Post mastectomy radiotherapy in breast cancer: a survey of current United Kingdom practice

Purpose: Radiotherapy (RT) is increasingly used following mastectomy for breast cancer While indications for post-mastectomy radiotherapy (PMRT) are clear in patient groups at high risk of local recurrence, guidelines are less clear in intermediate-risk patients and patients with ductal carcinoma in situ (DCIS). This study aimed to determine variations in the use of PMRT in the United Kingdom (UK).

Methods: A postal survey of all consultant breast surgeon members of the Association of Breast Surgery in the UK.

Results: Tumour size and nodal status were confirmed as the most important indications for PMRT There was significant variation in the influence of other factors such as tumour grade, lymphovascular invasion and margin status. Nineteen per cent of respondents stated that they would consider the use of PMRT in cases of DCIS alone.

Conclusions: There is significant variation in practice across the UK with regard to the use of PMRT in intermediate risk breast cancer and patients with DCIS. Further work is required to determine which patients in these groups are likely to benefit from the use of PMRT.

Potentially inappropriate prescribing among older people in the United Kingdom

Background: Potentially inappropriate prescribing (PIP) in older people is associated with increases in morbidity, hospitalisation and mortality. The objective of this study was to estimate the prevalence of and factors associated with PIP, among those aged ≥70 years, in the United Kingdom, using a comprehensive set of prescribing indicators and comparing these to estimates obtained from a truncated set of the same indicators.

Methods: A retrospective cross-sectional study was carried out in the UK Clinical Practice Research Datalink (CPRD), in 2007. Participants included those aged ≥ 70 years, in CPRD. Fifty-two PIP indicators from the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria were applied to data on prescribed drugs and clinical diagnoses. Overall prevalence of PIP and prevalence according to individual STOPP criteria were estimated. The relationship between PIP and polypharmacy (≥4 medications), comorbidity, age, and gender was examined. A truncated, subset of 28 STOPP criteria that were used in two previous studies, were further applied to the data to facilitate comparison.

Results: Using 52 indicators, the overall prevalence of PIP in the study population (n = 1,019,491) was 29%. The most common examples of PIP were therapeutic duplication (11.9%), followed by use of aspirin with no indication (11.3%) and inappropriate use of proton pump inhibitors (PPIs) (3.7%). PIP was strongly associated with polypharmacy (Odds Ratio 18.2, 95% Confidence Intervals, 18.0-18.4, P < 0.05). PIP was more common in those aged 70–74 years vs. 85 years or more and in males. Application of the smaller subset of the STOPP criteria resulted in a lower PIP prevalence at 14.9% (95% CIs 14.8-14.9%) (n = 151,598). The most common PIP issues identified with this subset were use of PPIs at maximum dose for > 8 weeks, NSAIDs for > 3 months, and use of long-term neuroleptics.

Conclusions: PIP was prevalent in the UK and increased with polypharmacy. Application of the comprehensive set of STOPP criteria allowed more accurate estimation of PIP compared to the subset of criteria used in previous studies. These findings may provide a focus for targeted interventions to reduce PIP.

Special Education Today in the United Kingdom

This chapter attempts to provide a critical analysis of special needs education within the United Kingdom today. Central to such an analysis is an understanding of the rapidly changing social and political milieu within which special needs education is embedded, including the rapidly changing demographics of schooling, and the devolution of political power into four separate but linked countries - England, Wales, Scotland and Northern Ireland. Following a discussion of such wider social, political and educational issues, the authors thoroughly explore the convergences and divergences in policy and practice across the four devolved administrations. They describe a plethora of contemporary texts within each of the four administrations that speak to the need for special needs education to change in response to 21st century concerns about the problems of access to, and equity in education for all children. Despite this, they explain why they remain circumspect about the potential of such developments to lead to successful inclusive practices and developments on the ground. Their analysis in the last section centres on the issue of teacher education for inclusion and some very innovative UK research and development projects that have been reported to successfully engage teachers with new paradigm thinking and practice in the field of inclusive special needs education.

The evolution of offshore wind power in the United Kingdom

In the United Kingdom wind power is recognised as the main source of renewable energy to achieve the European Union 2020 renewable energy targets. Currently over 50% of renewable power is generated from onshore wind with a large number of offshore wind projects in development. Recently the government has re-iterated its commitment to offshore wind power and has announced that offshore wind subsidies are to increase from £135/MWh to £140/MWh until 2019. This paper provides a detailed overview of the offshore wind power industry in the United Kingdom in terms of market growth, policy development and offshore wind farm costs. The paper clearly shows that the United Kingdom is the world leader for installed offshore wind power capacity as pro-active policies and procedures have made it the most attractive location to develop offshore wind farm arrays. The key finding is that the United Kingdom has the potential to continue to lead the world in offshore wind power as it has over 48 GW of offshore wind power projects at different stages of operation and development. The growth of offshore wind power in the United Kingdom has seen offshore wind farm costs rise and level off at approximately £3 million/MW, which are higher than onshore wind costs at £1.5–2 million/MW. Considering the recent increase in offshore wind power subsidies and plans for 48 GW of offshore wind power could see more offshore wind power becoming increasingly financially competitive with onshore wind power. Therefore offshore wind power is likely to become a significant source of electricity in the United Kingdom beyond 2020.

