Search

The ‘Lancet Commission on the Value of Death’ proposes radical change and challenges the very core of hospice service provision. Without action, inequalities in access to hospice care will continue to be amplified. The COVID-19 pandemic brought increased needs and demands in the community setting but also provided opportunities for new palliative partnerships and ways of working. Returning to the status quo should not be an option. Rather moving towards a shared vision and purpose, which has the person and their community network at its centre, enables hospices to have a pivotal role and bring about more equitable palliative care.

This report describes the diversity of experiences of people with life-limiting illnesses who were supported by hospices in the West Midlands during the pandemic. It is one of four cohort reports – the others focus on carers, frontline hospice staff, and senior managers respectively – that form the evidence base for a Policy Report into the impact of Covid-19 on hospices. In these reports we address the nine key themes that were identified as potentially important in our previous collaborative knowledge synthesis (MacArtney et al., 2021) and seek to address some of the policy gaps we identified in our review of recommendations for hospice practice and policy (Langen-Datta et al., 2022). Together these outputs are the result of an Economic and Social Research Council funded study (grant number: ES/W001837/1) that is one of the first studies to contribute an in-depth exploration of hospice-based experiences of the pandemic to the growing body of knowledge about the effectiveness and effects of changes to hospice services, at regional and national levels in response to Covid-19. The aim of this report is therefore to explore experiences of those with life-limiting conditions the effects of the Covid-19 pandemic on the care and support to identify recommendations for clinical practice and healthcare policy. Drawing on these findings, this report offers recommendations for hospices and clinicians who continue to provide care and support for people with life limiting conditions during the ongoing pandemic. These recommendations will also be of interest to local commissioners who will need to work with hospices in their region to ensure people with life-limiting conditions receive the support they need, and national policymakers who will need to ensure the necessary resources and guidance are available.

This report describes the diversity of experiences of people with life-limiting illnesses who were supported by hospices in the West Midlands during the pandemic. It is one of four cohort reports – the others focus on patients, carers, and frontline hospice staff respectively – that form the evidence base for a Policy Report into the impact of Covid-19 on hospices. In these reports we address the nine key themes that were identified as potentially important in our previous collaborative knowledge synthesis (MacArtney et al., 2021) and seek to address some of the policy gaps we identified in our review of recommendations for hospice practice and policy (van Langen-Datta et al., 2022). Together these outputs are the result of an Economic and Social Research Council funded study (grant number: ES/W001837/1) that is one of the first studies to contribute an in-depth exploration of hospice-based experiences of the pandemic to the growing body of knowledge about the effectiveness and effects of changes to hospice services, at regional and national levels, in response to Covid-19. As the key decision makers during the Covid-19 pandemic, this part of the ICoH study aimed to explore senior managers’ experiences and to understand how they responded to the challenges imposed on them whilst still delivering a high-quality palliative care service. Coupled with hospice grey evidence in the form of, for example, senior management emails to staff, policy and guideline documents, we can start to understand the pressures and context in which decisions were made, including what worked well and what did not. The aim of this report is therefore to explore experiences of senior managers during the Covid-19 pandemic to identify recommendations for clinical practice and healthcare policy. Drawing on these findings, this report offers recommendations for hospices managers and clinicians who continue to provide care and support for people with life limiting conditions during the ongoing pandemic. These recommendations will also be of interest to local commissioners who will need to work with hospices in their region to ensure people with life-limiting conditions receive the support they need, and national policymakers who will need to ensure the necessary resources and guidance are available.

This report describes the diversity of experiences informal carers for people with life-limiting illnesses who were supported by hospices in the West Midlands during the pandemic. It is one of four cohort reports – the others focus on patients, frontline hospice staff, and senior managers respectively – that form the evidence base for a Policy Report into the impact of Covid-19 on hospices. In these reports we address the nine key themes that were identified as potentially important in our previous collaborative knowledge synthesis (MacArtney et al., 2021) and seek to address some of the policy gaps we identified in our review of recommendations for hospice practice and policy (Langen-Datta et al., 2022). Together these outputs are the result of an Economic and Social Research Council funded study (grant number: ES/W001837/1). This is one of the first studies to contribute an in-depth exploration of hospice-based experiences of the pandemic to the growing body of knowledge about the effectiveness and effects of changes to hospice services, at regional and national levels in response to Covid-19. The aim of this report is therefore to explore experiences of those informal carers of people with life-limiting conditions and the effects of the Covid-19 pandemic on the care and support they experienced, to identify recommendations for clinical practice and healthcare policy. Drawing on these findings, this report offers recommendations for hospices and clinicians who continue to provide care and support for people with life limiting conditions and those that care them during the ongoing pandemic. These recommendations will also be of interest to local commissioners who will need to work with hospices in their region to ensure informal carers receive the support they need, and national policymakers who will need to ensure the necessary resources and guidance are available.

