after (August 2020) implementation of US flavor restrictions. Results. In August 2020, 78.7% of vapers in the United States reported using a flavor prohibited in cartridges or pods, versus 86.3% in Canada (adjusted odds ratio [AOR] = 1.73; 95% CI = 1.25, 1.40) and 79.8% in England (AOR = 1.10; 95% CI = 0.78, 1.55). Disposable e-cigarettes (exempt from flavor restrictions) increased to a greater extent among vapers in the United States (13.2% to 36.8%) versus Canada (7.7% to 14.2%; AOR = 2.01; 95% CI = 1.33, 3.04) and England (10.8% to 16.4%; AOR = 2.33; 95% CI = 1.52, 3.57). Puff Bar (disposable) emerged as the most popular brand in the United States. Conclusions. Usual flavors used by youth vapers in the United States were unchanged after 2020 restrictions on cartridge-based e-cigarettes. Youths used brands and devices exempt from the restrictions. (Am J Public Health. 2022;112(7):1014–1024. https://doi.org/10.2105/AJPH.2022.306780 )