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BackgroundGenetic testing for BRCA1 and BRCA2 pathogenic variants (PVs) has been available in North West England since 1995. We assessed uptake of pre-symptomatic testing in 1564 families with PVs over a 24.5year follow-up (FU) period.MethodsFirst-degree relatives (FDRs) in families with BRCA1 or BRCA2 PVs were eligible from date of index family report if unaffected by a relevant cancer and alive at report date. FDRs were censored as not having undergone a pre-symptomatic test at diagnosis of a relevant cancer, date of death, age 93 or 30/03/2019. Time to uptake of pre-symptomatic testing was assessed by Kaplan–Meier curves, by gender and children.Results2554 male and 3115 female FDRs were eligible. Overall uptake was 775 (30.3%) in men and 1935 (62.1%) in women. This increased at 15 years to 33.6% and 67.9%, and continued to rise until 24 years (p80% by 15 years. Uptake was higher in parous women (pConclusionUptake of BRCA1/2 pre-symptomatic testing is age, gender and time-dependent, and higher in women with children and men with daughters.

The Nightingale hospital in Manchester is open and ready to admit patients from across the north west of England. But, in a surprising twist, it is only admitting patients who do not have covid-19. The facility, based at the Manchester Central Convention Complex (formerly known as G-MEX), is the first of the Nightingale hospitals to reopen to help take pressure off local hospitals. Sunderland and Harrogate are expected to be next, and all the others are on standby. A spokesperson for the NHS in the north west confirmed that the NHS Nightingale Hospital North West was open, expecting its first patients …

IntroductionMany clinical education programmes have not incorporated the use of the electronic health record (EHR) into their curriculum. It is important to incorporate technologies that will be used in real-world settings to better prepare students for clinical practice.ObjectivesTo undertake a review of literature to identify a training evaluation framework; to conduct a self-completion survey, pretraining and post-training, to determine students’ perceptions on the benefit of using EHR training system.SettingNursing School, University, North West England, UK; University Ethic Committee Approval Received.ParticipantsRegistered nurses undertaking a validated return to practice course; 24 participants for the first cohort who completed pretraining questionnaire and 23 for the second post-training cohort.ResultsThe statistical results show that the students perceived that the training improved their capability in employing digital systems with statistically significant difference in the assessed preproficiency and post proficiency in the use of digital clinical systems (premedians and post medians are 2 and 5 on 10-point Likert scale, p=0.041). There was also an indication of an improvement in the knowledge of EHR systems although not statistically significant. Most students perceived it increased their knowledge on digital systems.ConclusionStudents perceived an increase in proficiency with the EHR. There was evidence of improvement in confidence in the use of the EHR, but this confidence would be enhanced by additional use of the system. Some desire to increase confidence further and to develop knowledge of digital systems was expressed.

Almost all areas of England that have been under covid-19 lockdown restrictions for two months have seen an increase in infection rates despite the measures, an analysis by the Labour Party has shown. Currently, 20 areas in England are under restrictions, which were announced from 29 June to mid-September. Many of these are in the north west of England. But Labour’s analysis shows that 19 of these areas have seen infection rates increase since the restrictions were announced (see table). Examples …

Deaths from covid-19 in England and Wales dipped to their lowest in 20 weeks in the first week of August, latest figures from the Office of National Statistics (ONS) show. Of the deaths registered, 152 (1.7%) mentioned covid-19—down from 193 the previous week.1 Wales and the north west of England were the only regions where deaths were increasing. All other areas of England saw a reduction in fatalities. The latest findings from the monthly covid-19 infection survey conducted in England show that between 26 April and 2 August only 28% of 165 people who tested positive for SARS-CoV-2 or virus antibodies reported symptoms around the time of their test.2 James Naismith, of the Rosalind Franklin Institute at the University of Oxford, said, “While this is good news, since for the vast majority covid-19 …

IntroductionColorectal cancer (CRC) is one of the most prevalent cancers among Iranian people. The study of spatio-temporal distribution of disease has an important role in the design of disease prevention programmes. The purpose of the current study was to describe the spatio-temporal distribution of CRC in the Iranian military community as a sample of the Iranian population.MethodsIn the current ecological study, all registered cancer cases in the Iranian military community during the period 2007–2016 were considered. To identify hotspots, Getis-Ord Gi statistics were used. All analyses were performed using ArcGIS 10.5 and Excel 2010.ResultsThe highest incidences of CRC in 2007–2008, 2009–2010 and 2011–2012 were recorded in Kermanshah province. The highest incidences of CRC in 2013–2014 were seen in Kermanshah, Ghilan, Tehran and North Khorasan. In 2007–2008 and 2009–2010, hotspots were detected in West Azarbayjan. In 2011–2012, hotspots were detected in Zanjan and Qazvin. In 2013–2014, a hotspot was detected in Qazvin. Finally, West Azerbaijan was the hotspot for CRC in 2015–2016.ConclusionsThe incidence of CRC in men was higher than in women. Also it appeared that North and North West Iran were risk areas for this disease, and so these areas should be considered in the design of disease prevention programme for this cancer type. Additionally, the determination of individual risk factors in the aforementioned geographical areas can play an important role in the prevention of this type of cancer.

Northern Syria is experiencing its most severe wave of covid-19, with facilities running out of tests, oxygen, and ventilators, Medecins Sans Frontieres (MSF) has warned.1 Only 16 out of 33 covid-19 treatment centres in the north west of the country are currently functioning, while the number of confirmed cases has nearly doubled from 39 000 in August to 73 000 in September. However, MSF has said it’s impossible to assess the real extent of the spread because of …

Maria Helena Gilleece was a distinguished and talented student, attaining scholarships, winning the Henry Cohen and W.F Jones year prizes in medicine and general practice, and intercalating with a BSc honours in biochemistry. She was a keen member of the renowned Liverpool Medical Students Society and, in her capacity as its secretary, edited their long running publication “Sphincter.” A keen interest in haematology was apparent from an early stage and on completing general medical training, Maria took a post as a haematology registrar at the Royal Liverpool Hospital in 1989. She moved on to Manchester’s Paterson Research Institute (now the CRUK-MI) for four years, firstly as the Joseph Starkey research fellow and then as a Leukaemia Research Fund clinical fellow. She then remained in the north west as a senior registrar, completing her specialty training and submitting her MD thesis. In 1997, she left British shores to take up a two year Kay Kendall Leukaemia Fund fellowship …