This report describes the diversity of experiences of hospice staff who worked in operational roles in hospices in the West Midlands during the Covid-19 pandemic. It is one of four cohort reports – the others focus on patients, carers, and senior managers respectively – that form the evidence base for a Policy Report into the impact of Covid-19 on hospices. In these reports we address the nine key themes that were identified as potentially important in our previous collaborative knowledge synthesis (MacArtney et al., 2021) and seek to address some of the policy gaps we identified in our review of recommendations for hospice practice and policy (van Langen-Datta et al., 2022). Together these outputs are the result of an Economic and Social Research Council funded study (grant number: ES/W001837/1). This is one of the first studies to contribute an in-depth exploration of hospice-based experiences of the pandemic to the growing body of knowledge about the effectiveness and effects of changes to hospice services, at regional and national levels in response to Covid-19. The aim of this report is therefore to explore the effects the Covid-19 pandemic had on the experiences of hospice staff as they sought to provide care and support to people with life-limiting conditions and those that cared for them so that we can identify recommendations for clinical practice and healthcare policy. Drawing on these findings, this report offers recommendations for hospices and clinicians who continue to provide care and support for people with life limiting conditions and those that care them during the ongoing pandemic. These recommendations will also be of interest to local commissioners who will need to work with hospices in their region to ensure informal carers receive the support they need, and national policymakers who will need to ensure the necessary resources and guidance are available.

Background: Trigger warnings—advance notification of content so recipients may prepare for ensuing distress—feature in discussions in higher education. Students' expectations for warnings in some circumstances are recognised, and some educators and institutions have adopted use. Medical education necessitates engagement with potentially distressing topics. Little is known about medical students' expectations regarding warnings in education. Methods: All students from a 4‐year graduate‐entry UK medical degree programme were contacted via digital message outlining study details and were openly sampled. Qualitative methodology was chosen to explore participant expectations, experiences and meanings derived from experiences. Students participated in semi‐structured interviews exploring perspectives on functions, benefits and drawbacks of trigger warnings in classroom‐based medical education. We analysed interview transcripts using thematic analysis. Results: Thirteen semi‐structured, qualitative interviews were undertaken. Themes in the following areas were identified: (1) students' experiences influence understanding of trauma and trigger warnings, (2) warnings as mediators of learning experiences, (3) professional responsibilities in learning, (4) exposure to content, (5) professional ethos in medical education and (6) how to issue trigger warnings. Students recognised the term ‘trigger warning’, and that warnings are an accommodation for those affected by trauma. Students' conceptualisation of warnings was influenced by personal experiences and peer interactions both within and outside education. Students expressed both support and concerns about use of warnings and their ability to influence learning, assuming of responsibility and professional development. Discussion: Diverse student opinions regarding warnings were identified. Most students suggested that warnings be used prior to topics concerning recognised traumas. Incremental exposure to distressing content was recommended. Students should be supported in managing own vulnerabilities and needs, while also experiencing sufficient formative exposure to develop resilience. Greater understanding of trauma prevalence and impacts and underpinnings of warnings amongst students and educators are recommended to optimise education environments and professional development.

Background:\ud Trigger warnings - prior notification of topics so recipients may prepare for ensuing distress - are encountered widely in contemporary culture. Students at some universities have expressed expectations for trigger warnings. Medical education routinely exposes students to numerous potentially distressing topics. However, this topic remains understudied in medical education. Little is understood about educators’ views or practice relating to warnings in the context of medical education.\ud \ud Methods:\ud Twenty medical educators from a medical degree programme in the UK participated in a semi-structured qualitative interview study, exploring medical educators’ views and experiences of managing distressing situations and, specifically, their use of warnings. We analysed interview transcripts by thematic coding and identified themes.\ud \ud Results:\ud Analysis identified themes relating to educators’ conceptualisation of trigger warnings and rationale for use, concerns about the use of warnings and the critical purpose of medical school in ensuring preparedness for clinical practice.\ud \ud Participants: shared that warnings were given to empower students in approaching distressing topics and to enable engagement with learning. Warnings acknowledged that some experiences would be distressing and normalised and signalled acceptability of emotional responses. Decisions to use warnings were influenced by the nature of content and, reactively, in response to experiences of student distress. Terminology regarding trigger warnings was interpreted varyingly by participants. A broad variety of topics were identified as potentially sensitive. A number of concerns were noted regarding the use of warnings.\ud \ud Discussion:\ud Warnings alone did not fulfil educators’ responsibility in supporting students’ professional development, but may be a useful adjunct, signalling that self-care is valued and should be prioritised. Despite frequent use of warnings, individual educator practice was shaped by varying rationale. A framework that addresses competing tensions of preventing distress while supporting professional development is needed as part of a trauma-informed approach to medical education.

