Clevedon Hospital

BACKGROUND: The Confidential Inquiry into premature deaths of people with intellectual disabilities in England was commissioned to provide evidence about contributory factors to avoidable and premature deaths in this population. METHODS: The population-based Confidential Inquiry reviewed the deaths of people with intellectual disabilities aged 4 years and older who had been registered with a general practitioner in one of five Primary Care Trust areas of southwest England, who died between June 1, 2010, and May 31, 2012. A network of health, social-care, and voluntary-sector services; community contacts; and statutory agencies notified the Confidential Inquiry of all deaths of people with intellectual disabilities and provided core data. The Office for National Statistics provided data about the coding of individual cause of death certificates. Deaths were described as avoidable (preventable or amenable), according to Office for National Statistics definitions. Contributory factors to deaths were identified and quantified by the case investigator, verified by a local review panel meeting, and agreed by the Confidential Inquiry overview panel. Contributory factors were grouped into four domains: intrinsic to the individual, within the family and environment, care provision, and service provision. The deaths of a comparator group of people without intellectual disabilities but much the same in age, sex, and cause of death and registered at the same general practices as those with intellectual disabilities were also investigated. FINDINGS: The Confidential Inquiry reviewed the deaths of 247 people with intellectual disabilities. Nearly a quarter (22%, 54) of people with intellectual disabilities were younger than 50 years when they died, and the median age at death was 64 years (IQR 52-75). The median age at death of male individuals with intellectual disabilities was 65 years (IQR 54-76), 13 years younger than the median age at death of male individuals in the general population of England and Wales (78 years). The median age at death of female individuals with intellectual disabilities was 63 years (IQR 54-75), 20 years younger than the median age at death for female individuals in the general population (83 years). Avoidable deaths from causes amenable to change by good quality health care were more common in people with intellectual disabilities (37%, 90 of 244) than in the general population of England and Wales (13%). Contributory factors to premature deaths in a subset of people with intellectual disabilities compared with a comparator group of people without intellectual disabilities included problems in advanced care planning (p=0·0003), adherence to the Mental Capacity Act (p=0·0008), living in inappropriate accommodation (p<0·0001), adjusting care as needs changed (p=0·009), and carers not feeling listened to (p=0·006). INTERPRETATION: The Confidential Inquiry provides evidence of the substantial contribution of factors relating to the provision of care and health services to the health disparities between people with and without intellectual disabilities. It is imperative to examine care and service provision for this population as potentially contributory factors to their deaths--factors that can largely be ameliorated. FUNDING: Department of Health for England.

BACKGROUND: People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID. METHODS: We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme. FINDINGS: We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47-2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10-8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5-49·9, p<0·0001), and medication reviews (2·23, 1·68-2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41-26·9, p=0·0156) and secondary care referrals (1·47, 1·05-2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09-6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03-3·65, p=0·0390), and obesity (2·49, 1·76-3·53, p<0·0001). INTERPRETATION: Targeted annual health checks for people with ID in primary care could reduce health inequities. FUNDING: National Institute for Health Research.

Background Since the 1990s reports have consistently highlighted health inequalities faced by people with learning disabilities. Data from the Primary Care Research Database suggests an all-cause standardised mortality ratio for people with learning disabilities of 3.18, and that people with learning disabilities die approximately 20 years sooner than people without learning disabilities. Aim This presentation will provide an overview of the Learning Disabilities Mortality Review (LeDeR) programme. LeDeR aims to contribute to improvements in the quality of health and social care for people with learning disabilities in England through retrospective mortality reviews. Method Initial reviews are undertaken of all deaths notified to the LeDeR programme of people with learning disabilities aged 4 years and over. Where indicated, a full multiagency review is conducted. Deaths of young people aged 18–24, and of people from Black and Minority Ethnic communities are subject to priority themed review; each of these receive a full multiagency review. Results The LeDeR programme will be fully rolled out across England by the end of 2017. In this presentation we will share some of the learning from reviews that are particularly pertinent to GPs, and some of the service improvements that have resulted. Conclusion To our knowledge, this is the first national programme of mortality reviews of people with learning disabilities in the world. Its focus is service improvement: it is about learning lessons and making changes to improve the lives of, and support for people with learning disabilities.