People with suspected covid-19 in London are being tested in their homes as part of a pilot that was developed by doctors to stop unnecessary ambulance use and hospital visits. The community testing scheme started at the end of January at North West London NHS Trust and has now been implemented in three other trusts: University College London Hospital, St George’s University Hospital, and Guys and St Thomas’. More than 130 patients have been tested in two weeks. The home testing initiative was started by Laurence John from the infectious diseases department at Northwick Park Hospital. He told The BMJ that the need for community testing became clear after 25 London ambulances had to be taken out of service in one afternoon to be decontaminated after carrying potential cases …

Lolita Mei Wan Chan was born in Leeds, the youngest and brightest of two siblings, to proud parents Chi Ming and Yuk Lin. She was among the first in our family to go to university and was a mathematician before studying medicine at St Andrews University and the University of Manchester. Lolita started as an academic foundation doctor and continued as academic clinical fellow in the north west of England. She undertook her medical training in gastroenterology before entering general practice. Lolita had a passion for medical education and was a visiting lecturer at the University …

Covid-19 vaccination centres are working at 30% capacity because many young adults think they are “invincible” and don’t need the vaccine to protect themselves, a healthcare leader in London has said. After an initial rush when vaccination slots were first opened up to younger age groups, likened to a sale for Glastonbury tickets,1 interest has waned. “We’ve had the challenge of having people and not vaccine; we’ve now got the flip of that, where we’ve got absolutely lots of vaccine and we don’t have the people coming forward,” Pippa Nightingale, chief nursing officer at Chelsea and Westminster NHS Foundation Trust, told a meeting of NHS North West London’s joint health overview and scrutiny committee on 14 July. She said activity had “plummeted” this week. “Our vaccination centres are only really operating to about 30% of their …

Governments in south western Canada and the north west corner of the US are now counting the dead and considering the region’s ability to respond to extreme temperatures after an unprecedented heat wave in late June. The weather in this part of the world is usually temperate. Warnings of a massive “heat dome”1 started a few days before the thermometers began to rise on 27 June. Meteorologists predicted temperatures near 38°C in Seattle, Washington, and 43°C in Portland, Oregon. Many areas began setting up wading pools, spray parks, and cooling centres. The heat dome, which lasted five days, turned out to be worse than expected. Seattle hit a record high of 42°C and Portland reported temperatures of 47°C. In British Columbia, temperatures …

Biography Sujala Kalipershad is a surgical ST8 with an interest in healthcare leadership. She is currently undertaking her dissertation module of the Elizabeth Garrett Anderson Programme (Leadership Academy), culminating in a masters from University of Birmingham and University of Manchester. She was a medical leadership fellow (HEE NW), co-chair and specialty lead for surgery in the Junior Doctors Leaders Group (North Manchester General Hospital). She is a British Medical Association (BMA) NW JDC representative to the North West Regional Consultants Committee and visiting member of the BMA Committee of Medical Managers (CMM). ### Biography Dr Rosalind Ranson is the Medical Director of the Isle of Man Department of Health and Social Care, where they have eliminated SARS-CoV-2 virus. Her vast experience includes 26 years as a general practitioner, 9 years as a council member of the General Medical Council, 5 years as a commissioner on the Commission on Human Medicines and 2 years as a national professional advisor to Care Quality Commission. The challenges of obtaining good, consistent care for her father-in-law, following his devastating stroke in 2011, brought a realisation that greater influence arises from strong medical leadership. In 2012, she commenced her ‘Medical Director’ career, was subsequently awarded a Faculty of Medical Leadership and Management Senior Fellowship in 2019 and is a member of the BMA CMM. ![Graphic][1] Medical leadership can be a powerful tool. It centres around the team and the strategy. Be truly accustomed with your sphere of influence and actively listen to others. We are all members of multiple teams. The medical leader needs to always consider whether the correct teams are in place for a well-governed system, capable of delivering the strategy. The leader and each team member is equally important, but collectively, the whole really is greater than the sum of its constituent parts. The key to … [1]: /embed/inline-graphic-1.gif

Thousands of young people with drug and alcohol problems are missing out on specialist help because of £26m (€30m; $36m) (37%) worth of cuts to youth addiction services in England in real terms between 2013-14 and 2019-20, psychiatrists have warned. An analysis by the Royal College of Psychiatrists found that eight of the nine regions in England made real terms cuts, with services in the north west (£9.3m), the west Midlands (£7.6m), and London (£4.6m) hit hardest. The number of young people accessing treatment in England has …

Nicola Jean Campbell was born in Salford. Her parents, Mary and Joe Campbell, were very proud when she went to the University of Liverpool to study medicine as she had wanted to be a doctor from an early age. She started her anaesthesia career in 1996 at the Countess of Chester Hospital, where she certainly made her mark with her future consultant colleagues. Nicola completed the rest of her anaesthetic training in the North West Deanery, during which she undertook a year long obstetric anaesthesia fellowship in Ottawa, Canada, in …

Public Health England (PHE) was formed in April 2013; at that time, regional congenital anomaly registers covered just 49% of births in England.1 A national congenital anomaly surveillance system managed by the Office for National Statistics did exist in the past but was closed in 2010 following concerns about the quality and completeness of the data.2 A number of geographical regions, including London, the South East, the North West and the East of England, had no coverage. All the registers belonged to the British Isles Network of Congenital Anomaly Registers (BINOCAR) and most were members of the European Surveillance of Congenital Anomalies (EUROCAT). BINOCAR went some way towards standardising the ways in which data were coded and reported, but cases were sometimes lost to regions with no reporting mechanism, comparisons between regions collecting data were not always easy, and the usefulness of data was sometimes limited by the incomplete picture in England. Funding for the individual registers was precarious, each register invested in its own separate data management system, and data collection was largely a paper-based manual system that was administratively dense. High-quality data and the information derived from it is central to any healthcare system; it underpins high-quality patient care, research, commissioning decisions, public health and much more. Collecting data on common diseases is challenging; on rare diseases data are scarce and often fragmented. There are between 6000 and 8000 rare diseases worldwide; 75% affect children, and 30% of patients with rare disease die before the age of 5.3 Most congenital anomalies are rare, and EUROCAT estimates that 12%–15% of the estimated total persons affected by rare diseases in Europe have congenital anomalies.4 Patients have complex care pathways, present through a wide variety of routes and through many different providers.5 At a technical level the …