Background: Prior to undertaking a study looking at the effects of the COVID-19 pandemic upon lived experiences of hospice services in the West Midlands, we sought to identify the range of issues that hospice service users and providers faced between March 2020 and July 2021, and to provide a report that can be accessed and understood by all interested stakeholders. Methods: We undertook a collaborative multi-stakeholder approach for scoping the range of potential issues and synthesising knowledge. This involved a review of available literature; a focus group with hospice stakeholders; and a collaborative knowledge exchange panel. Results: The literature on the effects of the COVID-19 pandemic on hospices remains limited, but it is developing a picture of a service that has had to rapidly adapt the way it provides care and support to its service users, during a period when it faced many fundamental challenges to established ways of providing these services. Conclusions: The impacts of many of the changes on hospices have not been fully assessed. It is also not known what the effects upon the quality of care and support are for those with life-limiting conditions and those that care for them. We found that the pandemic has presented a new normative and service context in which quality of care and life itself was valued that is, as yet, poorly understood.

Objectives(a) To adapt the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)-patient-reported outcome (PRO) Extension guidance to a user-friendly format for patient partners and (b) to codesign a web-based tool to support the dissemination and uptake of the SPIRIT-PRO Extension by patient partners.DesignA 1-day patient and public involvement session.ParticipantsSeven patient partners.MethodsA patient partner produced an initial lay summary of the SPIRIT-PRO guideline and a glossary. We held a 1-day PPI session in November 2019 at the University of Birmingham. Five patient partners discussed the draft lay summary, agreed on the final wording, codesigned and agreed the final content for both tools. Two additional patient partners were involved in writing the manuscript. The study compiled with INVOLVE guidelines and was reported according to the Guidance for Reporting Involvement of Patients and the Public 2 checklist.ResultsTwo user-friendly tools were developed to help patients and members of the public be involved in the codesign of clinical trials collecting PROs. The first tool presents a lay version of the SPIRIT-PRO Extension guidance. The second depicts the most relevant points, identified by the patient partners, of the guidance through an interactive flow diagram.ConclusionsThese tools have the potential to support the involvement of patient partners in making informed contributions to the development of PRO aspects of clinical trial protocols, in accordance with the SPIRIT-PRO Extension guidelines. The involvement of patient partners ensured the tools focused on issues most relevant to them.

The ‘hospital at night’ concept was developed at a joint conference of the London Deanery and Clinical Staff in 2002, as an issue for education and service provision. At the start of the project, our trust had issues with both the structure of the hospital at night handover and the working practices overnight. The vision was to improve team working out of hours, expedite review of sick patients and reorganise care to seek a reduction in bleeps to medical junior doctors overnight in a way that all patients had access to the right person with the right skills for their needs at the right time. The hospital at night project at our hospital was started in 2019 by a multidisciplinary working group. We tried bleep filtering for 4 months and this was later followed on by the development of an electronic out of hour’s task list as part of our hospital at night set-up. The bleep analysis data showed an improved distribution of workload but the process was dependent on individuals. The electronic task management system was built in pre-existing online software. The system helped prioritise and review tasks requested by nurses on medical wards. But it was not without its limitations. We worked with the local information technology (IT) team to improve speed and proposed developing an IT solution that is fast and not desktop based to ensure tasks can be assigned and viewed while on the go. The project was overall a success as it demonstrated positive feedback from junior doctors, improved perception of teamwork and ability to take rest breaks. It also demonstrated a drop in ward-based cardiac arrest rates. The hospital at night project at our trust remains a work in progress, but a lot of positive changes have been delivered.

The Internet is widely used as a source of health information to assist decision making in pregnancy. Concerningly, the quality of information shared on online pregnancy forums is unclear. Our objectives were to explore online pregnancy forum health-related use and evaluate quality of information shared. This retrospective qualitative study had two phases of data collection and analysis. First, thematic analysis of a representative sample (n = 480) of posts explored motivators for forum use. Second, a subgroup (n = 153) of threads with clinical content was assessed for congruence with reputable sources. Common motivators for forum engagement were a desire for lived experience, unlimited access, and the opportunity to express emotions. Of 1098 responses sharing advice, information, or experience, 601 (54.7%) were accurate; 230 (20.9%) were erroneous, incomplete, or misleading; and 267 (24.3%) lacked credible evidence. Of these, 60 (5.5%) were potentially harmful. Responses often directed women to a health care practitioner, but concerningly, failed to refer ten women in need of urgent medical assessment. Few discussions were self-regulating, with only 12 of 230 (5.2%) poor-quality messages subsequently rectified. Exchange of information and emotional support among peers are key functions of online pregnancy forums. There is a modest prevalence of poor-quality or potentially harmful information but more concerningly a lack of peer moderation. We suggest health care practitioners ensure pregnant women have a clear understanding of when clinical consultation is required. Clinicians may wish to discuss the supportive community aspects of online forums in cases where offline support is lacking. [Abstract copyright: © 2019 Wiley Periodicals, Inc.]