The European Convention on Human Rights and the United Kingdom's Supreme Court

This article reviews the attitudes displayed by the UK's Supreme Court towards claims based on human rights law.

A review of offshore wind power development in the United Kingdom

Currently wind power is dominated by onshore wind farms. However, as the demand for power grows driven by security of energy supply issues, dwindling fossil fuel supplies and greenhouse gas emissions reduction targets, offshore wind power will develop rapidly because of the decline of viable onshore sites. The United Kingdom has a target of 21% renewable electricity by 2020 and this is expected to come mostly from wind power. Britain is the most active internationally in terms of offshore wind farm development with almost 48GW in some stage of development. In addition the Scottish Government, the Northern Ireland Executive and the Government of Ireland undertook the 'Irish-Scottish Links on Energy Study' (ISLES), which examined the feasibility of creating an offshore interconnected transmission network and subsea electricity grid based on renewable energy sources off the coast of western Scotland and the Irish Sea. The aim of this paper is to provide an appraisal of offshore wind power development with a focus on the United Kingdom. © 2013 IEEE.

Power system performance of offshore wind in the United Kingdom in 2030

At least 34 % of the United Kingdom’s power must come from renewable energy sources to meet planned European Union targets in 2030. Wind power will provide the majority of this renewable electricity with an estimated 36 GW offshore and 21 GW onshore. The success of the Crown Estate’s leasing rounds 1 and 2 in offshore wind has meant the United Kingdom is now one of the world leaders in offshore wind power development. Leasing round 3 will see offshore wind in the United Kingdom surpass 36 GW of installed capacity. This is a significant increase from the current installed offshore wind capacity of 3.6 GW. This research investigates the power system performance of offshore wind power in the United Kingdom in 2030.

How should teaching on whole person medicine, including spiritual issues, be delivered in the undergraduate medical curriculum in the United Kingdom?

Background

Although the General Medical Council recommends that United Kingdom medical students are taught ‘whole person medicine’, spiritual care is variably recognised within the curriculum. Data on teaching delivery and attainment of learning outcomes is lacking. This study ascertained views of Faculty and students about spiritual care and how to teach and assess competence in delivering such care.

A questionnaire comprising 28 questions exploring attitudes to whole person medicine, spirituality and illness, and training of healthcare staff in providing spiritual care was designed using a five-point Likert scale. Free text comments were studied by thematic analysis. The questionnaire was distributed to 1300 students and 106 Faculty at Queen’s University Belfast Medical School.

351 responses (54 staff, 287 students; 25 %) were obtained. >90 % agreed that whole person medicine included physical, psychological and social components; 60 % supported inclusion of a spiritual component within the definition. Most supported availability of spiritual interventions for patients, including access to chaplains (71 %), counsellors (62 %), or members of the patient’s faith community (59 %). 90 % felt that personal faith/spirituality was important to some patients and 60 % agreed that this influenced health. However 80 % felt that doctors should never/rarely share their own spiritual beliefs with patients and 67 % felt they should only do so when specifically invited. Most supported including training on provision of spiritual care within the curriculum; 40-50 % felt this should be optional and 40 % mandatory. Small group teaching was the favoured delivery method. 64 % felt that teaching should not be assessed, but among assessment methods, reflective portfolios were most favoured (30 %). Students tended to hold more polarised viewpoints but generally were more favourably disposed towards spiritual care than Faculty. Respecting patients’ values and beliefs and the need for guidance in provision of spiritual care were identified in the free-text comments.

Students and Faculty generally recognise a spiritual dimension to health and support provision of spiritual care to appropriate patients. There is lack of consensus whether this should be delivered by doctors or left to others. Spiritual issues impacting patient management should be included in the curriculum; agreement is lacking about how to deliver and assess.

Research in Progress: Medical Research Council United Kingdom Refractory Asthma Stratification Programme (RASP-UK)

The UK Refractory Asthma Stratification Programme(RASP-UK) will explore novel biomarker stratificationstrategies in severe asthma to improve clinicalmanagement and accelerate development of newtherapies. Prior asthma mechanistic studies have notstratified on inflammatory phenotype and theunderstanding of pathophysiological mechanisms inasthma without Type 2 cytokine inflammation is limited.RASP-UK will objectively assess adherence tocorticosteroids (CS) and examine a novel compositebiomarker strategy to optimise CS dose; this will alsoaddress what proportion of patients with severe asthmahave persistent symptoms without eosinophilic airwaysinflammation after progressive CS withdrawal. There will be interactive partnership with the pharmaceutical industry to facilitate access to stratified populations for novel therapeutic studies.

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK).

Background
The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention.

Methods
Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff.

Results
Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision.

Conclusions
We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes.