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When an individual is in a position of trust over another person, the age of consent is raised from 16 to 18 in the United Kingdom. Currently, the definition of a Position of Trust is restricted to professions such as teachers, care workers and youth justice workers. Recent high-profile cases have contributed to a growing consensus amongst key stakeholders of the need to broaden this legislation to include other roles, such as a sports coach. This study represents the first investigation into the number of concerns recorded by local authorities across England and Wales regarding sexual relationships between a person who is in a potential Position of Trust which is not currently covered by the legislation and someone who was aged 16 or 17 years old. Freedom of Information Requests resulted in full responses from 142 out of the 172 local authorities. A total of 653 cases were recorded over a 4-year period. The most prevalent of the identified roles were related to sport, however, roles related to religion, youth work, transport and uniform services were also cited. Regional differences regarding the number of cases recorded are highlighted and the implications of these findings are discussed.

A blister is a fluid-filled, circumscribed elevation of the skin. By convention, blisters are divided by size; blisters less than 0.5 cm wide are called vesicles, and those greater than 0.5 cm wide are called bullae. A blistering rash is used to describe any skin condition which morphologically consists of vesicles or bullae. Vesicles more than 48 hours old may evolve into pustules (pus-filled lesions). Pustular eruptions have not been included in this chapter. Secondary lesions include erosions (partial loss of epidermis), which may occur when a superficial blister ruptures or is scratched, and ulcers (loss of epidermis and superficial papillary dermis), which may occur either as part of the blistering process or secondary to infection.

This chapter focuses on immunobullous diseases. The immunobullous disorders are a group of diseases in which pathogenic autoantibodies bind to target antigens either in desmosomes (intra-epidermal intracellular adhesion junctions) or in part of the basement membrane zone, resulting in loss of adhesion, and blister formation. This chapter will focus on pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, linear IgA disease, chronic bullous disease of childhood, and dermatitis herpetiformis; it will also mention mucous membrane pemphigoid, pemphigoid gestationis, and epidermolysis bullosa acquisita.

This chapter discusses leg ulcers, including definitions, differential diagnosis, context, approach to diagnosis, specific clues to the diagnosis, key diagnostic tests, treatment and therapy, prognosis, and how to handle uncertainty in the diagnosis of the symptom. Leg ulcers are defined as open wounds, usually below the knee, persisting for more than 6 weeks.

A woman was admitted for planned induction at 39+5 weeks gestation. This was her third pregnancy. She had two previous children who were fit and well. Antenatal scans showed a fetal intra-abdominal mass measuring 6.2×5.5×7 cm in the lower abdomen, which was compressing the bladder. The mass was thought to be originating from the ovary or the bowel. On postnatal examination, the baby girl had a distended and full abdomen. There was a right-sided abdominal mass palpable above the umbilicus and 3 cm in size. It was firm, smooth and mobile in consistency. She had a normal anus and external female genitalia, with evidence of a prolapsed vagina on crying. She had passed urine and opened her bowels. The baby was kept nil by mouth and on intravenous fluids until the abdominal radiography was performed. The image is shown in figure 1. Figure 1 Neonatal abdominal radiograph. Describe the findings noted on the abdominal radiograph? She was …

Purpose: The PARP inhibitor, Olaparib, is approved for women with BRCA-mutated ovarian cancer. Therefore there is an urgent need to test patients and obtain results in time to influence treatment. Models of BRCA testing, such as the mainstreaming oncogenetic pathway, involving oncology health professionals are being used. The authors report on the establishment of the extended role of the clinical nurse specialist in consenting women for BRCA testing in routine gynaecology-oncology clinics using the mainstreaming model. Methods: Nurses undertook generic consent training and specific counselling training for BRCA testing in the form of a series of online videos, written materials and checklists before obtaining approval to consent patients for germline BRCA1 and BRCA2 mutations. Results: Between July 2013 and December 2015, 108 women with ovarian cancer were counselled and consented by nurses in the medical oncology clinics at a single centre (The Royal Marsden, UK). This represented 36% of all ovarian cancer patients offered BRCA testing in the oncology clinics at the centre. Feedback from patients and nurses was encouraging with no significant issues raised in the counselling and consenting process. Conclusion: The mainstreaming model allows for greater access to BRCA testing for ovarian cancer patients, many of whom may benefit from personalised therapy (PARP inhibitors). This is the first report of oncology nurses in the BRCA testing pathway. Specialist oncology nurses trained in BRCA testing have an important role within a multidisciplinary team counselling and consenting patients to undergo BRCA testing.