Online teacherpreneurs are teachers who use social media platforms to create, sell, and distribute educational resources to others. For many teachers, they have become the new curriculum developers in our virtually intensive world. Curriculum development in mathematics education has a large impact on how students understand concepts, but little is known about these online mathematics teacherpreneurs influences on the curriculum. Therefore, as part of a larger study investigating the top 500 free elementary mathematics educational resource developers on TeachersPayTeachers.com (TpT), we surveyed the teacherpreneurs who created these top resources. Using the constant comparative method, we analyzed 58 responses to learn more about the online mathematics TpT teacherpreneurs: who they are, how they believe they became popular, and what they believe their teacher customers want when searching for resources. We found these teacherpreneurs identified themselves as teachers with typically over 10 years of experience creating classroom resources. Many attributed their popularity to advertising their resources via social media and having a large number of products available for teachers. They identified beliefs that teachers want easy to use, free, quality materials that are visually appealing. Implications, including findings that indicate a misalignment between what teachers say they want and what the teacherpreneurs believe teachers want, are discussed.

This paper reviews why an understanding of mortality data in general, and in relation to people with intellectual disabilities in particular, is an important area of concern, and introduces the papers in this Special Edition.

Summary A study was conducted over a 12 month period to assess the specificity and sensitivity of the ‘slap test’, using endoscopic evaluation, in the detection of cervical spinal cord and caudal brainstem lesions in horses. Fifteen ataxic horses were subjected to the ‘slap test’ and subsequently examined post mortem. Twelve out of the 15 had histopathological lesions consistent with their clinical signs. Thirteen horses with no history of neurological dysfunction and no histopathological evidence of cervical spinal cord or brainstem disease were used as controls. The laryngeal adductory responses exhibited by all horses were filmed and later scored independently by 3 assessors. The proportion of animals diagnosed with cervical spinal cord and/or brainstem disease, defined by histopathological criteria, was found to be statistically similar to the proportion with abnormal ‘slap test’ responses, using the McNemar chi‐Square test. Despite statistical significance between proportions, sensitivity of the ‘slap test’ was low, 50% for the left side on both days and 58% for the right side. Specificity was higher, 69% (Day 1) and 75% (Day 2) for the left side and 75% (Day 1) and 69% (Day 2) for the right side. In contrast to this, conventional neurological examination was found to be 100% sensitive and 81% specific in the detection of lesions of histopathological significance in the cervical spinal cord/caudal brainstem. Agreement between scores for the ‘slap test’ from the same assessor on different days was good, with values for kappa of 0.59 to 0.85. In contrast, agreement between assessors on the ‘slap test’ score was poor, with kappa 0.35. With a theoretical prevalence of 50% for mild posterior ataxia, the predictive value of a positive test indicated that the ‘slap test’ could at best increase the index of suspicion of cervical spinal cord or caudal brainstem disease from 50% to 70%. The predictive value of a negative test under the same conditions was lower, increasing the chance of normality from 50% to 64%.

A study was conducted over a 12 month period to assess the accuracy of the 'slap test' in the diagnosis of laryngeal adductor myopathy. The thoraco-laryngeal reflexes of 15 horses with no clinical signs of idiopathic laryngeal hemiplegia (ILH) were recorded using a video-endoscope. These 'slap test' responses were examined independently by 3 assessors. The horses were subsequently subjected to euthanasia and samples taken from the cricoarytenoideus lateralis (CAL) muscles for histopathological examination and assessment of denervation atrophy. Despite normal adductory responses, moderate to severe atrophy of the left CAL muscles was seen in 5 horses. The remaining horses had varying degrees of adductor myopathy, invariably worse in the left side of the larynx. The 'slap test' as performed in this study was therefore unable to differentiate between horses with moderate to severe muscle changes and those without, making it useless as a diagnostic test for adductor myopathy. The reason for the preservation in adductor function despite advanced histological atrophy of the muscle may lie in the degree of reinnervation found in the muscles.

The thermal decomposition of CF4 (+Ar) → CF3 + F (+Ar) was studied in shock waves over the temperature range 2000-3000 K varying the bath gas concentration [Ar] between 4 × 10(-6) and 9 × 10(-5) mol cm(-3). It is shown that the reaction corresponds to the intermediate range of the falloff curve. By combination with room temperature data for the reverse reaction CF3 + F (+He) → CF4 (+He) and applying unimolecular rate theory, falloff curves over the temperature range 300-6000 K are modeled. A comparison with the reaction system CH4 (+M) ⇔ CH3 + H (+M) is made.

ABSTRACT An experiment in online peer review was carried out by the Royal Society, on the journal Proceedings : Biological Sciences. Authors were asked to provide Acrobat PDF files and uploaded them using a web interface. Referees were provided with a URL that gave access to the paper and entered their report into an online form. Almost 50% of the authors contacted used the online method and referees greeted the method with enthusiasm. Editorial staff found the online system easier than expected and were keen to continue its use.