IntroductionPressures on the National Health Service require improvement in quality of care on a reducing budget. Acute trusts spend £6 billion on procurement, an area highlighted in the Carter Report with the potential for up to £2 billion in efficiency savings. Meanwhile, cost awareness of products among clinicians is poor.Case studyA survey of 20 ENT (ear, nose and throat) theatre doctors and nurses was carried out in a North West district general hospital to gauge the level of cost awareness in 2011. This was followed by a 2-month period of price labelling of selected products. A follow-up survey in 2017 looked at any sustained effect of awareness.ResultsWhile individual product prices were not recalled, awareness of price differences and specific expensive items was sustained in 75% of respondents, with influence on product choice also dependent on evidence base and clinical outcome. The remaining 25% included new staff employed post initial survey in 2011.ConclusionA combination of price labelling with education and a clinical evidence base has potential for efficiency savings. Clinicians willingly participate in product selection when shown that change will lower cost and leave patient outcome unaffected or improved.

Most of England moved into the highest tier of restrictions on 31 December because of an escalation in cases, hospital admissions, and deaths from covid-19, a measure that the health and social care secretary described as “absolutely necessary” as the new variant of the virus spread across the country. Matt Hancock announced on 30 December that the Midlands, North East, and parts of the North West and South West were among the areas to come under tier 4 restrictions, with almost all remaining areas, including Liverpool, escalated to tier 3. Planned reopening of schools was also delayed by at least two weeks for most secondary schools pupils, while some primary schools in the hardest hit areas would take in only vulnerable children and those of key workers, while providing online teaching to all others, said the government. Universities were asked to reduce the number of students who return in January and to prioritise those who need practical learning, such as medical students. The new restrictions were announced as figures showed that 981 covid related deaths were recorded in the UK on 30 December, one of the highest daily totals since April. In the previous 24 hours 50 023 new cases of the disease were recorded and 2430 people were admitted to hospital. There were also reports of ambulances queuing outside hospitals as wards reached capacity, of patients being transferred …

The prevalence of covid-19 fell by 30% across England, from 132 to 96 people infected per 10 000 between 13 and 24 November, show the latest results from the React study.1 More than 105 000 volunteers were tested in England as part of the study, which is carried out by Imperial College London and Ipsos MORI, to examine the levels of infection in the general population. It found that during lockdown the North West and North East of England saw the largest reductions, with infections falling by more than 50%. However, the researchers warned that national prevalence was still high, with around one in 100 people testing positive, …

Mohammad Azam Khan was born into a farming family in a remote village of Umarzai in the north west region of Pakistan on 1 October 1935. His early years were a time of great turmoil as the movement for the creation of Pakistan and independence of India from British rule was gaining significant momentum and the second world war was looming on the horizon. Azam pursued his primary education in a school located at a distance of about 10 miles from his home, necessitating a daily bike ride and having to wade through a river without a bridge holding his bike above the water. He won a scholarship and passed middle school. He came first in his school in his Matric (O level) examination. He then won another scholarship, and passed his FSc (A level) examination with merit. As a teenager, he was a keen sportsman, excelling in football, cricket, and wrestling, also with a broad spectrum of …

Background:The EULAR-ACR 2019 (EULAR19) classification criteria for systemic lupus erythematosus (SLE) were developed to improve the sensitivity and specificity of previous criteria. Notably, both the EULAR19 and existing SLICC-SLE 2012 (SLICC12) criteria can classify patients as having SLE by the presence of immunology and haematological abnormalities in the absence of any signs or symptoms.Objectives:To validate the EULAR19 criteria, with comparison to existing criteria, in a large cohort of patients with an established systemic autoimmune rheumatic disease (SARD).Methods:We recruited 227 adult patients who were ANA positive with ≥1 clinical feature suggestive of a SARD, from three hospitals in the North West of England. Clinician diagnosis was used as gold standard; we then applied the EULAR19, SLICC12 and the ACR-SLE 1997 (ACR97) criteria.Results:Of the 227 patients recruited, by clinician diagnosis, 89 patients (36%) had SLE, 43 (17%) primary Sjögren’s (pSS), 62 (25%) undifferentiated CTD (UCTD), 25 (10%) systemic sclerosis (SSc) and 8 (3%) an inflammatory myositis. The characteristics of these patients and the breakdown of the EULAR19 criteria are outlined in figure 1.Figure 1.Baseline characteristics and classification criteria compared across five SARD diagnoses.The sensitivity and specificity of the EULAR19 is similar to ACR97 (sensitivity 84% (95% CI 75-91%) vs. 87% (95% CI 78-93%) and specificity 78% (95% CI 70-84%) vs. 76% (95% CI 68-83%) respectively). The SLICC12 criteria by contrast are more sensitive (94% (95% CI 87-98%)) and less specific (61% (95% CI 52-69%)) in this cohort.Figure 2 illustrates patients with a clinician diagnosis of SLE or UCTD who meet each of the classification criteria. Of the 89 patients with a clinician diagnosis of SLE, 39 (44%) patients would have sufficient points to meet EULAR19 criteria on blood test results alone in the absence of clinical symptoms. Four pSS patients and 4 UCTD patients would also meet EULAR19 criteria from positive blood results alone.Figure 2.Venn diagrams illustrating patients with SLE and UCTD who meet the EULAR19, ACR97 and SLICC12 classification criteria. No criteria refers to the patients not meeting any of the three SLE classification criteria.Conclusion:These results suggest that the EULAR19 criteria perform comparably to the ACR97 criteria when applied to an established cohort of SARDs. Similar to SLICC12, it is possible to classify patients as having SLE using the EULAR19 criteria by haematological and other laboratory tests. To what extent haematological abnormalities can be potentially used as the sole ‘clinical criteria’ needs consideration.SLE n=89pSS n=43UCTD n=62SSc n=25Myositis n=8Female N (%)82 (92)42 (98)53 (85)24 (96)8 (100)Age, mean (SD) /years44 (13)52 (12)47 (13)60 (9)53 (7)Disease duration, mean (SD) /years12 (10)6 (5)5 (7)9 (11)3 (3)SLE classification criteriaEULAR SLE 2019, N (%)75 (84)10 (23)20 (32)1 (4)0ACR SLE 1997, N (%)77 (87)9 (21)21 (34)2 (8)1 (13)SLICC SLE 2012, N (%)84 (94)15 (35)33 (53)4 (16)2 (25)EULAR-ACR 2019 criteriaConstitutional, N (%)10 (11)2 (5)1 (2)01 (13)Neuropsychiatric, N (%)3 (3)01 (2)1 (4)0Mucocutaneous, N (%)71 (80)13 (30)27 (44)2 (8)2 (25)Serosal, N (%)13 (15)1 (2)2 (3)00Musculoskeletal, N (%)52 (58)14 (33)22 (35)3 (12)3 (38)Renal, N (%)30 (34)001 (4)0Haematological, N (%)44 (49)12 (28)10 (16)3 (12)0Antiphospholipid antibodies, N (%)43 (48)7 (16)17 (27)4 (16)0Low complement, N (%)48 (54)10 (23)10 (16)3 (12)1 (13)Anti-Sm, N (%)19 (21)2 (5)4 (6)1 (4)0Anti-dsDNA, N (%)50 (56)8 (19)12 (19)01 (13)Disclosure of Interests:Sarah Dyball: None declared, John Reynolds: None declared, Eoghan McCarthy: None declared, Sahena Haque: None declared, Ariane Herrick: None declared, Hector Chinoy: None declared, Ellen Bruce: None declared, Ben Parker Grant/research support from: GSK and Sanofi Genzyme, Consultant of: GSK, AstraZenaca, UCV, Abbvie, Pfizer, BMS, Celltrion, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

Background:Hydroxychloroquine (HCQ) is widely used in the management of rheumatoid arthritis and connective tissue disease. The prevalence of retinopathy in patients taking long-term HCQ is approximately 7.5%, increasing to 20-50% after 20 years of therapy. Hydroxychloroquine prescribed at ≤5 mg/kg poses a toxicity risk of 5mg/kg/day, concomitant tamoxifen or chloroquine use and renal impairment. The UK Royal College of Ophthalmologists (RCOphth) 2018 guidelines for HCQ screening recommend optimal treatment dosage and timing for both baseline and follow-up ophthalmology review for patients on HCQ, with the aim of preventing iatrogenic visual loss. This is similar to recommendations made by the American Academy of Ophthalmology (2016).Objectives:To determine adherence to the RCOphth guidelines for HCQ screening within the Rheumatology departments in the North-West of the UK.Methods:Data for patients established on HCQ and those initiated on HCQ therapy were collected over a 7 week period from 9 Rheumatology departments.Results:473 patients were included of which 56 (12%) were new starters and 417 (88%) were already established on HCQ. 79% of the patients were female, with median ages of 60.5 and 57 years for new and established patients respectively. The median (IQR) weight for new starters was 71 (27.9) kg and for established patients, 74 (24.7) kg.20% of new starters exceeded 5mg/kg daily HCQ dose. 16% were identified as high risk (9% had previously taken chloroquine, 5% had an eGFR 2and 2% had retinal co-pathology). Of the high-risk group, 44% were taking In the established patients, 74% were taking ≤5mg/kg/day HCQ dose and 16% were categorized as high risk (10% had an eGFR less than 60ml/min/m2, 3% had previous chloroquine or tamoxifen use and 2% had retinal co-pathology). In the high-risk group, 75% were not referred for spectral domain optical coherence tomography (SD-OCT). 41% of patients established on HCQ for 5 years were not referred for SD-OCT. Reasons for not referring included; awaiting 5 year review, previous screening already performed and optician review advised.Since the introduction of the RCOphth guidelines, 29% patients already established on HCQ had an alteration in the dosage of HCQ in accordance with the guidelines. In the high-risk group, 16% were not on the recommended HCQ dose.Conclusion:This audit demonstrates inconsistencies in adherence to the RCOphth guidelines for HCQ prescribing and ophthalmology screening within Rheumatology departments in the North-West of the UK for both new starters and established patients. Plans to improve this include wider dissemination of the guidelines to Rheumatology departments and strict service level agreements with ophthalmology teams to help optimize HCQ prescribing and screening for retinopathy.Acknowledgments:Drs. S Jones, E MacPhie, A Madan, L Coates & Prof L Teh. Co-1st author, T David.Disclosure of Interests:None declared

More than a third of England’s care homes have now had cases of covid-19, the country’s healthcare regulator has reported. In a report published on 19 May,1 the Care Quality Commission (CQC) said that around 36% of care homes in England had been affected by the disease, as of the week ending 10 May. The worst affected regions have been the north east, where 47% of all care homes have had an outbreak; London (42%); and the north west (41%), in the CQC’s analysis of Public Health England data. Additional data from the CQC’s own tracking survey found that, of 6258 domiciliary care agencies that submitted data from 2 to 8 May, 19% (1179) were caring for at least one person with suspected or confirmed …

Background Coverage of the UK National Health Service Cervical Screening Programme is declining. Under-screened women whose daughters participate in the human papillomavirus (HPV) vaccination programme could be stimulated to attend. We investigated whether factors associated with the vaccination programme changed mothers’ intentions for future screening. Methods Questionnaires were sent to mothers of girls aged 12–13 years across two North West primary care trusts ( n =2387) to assess the effect of the HPV vaccination programme on screening intentions. This identified mothers whose intentions had changed. Consent was sought to contact them for a semi-structured interview to discuss their screening intentions. Key themes were identified using framework analysis. Results 97/606 women responding to the questionnaire had changed their views about cervical screening. 23 women were interviewed, 10 of whom expressed a positive change and 13 no change. Most had discussed the vaccine information, including cervical screening, with their daughters. Mothers who made a positive change decision recognised their daughters’ risk of cervical cancer, the need for future screening, and the importance of their own example. In this way daughters became ‘significant others’ in reinforcing their mothers’ cervical screening motivation. Conclusions A daughter9s invitation for HPV vaccination instigates a reassessment of cervical screening intention in some under-screened mothers.

ObjectiveTo record how breast screening centres in England deliver all biopsy results (cancer/non-cancer) from the breast assessment visit.DesignOnline survey of 63 of 79 breast screening centres in England from all regions (East Midlands, East of England, London, North East Yorkshire & Humber, North West, South East, South West, West Midlands). The survey contained quantitative measures of frequency for telephoning biopsy results (routinely, occasionally or never) and optional qualitative free-text responses. Surveys were completed by a staff member from each centre.ResultsThere were no regional trends in the use of telephone results services, (X² (14, n=63)=11.55, p=0.64), Centres who telephoned results routinely did not deliver results sooner than centres who deliver results in-person (X² (16, n=63)=12.76, p=0.69).When delivering cancer results, 76.2% of centres never telephone results and 23.8% of centres occasionally telephone results. No centres reported delivering cancer results routinely by telephone. Qualitative content analysis suggests that cancer results are only telephoned at the patient request and under exceptional circumstances.When delivering non-cancer results, 12.7% of centres never telephoned results, 38.1% occasionally telephoned results and 49.2% routinely telephoned results. Qualitative content analysis revealed different processes for delivering telephone results, including patient choice and scheduling an in-person results appointment for all women attending breast assessment, then ringing non-cancer results unexpectedly ahead of this prebooked appointment.ConclusionsIn the National Health Service Breast Screening Programme, breast assessment results that are cancer are routinely delivered in-person. However, non-cancer breast assessment results are often routinely delivered by telephone, despite breast screening policy recommendations. More research is needed to understand the impact of telephoning results on women attending breast assessment, particularly women who receive a non-cancer result. Future research should also consider how women themselves might prefer to receive their results.

Dawn Elizabeth Hazlehurst was a very experienced, committed, and dedicated general practitioner. She grew up in Manchester, attended Manchester University Medical School, and carried out her training in hospitals throughout north west England. During her early career she was a senior house officer (SHO) for paediatrics, psychiatry, obstetrics and gynaecology, and accident and emergency medicine in various hospitals around north west England. Following on from her SHO positions, Dawn entered primary care and …

IntroductionInfection with theCryptosporidiumparasite causes over 4000 cases of diagnosed illness (cryptosporidiosis) in England and Wales each year. Risk factors are often estimated from outbreak investigations, and in the UK include ingestion of contaminated water and food, farm/animal contact and person-to-person spread in institutions. However, reported outbreaks only represent about 10% of cases and the transmission routes for sporadic disease may not be the same. Contact with other people has been highlighted as a factor in the transmission ofCryptosporidium, but the incidence of sporadic disease has not been sufficiently established, and how frequently this arises from contact with other infected people is not well documented. This project will estimate the amount of secondary spread that occurs in the home and potentially identify asymptomatic infections which might have a role in transmission. Risk factors and characteristics associated with secondary spread will be described including any differences in transmission betweenCryptosporidiumspecies.Methods and analysisThe study will prospectively identify cryptosporidiosis cases from North West England and Wales over 1 year and invite them and their household to take part. Each household will complete a questionnaire and each household member will be asked to provide a stool sample. Clinical, demographic and home variables will be described, and further analyses undertaken to investigate associations with secondary spread in the home.Cryptosporidium-positive stool samples, identified by immunofluorescence microscopy, will be characterised using molecular methods to describe patterns of transmission. Data collection is expected to take 1 year, beginning in September 2018.Ethics and disseminationThe study has been approved by the North West–Liverpool East NHS Research Ethics Committee (Reference: 18/NW/0300) and the Confidentiality and Advisory Group (Reference 18/CAG/0084). Outputs will include scientific conferences and peer-reviewed publications. In addition, a short, lay report of findings will be produced for participants, who can opt to receive this when they take part.Trial registration numberCPMS ID: 39458.

Objective Congenital adrenal hyperplasia (CAH) is not currently included in the UK newborn screening programme. We investigated the hypothesis that, owing to non-specificity of symptoms, a proportion of males affected by salt-wasting (SW) CAH have died in infancy without being diagnosed. Design Stored newborn screening blood spot samples were analysed for 17α-hydroxyprogesterone (17-OHP) in the following groups: Infants born in the North West of England, 1994 to 2006, who had died by 6 months age; (n=1198), a neonatal reference group (full-term n=100; preterm n=100) and a CAH positive control group. A newborn blood spot sample collected before diagnosis was available in 29/61 CAH patients recruited. SW CAH was present in 18/29 patients (16 males and 2 females). Samples from the deceased group with elevated 17-OHP were analysed for 8 common mutations in the 21-hydroxylase gene ( CYP21A2 ). Setting North West of England. Results Grouped by gestational age, mean (maximum) blood spot 17-OHP in nmol/L was as follows. Deceased full-term n=279, 6 (107); deceased premature n=365, 28 (251); deceased unknown gestational age n=553, 13 (>394). In the SW positive control group, the lowest level of 17-OHP was 179 nmol/L and 14 had levels greater than the highest standard (>268 to >420 nmol/L). All samples from the deceased group with 17-OHP results >179 nmol/L (n=6) and a further 13 samples underwent mutation analysis. No mutations were identified. Conclusions Our findings do not support the hypothesis that, in our unscreened population, males affected by SW CAH are dying prior to diagnosis.

In January 2017 EJHP published a themed issue on the subject of deprescribing, a ‘hot topic’ for clinicians who are challenged with managing inappropriate medication use and polypharmacy. However, it was clear that, despite the enthusiasm of clinicians to manage this issue, there was a paucity of validated tools for use in practice and knowledge of the patient’s view of deprescribing. A literature search on this subject has revealed some interesting developments during 2016/7. Deprescribing in specific therapeutic areas and new deprescribing tools have been explored, as well as publications on both patient and general practitioner beliefs about and attitudes to deprescribing. In diabetes, medication for care home residents in the UK was reviewed using a medicines optimisation tool. The majority had been prescribed potentially inappropriate medication. Deprescribing was endorsed by the physician in over one-third of cases (39% of 106 residents).1 Another study involving deprescribing of benzodiazepines and ’Z drugs' in primary care described how the switching rate was higher than the deprescribing rate when a tool was used to support review.2 Effective deprescribing in a haemodialysis unit was undertaken using a bespoke tool resulting in 88% of eligible patients (n=41) having at least one medication deprescribed.3 The Tool to Reduce Inappropriate Medicines (known as TRIM), has been used to link electronic health records to clinical decision … Correspondence to Professor Nina Barnett, Medicines Use and Safety, NHS Specialist Pharmacy Service, London North West Healthcare NHS Trust, Harrow HA1 3UJ, UK; nina.barnett{at}nhs.net

Objective To examine emergency department (ED) data sharing via a local injury surveillance system and assess its contribution to the prevention of violence and alcohol-related harms. Methods 6-year (2004–2010) exploratory study analysing injury attendances to one ED in the North West of England using descriptive and trend analyses. Results Over the 6-year period, there were 242 796 ED injury attendances, including 21 683 for intentional injuries. Compared with unintentional injury patients, intentional injury patients were more likely to be men, aged 18–34 years, live in the most deprived communities, have attended the ED at night/weekends, have been injured in a public place and have consumed alcohol prior to the injury. Detailed data collected on alcohol and violence-related ED attendances were shared with local partners to monitor local trends and inform prevention activity including targeted policing and licensing enforcement. Over the 6-year period, intentional ED injury attendances decreased by 35.6% and alcohol-related assault attendances decreased by 30.3%. Conclusions The collection of additional ED data on assault details and alcohol use prior to injury, and its integration into multi-agency policy and practice, played an important role in driving local violence prevention activity. Further research is needed to assess the direct contribution ED data sharing makes to reductions in violence.

Three appeal court judges have ruled that an NHS trust should have been allowed to go ahead with disciplinary proceedings against a consultant while a police investigation into his conduct was ongoing.1 Andrew Gregg, a consultant anaesthetist, won a High Court injunction in February 2018 barring North West Anglian NHS Foundation Trust from proceeding with its internal disciplinary process before police had finished investigating allegations that he had hastened two patients’ deaths.2 His solicitor had advised him that participating in the trust process could prejudice the criminal investigation. Police decided in June 2018 to take no action against Gregg, who maintains that his actions were clinically appropriate, and the …

A 39-year-old woman presented to the neurology clinic with an abnormal gait. Subsequent investigations confirmed a rare neurodegenerative disease. This case highlights the key clinical features and diagnostic approach to neuroferritinopathy, and describes the discovery of the disease in a family from Cumbria in the north west of England.

A pharmaceutical company which supplies intravenous feed for babies has been charged with offences after a four year investigation by the Metropolitan Police and the Medicines and Healthcare Products Regulatory Agency (MHRA). A total of 23 babies at nine hospitals in north west London developed a bacterial infection after receiving total parenteral nutrition supplied by ITH Pharma. Three died but only the death of Yousef Al-Kharboush, a twin who …

The neuro network is a well-developed model in North West England and North Wales, hosted by the Walton Centre Liverpool. It is based on the principle of an equitable, locally accessible service taking responsibility for a regional population, rather than one based on a single unit or small area.Centralised tertiary activity is based in Liverpool – for patients requiring specialised diagnostic or therapeutic intervention and care; particularly neurosurgery, thrombectomy, neurological ITU or frequent review of complex acute neurological disorders.Acute neurological support is delivered to 12 acute sites across the region using a combination of consultant visits and ward liaison sessions (typically 3–4 days each week), telemedicine video consultations (presently being developed at pilot sites), 24/7 telephone advice and a weekday consultant advice line for GP’s. Patients are then treated, whenever possible, by a local medical team (or HASU) supported by a neurology management plan (and subsequent on-site or remote review if necessary) or by transfer to the centre if clinically appropriate.The model offers acute neurology provision to a wide area, by the most effective, resilient and equitable deployment of limited resources.

The government of the Democratic Republic of the Congo (DCR) has declared a new outbreak of Ebola. So far 17 people have died in the north west of the country, where the outbreak was declared on 8 May after two cases of Ebola virus disease were confirmed. …

Objectives To look at patients9 views about the way in which they are recruited to assist with postgraduate medical training (i.e. Who is the best person to ask patients to participate? When is the best time for patients to be asked?) and to compare these with clinical practice. Methods Questionnaire surveys of 103 female family planning clinic (FPC) patients and 40 Diploma of the Faculty of Family Planning (DFFP) instructing doctors. Patients were recruited from the waiting room of a community FPC, and DFFP instructing doctors from the North West of England were recruited at an updating meeting. Results Patients preferred to be recruited by non-medical staff (i.e. receptionist and nurses). Few patients wanted to be asked by the training doctor. Only 9% would find it difficult to refuse a receptionist, 47% would find it difficult to refuse the instructing doctor and 65% would find it difficult to refuse the training doctor. In practice, the commonest person to recruit patients is the instructing doctor. Patients wanted to be given some time to consider the request; this was not always given. Discussion and conclusions Patients may feel coerced into seeing training doctors because they find it difficult to refuse requests, particularly when they are being recruited by doctors. Non-medical staff may be more appropriate for the initial recruitment of patients. Patients need time to consider their involvement. The provision of written information may be useful. Further research is indicated to empower patients9 decision-making and reduce the likelihood of coercion.

Objectives To survey family planning clinic (FPC) patients who may be involved in the Diploma of the Faculty of Family Planning (DFFP) practical training; to obtain their views about the process of giving consent to their involvement; and to compare their views with current practice. Methods Questionnaire surveys of 103 female FPC patients and 40 DFFP instructing doctors. Patients were recruited from the waiting room of a community FPC, and DFFP instructing doctors from the North West of England were recruited at an updating meeting. Results Patients felt strongly that they wanted to know what to expect before deciding whether to agree to be involved in the training. Several items of information were requested. The most important of these were whether the training doctor would be seeing the patient alone; the gender of the training doctor; and the training doctor9s level of experience. Patients had not always been given this information. Conclusions Clinical experience is an important part of postgraduate medical training and patients need to be able to give fully informed consent to their involvement. The information currently given to patients may be insufficient. A reluctance to see male training doctors may have implications as regards the breadth of experience gained by male training doctors; this needs further investigation. Further research including different patient populations could inform guidelines for patient involvement in training.

Background Classical risk factors for cardiovascular disease such as hypertension and diabetes, and their association with myocardial infarction (MI), have been thoroughly investigated. However, more research is needed to investigate the correlation between these risk factors and the impact on length of stay (LOS) and mortality in patients presenting with MI, which was the aim of this study. Methods We reviewed anonymous patient data including demographics, LOS, prevalence of cardiovascular comorbidities, and mortality during 25,287 consecutive admissions for MI from seven hospitals in the North West of England between 1 January 2000 and 31 March 2013. The ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) protocol, using ICD-10 and OPCS-4 coding systems, was used to track patient data. LOS and mortality of MI patients with and without cardiovascular comorbidities was compared by multinomial logistic regression. P values Results Of 25,287 patients admitted with MI over the study period, mean (± SD) age was 66.6 ± 14.3 and 64.2% were male. The mean (± SD) LOS was 7.0 ± 16.2 days and there were a total of 9,653 (38.2%) deaths. The classical cardiovascular risk factors hypertension and hyperlipidaemia were associated with a decreased LOS and mortality (7.0 and 4.8 days respectively, P Conclusion Cardiovascular risk factors and concomitant disease have a significant impact on LOS and mortality in patients presenting with MI. The presence of these diseases should be used to identify patients at an increased risk of prolonged admissions and death post MI, and services should be directed accordingly.

Introduction Tobacco smoking contributes significantly to the global health burden and its negative impact on cardiovascular morbidity and mortality in particular have been well documented. Smoking is affected by sociodemographic factors though with rates varying according to sex, social class and ethnicity. However, the impact of ethnicity on mortality amongst hospitalised tobacco abusers is yet to be studied. Objectives We aimed to investigate the impact of ethnicity on mortality of hospitalised patients with a comorbid diagnosis of tobacco abuse. We did this using a large database of patients admitted with comorbid tobacco abuse to hospitals in the North of England between 2000–2013. Methods Anonymous information on adult tobacco abusers was obtained for hospitals in North West England between 1st January 2000 and 31st March 2013. This data was analysed according to the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol. ICD-10 and OPCS-4 codes were used to trace patients coded for tobacco abuse, patient demographics and mortality data. Mortality of tobacco abuse patients was compared by logistic regression. P values of Results 28379 patients had comorbid tobacco abuse during the study period. Mean age of tobacco abusers was 44.9 years, 51.2% were male and 1918 (6.8%) tobacco abuse patients died. The majority were Caucasian (84.8%) with lower proportions of South Asian (4.7%), Afro-Caribbean (1.9%), Oriental (0.2%), mixed (1.0%), other (2.5%) and unknown (4.8%) ethnicities. Crude mortality was highest amongst Caucasian patients (7.3%) compared to South Asian (2.2%), Afro-Caribbean (2.7%), Oriental (1.7%), mixed (0.3%), other (3.1%) and patients with unknown ethnicities (6.1%). Of all these ethnic groups, logistic regression accounting for age and sex showed that only South Asian ethnic origin affected mortality rates amongst patients with comorbid tobacco abuse. South Asian patients were 1.90 times more likely to die (95% CI 1.21–2.97). Conclusion Our results demonstrate that mortality of tobacco abusers varies according to ethnicity with higher mortality amongst South Asian patients in particular. This could represent differences in smoking rates or an increased susceptibility to smoking. This is particularly important given that smoking and South Asian ethnicity are both known risk factors for developing cardiovascular disease.

Police and the General Medical Council are investigating a consultant anaesthetist on suspicion of having inappropriately hastened the deaths of several patients. Andrew Gregg, a consultant with North West Anglia NHS Foundation Trust, was originally investigated over the death of a 41 year old man with acute myeloid leukaemia, “Patient A,” who died in January 2016 two hours after his doses of sedative and analgesia were increased. The trust excluded Gregg from work and notified police after a formal trust investigation concluded that there was a case to answer that the death had been inappropriately hastened. Police completed an investigation in November 2016 and decided to treat the death as homicide, …

Background Moyamoya disorder is a progressive intracranial cerebrovascular disease of unknown aetiology. The Walton Centre is a tertiary neuroscience centre serving a population of 3.5 million, Alder Hey Children’s Hospital is a tertiary paediatric hospital. Aim To compare stroke type, radiological features and clinical outcome in paediatric and adult population with Moyamoya disorder. Methodology Retrospective case note review of patients diagnosed with Moyamoya disorder at both sites from January 2007 to December 2016. Results 27 adults and 9 paediatric patients were identified. 5 of the adult patients presented during childhood. Mean age of presentation was 39 in the adult cohort and 7 in the paediatric cohort. Female to male ratio was 2:1. A majority were Caucasian. The commonest presentation in both groups was ischaemic stroke. Unilateral radiological features were seen in a majority of adult patients compared to bilateral features in paediatric cohort. 11 of the patients were managed surgically with procedures including EC-IC bypass and encephaloduroarteriosynangiosis. Conclusion This study demonstrated that a majority adult cohort had ischaemic stroke with unilateral radiological features and majority paediatric population had bilateral moyamoya disease. We conclude that the primary pathogenesis is likely to be different in the adult and paediatric population.

The UK has an ageing population and various steps have been taken to improve the management of HIV in this population. However, not much has been done regarding STI and older people despite the increasing incidence of STIs in this group.1 This audit aimed to assess how older people are screened for risk in a sexual health clinic. Fifty randomly selected case …

Background An innovative policy developed and implemented by a UK Ambulance Service allows paramedics to refer patients to the GP Acute Visiting Service scheme. Initial evidence suggests that using this alternate route of care can decrease hospital admission rates, increase bed availability, decrease wait time in A and Es and provide substantial savings for the NHS. However, there are many unrecognised barriers to referral that have not been captured by the quantitative analysis. The goal of this qualitative-observational study was to gain insight into the GP referral scheme from a paramedic’s perspective. Methods We observed eight paramedics throughout full shifts of 8–12 hours. Data was collected using participant demographics, researcher observations and informal semi-structured interviews. All notes were transcribed, coded and analysed using a Grounded Theory approach to identify emerging themes. Results Paramedics expressed a wide range of frustrations with the scheme, identifying the waiting time, the process and a lack of confidence, experience and training as the three major barriers to referrals. They described how they approached patients with the GP referral scheme in mind, identified common characteristics of referrals, described how the triage tool shaped their decision making and shared how they involved the patient in the decision making. They shared too their frustrations with some GP decision making, which they admitted then influenced their future decision making. Finally, they described what motivated them to refer and discussed the lack of awareness and understanding of the scheme’s impact and aims. Conclusions This study provided valuable insight into the paramedic’s perspective of the GP referral scheme. Maximising understanding of the scheme, investigating the GP’s perspective in decision making and ensuring knowledge and accountability of paramedics, GPs and the public were identified as solutions to strengthen and increase referral rates and scheme success.

The General Medical Council has won a High Court appeal against a finding by a medical practitioners tribunal that a doctor’s fitness to practise was not impaired despite his dishonesty. The GMC exercised new powers it won in 2015 to appeal against tribunal decisions,1 after the tribunal let Iheanyi Nwachuku off with a warning. Nwachuku was in his final year of GP training at Southampton in October 2015 when he agreed with an agency to provide senior house office cover for three weekend nights, including a Sunday night from 8 pm till 8 am, at the Royal National Orthopaedic Hospital at Stanmore, north west London. He was allowed to …

Tony Barwell Maggie’s Oldham, the latest centre opened by the cancer charity Maggie’s, has won the Building Project of the Year 2017 award at the Constructing Excellence Awards North West. The Maggie Keswick Jencks Cancer Caring Centres Trust, known as Maggie’s, provides free practical, emotional, and social support to people …

Background Infective Endocarditis (IE) occurs in groups of people who are deemed high risk. Previously high-risk individuals undergoing invasive procedures were recommended prophylactic antibiotics. In 2008 NICE issued new guidance to avoid prophylactic antibiotics use. Aim We aimed to evaluate the incidence of confirmed Infective Endocarditis in two sites across the North West region prior to and after the implementation of the 2008 guidance, including causative infective organisms, Echo findings, subsequent morbidity and mortality. Methods OPCS-4 (Office of Population, Censuses and Surveys classification-4th Edition) system and the standard code allocated were retrospectively analysed for all admissions related to Infective Endocarditis for the years 2007–2008 and then again for the years 2012–2015. Results The incidence of IE dramatically increased for the years after the guidance came in to effect compared to prior to the guidance. Initial data from one sites showed an increase in total numbers of cases year on year. All except 3 patients had positive blood cultures. Our data also shows that mortality remains high due to IE (2012%–18% of patients died as a direct result of IE, 2013%–38%, 2014%–11%, 2015%–21%). Conclusions Incidence of IE has increased subsequently to the universal change in NICE guidance. Mortality associated with IE being still high. Although this is a small initial study from one centre, data from our second site is being collated to add support to our findings.

NHS bosses must properly assess the evidence before shutting or downgrading emergency departments given the damaging impact of previous closures, a new analysis has warned. A report1 published by the think tank the Centre for Health and the Public Interest examined how the closure of two emergency departments in north west London in 2014 affected performance against the target of seeing 95% of patients within four hours. In the winter that followed the closures of departments at Central Middlesex and Hammersmith hospitals, performance against the target dropped …

OBJECTIVES—To explore the use of routinely collected trihalomethane (THM) measurements for epidemiological studies. Recently there has been interest in the relation between byproducts of disinfection of public drinking water and certain adverse reproductive outcomes, including stillbirth, congenital malformations, and low birth weight. METHOD—Five years of THM readings (1992-6), collected for compliance with statutory limits, were analysed. One water company in the north west of England, divided into 288 water zones, provided 15 984 observations for statistical analysis. On average each zone was sampled 11.1 times a year. Five year, annual, monthly, and seasonal variation in THMs were examined as well as the variability within and between zones. RESULTS—Between 1992 and 1996 the total THM (TTHM) annual zone means were less than half the statutory concentration, at approximately 46 µg/l. Differences in annual water zone means were within 7%. Over the study period, the maximum water zone mean fell from 142.2 to 88.1 µg/l. Mean annual concentrations for individual THMs (µg/l) were 36.6, 8.0, and 2.8 for chloroform, bromodichloromethane (BDCM), and dibromochloromethane (DBCM) respectively. Bromoform data were not analysed, because a high proportion of the data were below the detection limit. The correlation between chloroform and TTHM was 0.98, between BDCM and TTHM 0.62, and between DBCM and TTHM −0.09. Between zone variation was larger than within zone variation for chloroform and BDCM, but not for DBCM. There was only little seasonal variation (

Objectives—To evaluate the capability of accident and emergency (A&E) departments in six health regions of England to safely decontaminate casualties exposed to hazardous chemicals. Methods—In January 1999 a postal questionnaire was sent to the clinical director of all A&E departments in Trent, North and South Thames, South and West, North West and, Anglia and Oxford Health Regions. The questionnaire inquired about characteristics of the department, decontamination facilities and equipment, and staff training. Non-responders were sent a second questionnaire and contacted by telephone if they failed to respond to the second mailing. Results—308 of 326 departments identified (94%) returned a questionnaire. There was no significant difference in response rate by region (p = 0.99). Analysis was restricted to 154 major departments seeing more than 20 000 new attendances per year. Of these 154 departments, 109 (71%) had a written chemical incident plan but only 55 (36%) maintained a list of nearby industrial chemical sites. Fifty nine departments (38%) stated that members of staff had received training in the management of chemically contaminated casualties in the preceding year. Eighteen departments (12%) possessed the level of personal protective equipment (PPE) recommended for decontamination by the Ambulance Services Association. Ninety six departments (62%) had a designated decontamination room but only seven (7%) of them incorporated all the features generally considered necessary for safe decontamination. Forty one units (27%) had the capability to decontaminate casualties outside of the department either with warm water from a shower attachment or with a mobile decontamination unit. Thirty six departments (23%) had neither a decontamination room nor the ability to decontaminate casualties outside the department. Only 16 units (10%) had both adequate PPE and either a decontamination room or the capability to decontaminate outside the department. Conclusions—This study has identified deficiencies in the current NHS capability to respond to chemical incidents. To resolve this, nationally recognised standards for decontamination facilities, equipment and training should be formulated, agreed and implemented.

Edwin Chadwick, the very name evokes powerful images of Britain at its most self con fident and expansive. Victoria on the throne and the map of the world seemingly coloured pink. No challenge seemed too great for those mainly men who sought to conquer?other Peoples and Nations, the wilderness and the oceans and nature itself. Chadwick was truly a man of his times and a reflection of this unbounded self confidence, whose curiosity took him into a wide range of fields (fig 1). In his time his preoccupations ranged from working conditions (he was Chief Central Commissioner to the Factory Act in 1833), The Poor Law Report of 1832, which he in part wrote and the subsequent Poor Law Amend ment Act and Commission to which he was Secretary (fig 2). His Report on the Sanitary Conditions of the Labouring Population, for which he is perhaps