Objectives:The primary objective was to quantify the risk of perinatal mortality in non‐anomalous monochorionic monoamniotic (MCMA) twin pregnancies complicated by birth‐weight (BW) discordance. The secondary objectives were to investigate the effect of inpatientvsoutpatient fetal monitoring on the risk of mortality in weight‐discordant MCMA twin pregnancies, and to explore the predictive accuracy of BW discordance for perinatal mortality. Methods:This analysis included data on 242 MCMA twin pregnancies (484 fetuses) from three major research collaboratives on twin pregnancy (MONOMONO, STORK and NorSTAMP). The primary outcomes were the risks of intrauterine (IUD), neonatal (NND) and perinatal (PND) death, according to weight discordance at birth from ≥ 10% to ≥ 30%. The secondary outcomes were the association of inpatientvsoutpatient fetal monitoring with the risk of mortality in weight‐discordant pregnancies, and the accuracy of BW discordance in predicting mortality. Logistic regression and receiver‐operating‐characteristics‐curve analyses were used to analyze the data. Results:The risk of IUD was significantly increased in MCMA twin pregnancies with BW discordance ≥ 10% (odds ratio (OR), 2.2; 95% CI, 1.1–4.4;P= 0.022) and increased up to an OR of 4.4 (95% CI, 1.3–14.4;P= 0.001) in those with BW discordance ≥ 30%. This association remained significant on multivariate logistic regression analysis for BW‐discordance cut‐offs ≥ 20%. However, weight discordance had low predictive accuracy for mortality, with areas under the receiver‐operating‐characteristics curve of 0.60 (95% CI, 0.46–0.73), 0.52 (95% CI, 0.33–0.72) and 0.57 (95% CI, 0.45–0.68) for IUD, NND and PND, respectively. There was no difference in the risk of overall IUD, single IUD, double IUD, NND or PND between pregnancies managed as an inpatient compared with those managed as an outpatient, for any BW‐discordance cut‐off. Conclusions:MCMA twin pregnancies with BW discordance are at increased risk of fetal death, signaling a need for increased levels of monitoring. Despite this, the predictive accuracy for mortality is low; thus, detection of BW discordance alone should not trigger intervention, such as iatrogenic delivery. The current data do not demonstrate an advantage of inpatient over outpatient management in these cases. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Introduction Some individuals with Crohn’s Disease who take long term three monthly Vitamin B12 injections complain of lack of energy and tiredness prior to their next B12 injection. Some have persuaded their General Practitioners to give the B12 injection more frequently than 3 monthly. Methods We wanted to determine if this was a common experience,and also if seen in other causes of B12 deficiency besides Crohn’s Disease. 453 patients on long term B12 in the community were invited to complete a questionnaire, 148 agreed. Most of these patients were elderly with a history of pernicious anaemia. 445 patients completed the questionnaire online. Most of these patients had Crohn’s disease. 593 questionnaires were analysed. Results In the period prior to Vitamin B12 injection, the majority reported tiredness, lack of energy, poor concentration and mood. Selected control symptoms were only seen in 1/4, figure 1. Of those noticing fatigue, 65% noticed this in the week prior to B12 injection. The community recruited group and the online group showed a similar pattern of complaints, but the incidence was lower in the Community group. Following B12 injection there was an improvement in the majority, in energy, concentration, fatigue and mood. Multivariate analysis to identify factors differing between high and low symptom sufferer, showed only age and treatment interval which predicted greater symptom burden but this only explained a very small proportion of the variation seen (less than 9%) A small proportion reported worsening of symptoms following B12 injection; the most common symptom was feeling cold in 7%. Conclusions In summary, fatigue, lack of energy, poor mood, and difficulty in concentration are seen frequently as individuals approach the 3 monthly B12 injection both in Crohn’s Disease and pernicious anemia. These improve following injection

BackgroundSubclinical thyroid dysfunction — abnormal serum thyrotrophin (thyroid-stimulating hormone; TSH) concentrations with normal free thyroxine (FT4) is common in older people. It remains unclear whether individuals with subclinical serum status experience an increased symptom profile.AimTo compare the prevalence of those symptoms typically associated with overt thyroid dysfunction in older individuals with a subclinical and euthyroid serum profile.Design and settingCross-sectional study, nested within the Birmingham Elderly Thyroid Study (BETS); from 19 UK general practices.MethodAdults living in a community setting (aged ≥65 years), without overt thyroid dysfunction or associated treatment, self-reported the presence or absence of 18 symptoms (while serum result naïve). Serum concentrations of TSH and FT4 were measured to establish thyroid status.ResultsA total of 2870 individuals were screened: 2703 (94%) were categorised as euthyroid (normal), 29 (1%) subclinically hyperthyroid, and 138 (5%) subclinically hypothyroid. Symptoms were common in all groups. No significant differences in the prevalence of individual symptoms were observed between the euthyroid and subclinically hypothyroid groups nor in comparison with the subclinically hyperthyroid group. Multivariate logistic regression analysis failed to reveal an association between individual or multiple symptoms and subclinical status.ConclusionFindings suggest that subclinical thyroid dysfunction does not confer a symptom burden in older individuals and support adherence to guidelines in the non-treatment of subclinical thyroid dysfunction. GPs may use the findings to reassure older people presenting with symptoms that subclinical thyroid dysfunction is an unlikely explanation. The presence of persistently abnormal TSH concentrations may be linked to long-term risks of cardiovascular disease, especially atrial fibrillation, but whether this should prompt treatment and whether such treatment alters vascular outcomes is unknown.