Background. There is little information concerning how much health-related quality-of-life (HRQoL) information is elicited in dermatology outpatient consultations. Objectives. To observe and record ad hoc HRQoL discussion in inflammatory skin disease consultations, to systematically measure the patient’s HRQoL and to measure patient satisfaction with dermatology care. Methods. Clinic consultations of patients with inflammatory skin conditions attending a secondary care clinic were observed by a single researcher (CP). Data were collected on the 10 subject areas of the Dermatology Life Quality Index (DLQI) and on sleep, burden, frustration and depression. Patients were sent the DLQI and Medical Interview Satisfaction Scale (MISS)-21 questionnaires after the consultation. Results. In total, 100 consultations were observed (psoriasis n ¼ 50, eczema n ¼ 17, acne n ¼ 13 and others n ¼ 20). In 26% (n ¼ 26), there was no mention of HRQoL issues. In 59% (n ¼ 44), HRQoL discussions were initiated by the clinician. In only 26% (n ¼ 19) of consultations were ‡ 3 items on the observer’s checklist raised. In all, 57 evaluable DLQI and MISS-21 questionnaires were returned. The mean ± SD DLQI score was 7.2 ± 7.0 (n ¼ 18) for patients with whom there was no HRQoL discussion and 10.8 ± 6.7 (n ¼ 39, P ¼ 0.038) for those with whom HRQoL was discussed. The mean ± SD MISS-21 score was 108.8 ± 16.5 (n ¼ 18) for the patients with whom there was no HRQoL discussion and 111.3 ± 13.6 (n ¼ 39, P ¼ 0.42) for those with whom HRQoL was discussed. The mean ± SD patient expectation score was 5.5 ± 1.0 (median 5, range 3–7). There was a positive correlation between the patient expectation and MISS-21 scores (rs ¼ 0.815, P < 0.0001). Conclusions. Despite little extent or depth to HRQoL discussion, HRQoL issues were raised in the majority of inflammatory skin disease consultations. The consultations usually met the patients’ expectations and most patients were satisfied.

Childhood encephalopathy is an uncommon but significant paediatric presentation and is associated with significant mortality and long-term morbidity in survivors. By definition it is a somewhat non-specific presentation with a wide differential diagnosis and long list of possible investigations. Choice of investigation, including neuroimaging modality, can be a daunting prospect for the clinician faced with the encephalopathic child and it is important to select appropriately for a high diagnostic yield. Initial management centres on good emergency care irrespective of cause. More specific therapies however vary enormously, and appropriate treatment is important and influences outcome. Evidence exists for mana©gement of many of the individual conditions causing encephalopathy. This review aims to outline a clinical approach to selecting investigations to identify a specific cause and provides an overview of the treatment for the commoner causes of encephalopathy that a general paediatrician may reasonably expect to be faced with.

Emily Davies (1830–1921) was an English early feminist and suffragist who is best remembered for her pioneering campaign to allow women access to university education. Davies was one of the founders of Girton College, Cambridge and served as Mistress between 1873–1875. This volume, first published in 1866, discusses the state of female education after the ages of 16-18. Davies explores the contemporary differences between male and female education and advocates women's entry into higher education, providing specific suggestions on how this could occur and the benefits it could bring to both men and women. The concerns of early feminists and the differing contemporary attitudes towards female education are presented in this volume, which also includes the 1854 pamphlet Remarks on the Education of Girls by feminist Bessie Rayner Parkes and an influential 1854 pamphlet summarising the legal restrictions of married women by feminist activist Barbara Bodichon.

Background Topical corticosteroids are the most frequently prescribed dermatological treatment and are often used by pregnant women with skin conditions. However, little is known about their safety in pregnancy. Objectives To assess the effects of topical corticosteroids on pregnancy outcomes in pregnant women. Search methods This is an update of a review previously published in 2009. We updated our searches of the following databases to July 2015: the Cochrane Skin Group Specialised Register, the Cochrane Pregnancy and Childbirth Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 6), MEDLINE, EMBASE, and LILACS. We also searched five trials registers and checked the reference lists of included studies, published reviews, articles that had cited the included studies, and one author's literature collection, for further references to relevant RCTs. Selection criteria Randomised controlled trials and cohort studies of topical corticosteroids in pregnant women, as well as case-control studies comparing maternal exposure to topical corticosteroids between cases and controls when studies reported pre-specified outcomes. The primary outcomes included mode of delivery, major congenital abnormality, birth weight, and preterm delivery (delivery before 37 completed weeks gestation); the secondary outcomes included foetal death, minor congenital abnormality, and low Apgar score (less than seven at 5 min). Data collection and analysis We used standard methodological procedures expected by Cochrane. Two authors independently applied selection criteria, extracted data, and assessed the quality of the included studies. A third author was available for resolving differences of opinion. A further author independently extracted data from included studies that were conducted by authors of this systematic review. Main results We included 7 new observational studies in this update, bringing the total number to 14, including 5 cohort and 9 case-control studies, with 1,601,515 study subjects. Most studies found no causal associations between maternal exposure to topical corticosteroids of any potency and pregnancy outcomes when compared with no exposure. These outcomes included: mode of delivery (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.95 to 1.15, 1 cohort study, n = 9904, low quality evidence); congenital abnormalities, including orofacial cleft or cleft palate and hypospadias (where the urethral opening is on the underside of the penis) (RR 0.82, 95% CI 0.34 to 1.96, 2 cohort studies, n = 9512, low quality evidence; and odds ratio (OR) 1.07, 95% CI 0.71 to 1.60, 1 case-control study, n = 56,557); low birth weight (RR 1.08, 95% CI 0.86 to 1.36; n = 59,419, 4 cohort studies; very low quality evidence); preterm delivery (RR 0.93, 95% CI 0.81 to 1.08, 4 cohort studies, n = 59,419, low quality evidence); foetal death (RR 1.02, 95% CI 0.60 to 1.73, 4 cohort studies, n = 63,885, very low quality evidence); and low Apgar score (RR 0.84, 95% CI 0.54 to 1.31, 1 cohort study, n = 9220, low quality evidence). We conducted stratified analyses of mild or moderate potency, and potent or very potent topical corticosteroids, but we found no causal associations between maternal exposure to topical corticosteroid of any potency and congenital abnormality, orofacial clefts, preterm delivery, or low Apgar score. For low birth weight, although the meta-analysis based on study-level data was not significant for either mild to moderate corticosteroids (pooled RR 0.90, 95% CI 0.74 to 1.09, 3 cohort studies, n > 55,713) or potent to very potent corticosteroids (pooled RR 1.58, 95% CI 0.96 to 2.58, 4 cohort studies, n > 47,651), there were significant differences between the two subgroups (P = 0.04). The results from three of the individual studies in the meta-analysis indicated an increased risk of low birth weight in women who received potent to very potent topical corticosteroids. Maternal use of mild to moderate potency topical steroids was associated with a decreased risk of foetal death (pooled RR 0.70, 95% CI 0.64 to 0.77, 2 studies, n = 48,749; low quality evidence), but we did not observe this effect when potent to very potent topical corticosteroids were given during pregnancy (pooled RR 1.14, 95% CI 0.69 to 1.88, 3 studies, n = 37,086, low quality evidence). We used the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) Working Group approach to rate the overall quality of the evidence. Data from observational studies started at low quality. We further downgraded the evidence because of imprecision in low birth weight and inconsistency in foetal death. Lower quality evidence resulted in lower confidence in the estimate of effect for those outcomes. Authors' conclusions This update adds more evidence showing no causal associations between maternal exposure to topical corticosteroids of all potencies and pregnancy outcomes including mode of delivery, congenital abnormalities, preterm delivery, foetal death, and low Apgar score, which is consistent with the previous version of this review. This update provides stratified analyses based on steroid potency; we found no association between maternal use of topical corticosteroids of any potency and an increase in adverse pregnancy outcomes, including mode of delivery, congenital abnormality, preterm delivery, foetal death, and low Apgar score. Similar to the previous version of the review, this update identified a probable association between low birth weight and maternal use of potent to very potent topical corticosteroids, especially when the cumulative dosage of topical corticosteroids throughout the pregnancy is very large, which warrants further investigation. The finding of a possible protective effect of mild to moderate topical corticosteroids on foetal death could also be examined.

To delineate pathologic changes in retinal cross sections obtained with spectral (Fourier) domain optical coherence tomography (SDOCT), so that the findings are maintained when collapsed into a two-dimensional fundus image for comparison with conventional retinal studies.SDOCT of the posterior pole of 12 eyes (5 with neovascular age-related macular degeneration [AMD]; 7 with nonneovascular AMD) produced three-dimensional stacks of scans. Location of pathologic features was delineated with color markings in each scan before the stack was collapsed along the depth axis. This en face image contained retinal vessel shadowing and preserved color markings of delineated pathologic features relative to the vessel pattern and was superimposed onto conventional studies.For patients with neovascular AMD, location and extent of choroidal neovascularization, macular edema, and subretinal fluid were visible on the two-dimensional summed images and, in some cases, involved sites not suspected with conventional imaging. For patients with nonneovascular AMD, the location of drusen and geographic atrophy were correlated with autofluorescence images. For one eye with drusen and three eyes with neovascular AMD, presence or extent of subretinal fluid identified by SDOCT was not visible using other imaging methods.In this pilot AMD study, pathologic features within SDOCT scans were transferred into two-dimensional en face projections, enabling researchers to correlate lateral extent of pathologic features from SDOCT with conventional studies. This integration of SDOCT with other retinal studies is promising and will be useful to study the relationship between local OCT morphology and other parameters of retinal disease or function.

We report on the development of quantitative, reproducible diagnostic observables for age-related macular degeneration (AMD) based on high speed spectral domain optical coherence tomography (SDOCT). 3D SDOCT volumetric data sets (512 x 1000 x 100 voxels) were collected (5.7 seconds acquisition time) in over 50 patients with age-related macular degeneration and geographic atrophy using a state-of-the-art SDOCT scanner. Commercial and custom software utilities were used for manual and semi-automated segmentation of photoreceptor layer thickness, total drusen volume, and geographic atrophy cross-sectional area. In a preliminary test of reproducibility in segmentation of total drusen volume and geographic atrophy surface area, inter-observer error was less than 5%. Extracted volume and surface area of AMD-related drusen and geographic atrophy, respectively, may serve as useful observables for tracking disease state that were not accessible without the rapid 3D volumetric imaging capability unique to retinal SDOCT.

"Implementing a Contractor HSE Program in a New Overseas Operation" describes the incorporation of Chevron's "Contractor HSE Program" into the business of the Venezuelan 3rd Round Reactivation Project LL-652. The LL-652 Field was previously operated by Lagoven, an affiliate of the Venezuelan national oil company, Petroleos de Venezuela S.A. or PDVSA. The field is now currently operated by Chevron on behalf of partners Statoil, Arco and EPIC (the "Consortium"). The paper details the issues surrounding the application of the Program in principle and in practice, outlining the type and scope of the operation to which the program is applied. The paper also describes how the program was incorporated into the Consortium contracting strategy and its’ application to all contracts. The paper summarizes: "lessons learned" after sixteen months of operation; the improvements achieved by the application of proactive performance measures as evidenced by personnel training; the application of safe systems of work and the improvement in contractor equipment and facilities; and the benefits of a sustained Contractor HSE Program to the Consortium, to the contractors and to the local community.

This chapter presents a phenomenological analysis of the experience of forgiving another, based on a series of interviews. We start with a discussion of the importance of forgiveness as a topic for psychological study and attempt to account for psychologists’ neglect of this topic.

The identification of robust endotypes—disease subgroups of clinical relevance—is fundamental to stratified medicine. We hypothesized that HLA-C∗06:02 status, the major genetic determinant of psoriasis, defines a psoriasis endotype of clinical relevance. Using two United Kingdom–based cross-sectional datasets—an observational severe-psoriasis study (Biomarkers of Systemic Treatment Outcomes in Psoriasis; n = 3,767) and a large population-based bioresource (UK Biobank, including n = 5,519 individuals with psoriasis)—we compared demographic, environmental, and clinical variables of interest in HLA-C∗06:02–positive (one or two copies of the HLA-C∗06:02 allele) with those in HLA-C∗06:02‒negative (no copies) individuals of European ancestry. We used multivariable regression analyses to account for mediation effects established a priori. We confirm previous observations that HLA-C∗06:02–positive status is associated with earlier age of psoriasis onset and extend findings to reveal an association with disease expressivity in females (Biomarkers of Systemic Treatment Outcomes in Psoriasis: P = 2.7 × 10 –14, UK Biobank: P = 1.0 × 10 –8). We also show HLA-C∗06:02–negative status to be associated with characteristic clinical features (large plaque disease, OR for HLA-C∗06:02 = 0.73, P = 7.4 × 10 –4; nail involvement, OR = 0.70, P = 2.4 × 10 –6); higher central adiposity (Biomarkers of Systemic Treatment Outcomes in Psoriasis: waist circumference difference of 2.0 cm, P = 8.4 × 10 –4; UK Biobank: waist circumference difference of 1.4 cm, P = 1.5 × 10 –4), especially in women; and a higher prevalence of other cardiometabolic comorbidities. These findings extend the clinical phenotype delineated by HLA-C∗06:02 and highlight its potential as an important biomarker to consider in future multimarker stratified medicine approaches.