Introduction:\ud To determine the benefits of healing therapy (spiritual healing) as an adjunct to conventional management in irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD).\ud \ud Methods:\ud 200 outpatients with IBS or IBD were randomised to either conventional treatment (control) or conventional plus five sessions of healing therapy (intervention). After 12 weeks controls also had healing therapy. Outcomes used were, the Measure Yourself Medical Outcomes Profile (MYMOP). IBS-QOL, IBDQ, and symptom measures.\ud \ud Results:\ud There was a significant improvement in the MYMOP score at week 6 (p < 0.001) which was maintained to week 12 (p < 0.001) and 24 (p < 0.001). Improvements in MYMOP were significantly greater in the intervention group at both 6 (p < 0.001) and 12 weeks (p < 0.001) with effect sizes of 0.7 (95% CI: 0.4–1.1) and 0.8 (95% CI: 0.4–1.2). Condition-specific data for IBS showed that most QoL dimensions had a significant minimum 10-point score improvement at 6 and 12 weeks. The overall score improvement was 12.9 units at week 6 (p < 0.001), 12.4 units at week 12 (p < 0.001) and 13.8 units at week 24 (p < 0.001). In IBD there was also similar score improvement, but only up to week 12 were there associations of improved social and bowel functions (p < 0.001, respectively). Between group differences were identified for QoL scores in IBS at both week 6 (p < 0.001) and 12 (p < 0.001) but only for week 12 (p < 0.001) in the IBD group.\ud \ud Conclusions:\ud The addition of healing therapy to conventional treatment was associated with improvement in symptoms and QoL in IBS, and to a lesser extent in IBD.

BackgroundThyroid function tests (TFTs) are among the most requested tests internationally. However, testing practice is inconsistent, and potentially suboptimal and overly costly. The natural history of thyroid function remains poorly understood.AimTo establish the stability of thyroid function over time, and identify predictors of development of overt thyroid dysfunction.Design and settingLongitudinal follow-up in 19 general practices in the UK.MethodA total of 2936 participants from the Birmingham Elderly Thyroid Study (BETS 1) with a baseline TFT result indicating euthyroid or subclinical state were re-tested after approximately 5 years. Change in thyroid-stimulating hormone (TSH), free thyroxine (FT4), and thyroid status between baseline and follow-up was determined. Predictors of progression to overt dysfunction were modelled.ResultsParticipants contributed 12 919 person-years; 17 cases of overt thyroid dysfunction were identified, 13 having been classified at baseline as euthyroid and four as having subclinical thyroid dysfunction. Individuals with subclinical results at baseline were 10- and 16-fold more likely to develop overt hypothyroidism and hyperthyroidism, respectively, compared with euthyroid individuals. TSH and FT4 demonstrated significant stability over time, with 61% of participants having a repeat TSH concentration within 0.5 mIU/L of their original result. Predictors of overt hypothyroidism included new treatment with amiodarone (odds ratio [OR] 92.1), a new diagnosis of atrial fibrillation (OR 7.4), or renal disease (OR 4.8).ConclusionHigh stability of thyroid function demonstrated over the 5-year interval period should discourage repeat testing, especially when a euthyroid result is in the recent clinical record. Reduced repeat TFTs in older individuals is possible without conferring risk, and could result in significant cost savings.

OBJECTIVES: To explore the relationship between academic performance, extracurricular activity, and quality of life at medical school in the UK to aid our understanding of students' work-life balance. METHODS: A cross-sectional study, using an electronic questionnaire distributed to UK final year medical students across 20 medical schools (4478 students). Participants reported the hours of self-regulated learning and extracurricular activities undertaken each year at medical school; along with their academic decile (1 = highest, 10 = lowest). Self-reported quality of life (QoL) was assessed using an established screening tool (7 = highest, 1 = lowest). RESULTS: Seven hundred responses were obtained, across 20 participating medical schools, response rate 16% (700/4478). Factors associated with higher academic achievement were: graduate entry course students (2 deciles higher, p < 0.0001), more hours academic study during term and revision periods (rho=-0.1, p < 0.01), and involvement in teaching or research. Increased hours of study was associated with lower QoL (rho = -0.13, p < 0.01). CONCLUSIONS: Study skills may be more important than duration spent studying, for academic achievement and QoL. Graduate-entry students attain higher decile scores despite similar self-reported duration of study.

Haploinsufficiency of the transcription factor short stature homeobox (SHOX) manifests as a spectrum of clinical phenotypes, ranging from disproportionate short stature and Madelung deformity to isolated short stature. Here, we describe five infants with molecularly confirmed diagnoses of SHOX haploinsufficiency who presented in utero with short long bones during routine antenatal scanning from as early as 19 weeks gestation. Other foetal growth parameters were normal. The molecular basis of SHOX haploinsufficiency was distinct in each case. In four cases, SHOX haploinsufficiency was inherited from a previously undiagnosed parent. In our de novo case, SHOX haploinsufficiency reflected the formation of a derivative sex chromosome during paternal meiosis. Final adult height in the SHOX-deficient parents ranged from -1.9 to -1.2 SDS. All affected parents had disproportionately short limbs and two affected mothers had bilateral Madelung deformity. To our knowledge, SHOX haploinsufficiency has not previously been reported to present in utero. Our experience illustrates that SHOX deficiency should form part of the differential diagnosis of foetal short long bones and suggests a low threshold for genetic testing. This should be particularly targeted at, but not limited to, families with a history of features suggestive of SHOX deficiency. Data on the postnatal growth of our index cases is presented which demonstrates that antenatal presentation of SHOX haploinsufficiency is not indicative of severe postnatal growth restriction. Early identification of SHOX deficiency will enable accurate genetic counselling reflecting a good postnatal outcome and facilitate optimal initiation of growth hormone therapy.

Introduction : Transmission in serodiscordant couples (SDCs) accounts for approximately half of all new HIV infections, both in Kenya and the wider sub-Saharan region [1]. With evidence to suggest inconsistent condom use within this population [2], the World Health Organization has recommended two new methods of HIV prevention for SDCs: Treatment as Prevention (TasP) and Pre-Exposure Prophylaxis (PrEP). However, there has been little research about the attitudes of SDCs towards these strategies [3,4]; knowledge that is paramount for successfully predicting the acceptability and efficacy of each method, as well as for informing decisions regarding HIV policy changes in Kenya. Methods : An exploratory, qualitative study was conducted in the Muhoroni constituency of Nyando district, Kenya from January to March 2013. Purposive sampling was predominately used to recruit 21 HIV-positive and 17 HIV-negative individuals in a serodiscordant relationship from four hospitals and health centres. During face-to-face semi-structured interviews, topic guides were used to elicit information about participants’ attitudes and preferences towards TasP and PrEP. Collected data underwent framework analysis, allowing the development of overarching categories, sub-themes and inductive interpretation. Results : The majority of participants, irrespective of gender and HIV status, found TasP more acceptable than PrEP. A key factor influencing this decision was HIV-negative participants’ limited motivation to take and adhere to antiretrovirals (ARVs), primarily due to a predominantly external health locus of control, a lack of cultural acceptance of prophylactic medication and concerns about side effects. In addition to this, the likely health improvements TasP offers HIV-positive partners, as well as the attitude that the sick individual should be the first to receive HIV medication, also contributed to this conclusion. Issues of risk compensation were raised, with some HIV-negative partners indicating a desire to stop using condoms if ARV-based prevention methods were available. Conclusions : Findings from the study indicate that TasP may represent a more viable approach to HIV prevention in Kenya than PrEP. Couples’ preferences, however, may differ depending on local attitudes towards prophylaxis and health locus of control. (Published: 2 November 2014) Citation : Abstracts of the HIV Drug Therapy Glasgow Congress 2014 Fowler N et al. Journal of the International AIDS Society 2014, 17(Suppl 3): 19563 http://www.jiasociety.org/index.php/jias/article/view/19563 | http://dx.doi.org/10.7448/IAS.17.4.19563

Objective Single intrauterine death (sIUD) in twin pregnancy is associated with a significant risk of cotwin demise and preterm birth (PTB), especially in monochorionic (MC) twins. However, it is yet to be established whether the gestational age at loss may influence the pregnancy outcome. The aim of this study was to explore the risk of PTB according to the gestational age at diagnosis of sIUD. Methods This was a cohort study of all twin pregnancies booked for antenatal care in a large regional network of nine hospitals over a 10-year period. Ultrasound data were matched to hospital delivery records and to a mandatory national register for stillbirth and neonatal loss provided by the Centre for Maternal and Child Enquires. Cases with double fetal loss at the time of the scan and cases of sIUD occurring at or after 34weeks of gestation were not included in the analysis. The relative risk (RR) of PTB at Results The analysis included 3013 twin gestations (2469 dichorionic (DC) and 544 MC). Median gestational age at birth was lower in the pregnancies complicated by sIUD compared with those thatwere not (32.0weeks: interquartile range (IQR), 29.0–34.3weeks vs 36.7weeks: IQR, 35.0–37.6; P Conclusions Twin pregnancies complicated by sIUD, regardless of the chorionicity, have a significantly higher risk of PTB at

Objective To generate reference charts for expected fetal growth in dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies and to compare these with those from singleton pregnancies. Methods This was a retrospective study of biometric measurements from serial ultrasound examinations of twin pregnancies in the second and third trimesters, from 14 weeks' gestation to term, collected by nine hospitals over a 10-year period. The measurements obtained in each fetus at each examination included head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC) and femur length (FL). Multilevel mixed effects statistical models were used to evaluate growth in each biometric variable in relation to gestational age, taking account of the serial examinations and the association between the two fetuses in each pregnancy, with separate models constructed for DCDA and MCDA pregnancies. Results The final dataset for analysis included a total of 9866 second- and third-trimester ultrasound examinations in 1802 DCDA and 323 MCDA twin pregnancies, with a median of five (range, 1–14) scans per pregnancy. For each variable, the mean value for DCDA twins was close to the reported value in singletons at 20–30 weeks and showed a decrease relative to singletons beyond 30 weeks. The differences were greater for AC and HC, for which the mean in twins was approximately equivalent to the 30th percentile in singletons at 18 weeks, the 35th percentile at 25 weeks and the 30th percentile at 35 weeks. Fetuses in MCDA twin pregnancies displayed lower mean measurements than did those in DCDA pregnancies throughout the gestational age range considered. Conclusions Ultrasound biometry shows a small but statistically significant reduction in fetal growth in twin pregnancies relative to that in singletons, particularly in the third trimester, with a more marked difference for MCDA than for DCDA pregnancies. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

In Kenya, one of the most significant public health concerns is the spread of HIV. Additionally, 13,000 girls drop out of school every year due to pregnancy. Although the Kenyan Ministry of Education and other independent organisations have tried to implement various means of developing puberty and sexual health education for young people, the situation is not improving. Aims: To explore the opinions of teachers and parents in rural Kenya about delivering puberty and sex education and to identify their perceptions of barriers to young people accessing this education. Study Design: Qualitative study. Place and Duration of Study: Rural Nyanza Province, Western Kenya between January and March 2013. Methodology: semi-structured interviews with 19 teachers and 30 parents following a topic guide to explore their opinions about what young people need to learn about sex education and perceived barriers to accessing that education. The interviews were Original Research Article British Journal of Medicine & Medical Research, 4(4): 1014-1033, 2014 1015 transcribed and subjected to Framework analysis. Results: Analysis revealed a lack of continuity in teacher training for sex education and discrepancies in what is being taught in schools. It also highlighted internal contradictions in teachers’ and parents’ views about some aspects of sex education, particularly the emphasis on abstinence and negative attitudes towards contraception. Conclusion: Strategies for improvement may include a full evaluation of the formal sex education curriculum and retraining where necessary to ensure consistency in the sexual health messages that are delivered to young people. Additionally, parents and wider rural communities may need to be better supported in their ways of discussing puberty and sexual health with their children.

Evidence is emerging that rates of adverse events in patients taking warfarin may vary with ethnicity. This study investigated the rates of bleeds and thromboembolic events, the international normalised ratio (INR) status and the relationship between INR and bleeding events in Malaysia. Patients attending INR clinic at the Heart Centre, Sarawak General Hospital were enrolled on an ad hoc basis from May 2010 and followed up for 1 year. At each routine visit, INR was recorded and screening for bleeding or thromboembolism occurred. Variables relating to INR control were used as predictors of bleeds in logistic regression models. 125 patients contributed to 140 person-years of follow-up. The rates of major bleed, thromboembolic event and minor bleed per 100 person-years of follow-up were 1.4, 0.75 and 34.3. The median time at target range calculated using the Rosendaal method was 61.6 % (IQR 44.6–74.1 %). Of the out-of-range readings, 30.0 % were below range and 15.4 % were above. INR variability, (standard deviation of individuals’ mean INR), was the best predictor of bleeding events, with an odds ratio of 3.21 (95 % CI 1.10–9.38). Low rates of both major bleeds and thromboembolic events were recorded, in addition to a substantial number of INR readings under the recommended target range. This may suggest that the recommended INR ranges may not represent the optimal warfarin intensity for this population and that a lower intensity of therapy, as observed in this cohort, could be beneficial in preventing adverse events.

Background: Sunbed use in childhood increases risk of melanoma. The under-18s sunbed ban was introduced in England, April 2011. Impact on use has not been investigated since. This cross-sectional study estimates the prevalence of under-18s’ use in Sandwell after the commercial ban and identifies factors associated with use/intention. Methods: Adolescents aged 15 to 17 years in schools were surveyed using self-completed anonymous questionnaires. Data collected include demographics, sunbed use, tanning attitudes, knowledge of risks and ban awareness. All Sandwell schools were approached; adolescents available on the survey days were included. Results: Five out of 22 schools participated, 407 adolescents responded (95.1%). Twenty participants (5.3%; 95% confidence interval [CI] = 3.4-8.0) had used sunbeds, of who 16 reported use in commercial settings. After exclusion of one school cohort with atypical use (possibly associated with beauty vocational course and European migrants), the prevalence of use was 1.7% (95% CI = 0.7-3.9, n = 5). Less than half of all were aware of the ban (48.2%; 95% CI = 43.2-53.3). Users/potential users were less aware of associated risks. Being female, having family/friends who use sunbeds increased use/intention 2- to 4-fold. Conclusion: Strategies targeting parents, stricter enforcement, and greater publicity of the ban are needed. Further research exploring the possible association between certain vocational courses, migrants, and sunbed use is required.

The UK continues to punch well above weight in terms of global research impact, with 0.88% of global population, , 3.2% of global R&D; expenditure, and 4.1% of global researchers, accounting for 9.5% of research downloads, 11.6% of citations, and 15.9% of the world's most highly-cited articles (top 1% in 2012). We have the most productive science base amongst the G7 countries, now even topping the US in Field Weighted Citation Impact,3 and even producing the most cited patents from research. We must protect this research eminence.

Context: Population-based screening has been advocated for subclinical thyroid dysfunction in the elderly because the disorder is perceived to be common, and health benefits may be accrued by detection and treatment. Objective: The objective of the study was to determine the prevalence of subclinical thyroid dysfunction and unidentified overt thyroid dysfunction in an elderly population. Design, Setting, and Participants: A cross-sectional survey of a community sample of participants aged 65 yr and older registered with 20 family practices in the United Kingdom. Exclusions: Exclusions included current therapy for thyroid disease, thyroid surgery, or treatment within 12 months. Outcome Measure: Tests of thyroid function (TSH concentration and free T 4 concentration in all, with measurement of free T3 in those with low TSH) were conducted. Explanatory Variables: These included all current medical diagnoses and drug therapies, age, gender, and socioeconomic deprivation (Index of Multiple Deprivation, 2004) Analysis: Standardized prevalence rates were analyzed. Logistic regression modeling was used to determine factors associated with the presence of subclinical thyroid dysfunction Results: A total of 5960 attended for screening. Using biochemical definitions, 94.2% [95% confidence interval (CI) 93.8-94.6%] were euthyroid. Unidentified overt hyper- and hypothyroidism were uncommon (0.3, 0.4%, respectively). Subclinical hyperthyroidism and hypothyroidism were identified with similar frequency (2.1%, 95% CI 1.8-2.3%; 2.9%, 95% CI 2.6-3.1%, respectively). Subclinical thyroid dysfunction was more common in females (P < 0.001) and with increasing age (P < 0.001). After allowing for comorbidities, concurrent drug therapies, age, and gender, an association between subclinical hyperthyroidism and a composite measure of socioeconomic deprivation remained. Conclusions: Undiagnosed overt thyroid dysfunction is uncommon. The prevalence of subclinical thyroid dysfunction is 5%. We have, for the first time, identified an independent association between the prevalence of subclinical thyroid dysfunction and deprivation that cannot be explained solely by the greater burden of chronic disease and/or consequent drug therapies in the deprived population. Copyright © 2006 by The Endocrine Society.

Objectives To examine the effectiveness and cost-effectiveness of two interventions based in primary care aimed at increasing uptake of breast screening. Setting 24 General practices with low uptake in the second round of screening (below 60%) in north west London and the West Midlands, UK. Participants were all women registered with these practices and eligible for screening in the third round. Methods Pragmatic factorial cluster randomised controlled trial, with practices randomised to a systematic intervention (general practitioner letter), an opportunistic intervention (flag in women's notes prompting discussion by health professionals), neither intervention, or both. Outcome measures were attendance for screening 6 months after the practices had been screened and cost-effectiveness of the interventions. Results 6133 Women were included: 1721 control; 1818 letter; 1232 flag; 1362 both interventions. Attendance data were obtained for 5732 (93%) women. The two interventions independently increased breast screening uptake in a logistic regression model adjusted for clustering, with the flag (odds ratio (OR) 1.43, 95% confidence interval (95% CI) 1.14 to 1.79; p=0.0019) marginally more effective than the letter (OR 1.31, 95% CI 1.05 to 1.64; p=0.015). Health service costs per additional attendance were £26 (letter) and £41 (flag). Conclusions Although both interventions increased attendance for breast screening, the letter was the more cost-effective. Any decision to implement both interventions rather than just the letter will depend on whether the additional (£41) costs are judged worthwhile in terms of the gains in breast screening uptake.