The Mental Capacity Act is applicable to anyone without the capacity to make a decision for themselves at a particular time. This Endgame describes the care of a woman with intellectual disabilities who refused clinical examinations, and the processes that professionals were required to follow in order to work within the framework of the Mental Capacity Act.

. After modelling single-channel falloff curves for all reaction pathways, coupling effects of multichannel dissociations were interpreted in the framework of multichannel unimolecular rate theory.

A new species of the Sub-Saharan spider genus Quamtana Huber, 2003 is described that has been collected in garden centers in Poland and the UK. Its closest known relative is probably Q. lotzi Huber, 2003, known from Free State Province in South Africa. Working on the premise that placing species in time and space is the fundamental task of taxonomy, and acknowledging that we cannot provide biologically meaningful spatial information for this species, we prefer open nomenclature to make this species known to science without formally describing it, using the unique provisional name Quamtana sp. ZFMK Ar 24490 aff. lotzi. We argue that the judicious use of open nomenclature can serve to improve the quality of species lists, reducing the noise in large-scale analyses of biodiversity data. We expand this argument to ‘fragmentary’ species descriptions in general, such as single-sex descriptions in large genera with many male-only and female-only descriptions. Not every taxonomic act allowed by the Code is necessarily beneficial. Under certain conditions, the informal description of a putatively new species may serve science better than a formal description based on inadequate material or data.

A grit removal process that exploits the phenomenon of secondary currents induced in open-channel flow as water moves around a bend has been investigated by using both physical and computational fluid dynamics (CFD) modeling approaches. The flow field was first validated against a case study by solving the full Reynolds-averaged Navier-Stokes equations and Reynolds stress turbulence models with a finite-volume method. The air-water interaction at the free surface was simulated by using a volume of fluid multiphase model. Discrete phase modeling was then used to calibrate the hydrodynamic interaction with grit particles (varying in size from 63 to 2,000 µm) observed in a physical model with a 30° bend, with respect to particle diameter, flow rate, shape factor, and injection location. This was followed by detailed parametric investigations using the calibrated model at different flow rates, angle of bend, and radius of curvature that showed individual particle trajectories (and consequent grit removal efficiency of the process) for different particle sizes. The CFD model was also used to compare different configurations of receiving sump whereby different outflows and baffles were compared. Overall, the study shows that a very slightly curved channel or straight channel is, in fact, the optimum solution, because the secondary currents in curved channels act to uplift particles away from the sump, thus reducing grit removal efficiency.

Purpose – The purpose of this paper is to report the findings of the Confidential Inquiry into premature deaths of people with intellectual disabilities (CIPOLD) in relation to the Mental Capacity Act (England and Wales) (MCA) 2005. Design/methodology/approach – CIPOLD reviewed the deaths of all known people with intellectual disabilities (ID) aged four years and over who had lived in the study area and died between 2010 and 2012. Findings – The deaths of 234 people with ID aged 16 years and over were reviewed. There were two key issues regarding how the MCA was related to premature deaths of people with ID. The first was of the lack of adherence to aspects of the Act, particularly regarding assessments of capacity and best interests decision-making processes. The second was a lack of understanding of specific aspects of the Act itself, particularly the definition of “serious medical treatment” and in relation to Do Not Attempt Cardiopulmonary Resuscitation guidelines. Research limitations/implications – CIPOLD did not set out to specifically evaluate adherence to the MCA. It may be that there were other aspects relating to the MCA that were of note, but were not directly related to the deaths of individuals. Practical implications – Addressing the findings of the Confidential Inquiry in relation to the understanding of, and adherence to, the MCA requires action at national, local and individual levels. Safeguarding is everyone's responsibility, and in challenging decision-making processes that are not aligned with the MCA, the authors are just as effectively protecting people with ID as are when the authors report wilful neglect or abuse. Originality/value – CIPOLD undertook a retrospective, detailed investigation into the sequence of events leading to the deaths of people with ID. To the authors’ knowledge, this is the first time that such research has associated a lack of adherence to the MCA to premature deaths within a safeguarding framework.

The Improving Global Health (IGH) programme develops leadership capacity within the National Health Service (NHS) in a novel way. NHS employees collaboratively run quality improvement projects within organisations in low-income and middle-income countries with whom long-standing healthcare partnerships have been built. Leadership behaviours are developed through theoretical and experiential learning, alongside induction and mentorship. The health systems of overseas partners are strengthened through projects that align with local priorities. This article develops solutions to two main problems: how reciprocal global health programmes can be designed and how global health programmes based in leadership can attract women and black and minority ethnic groups into leadership. The outcomes of both sides of the IGH programme are described here. The overseas perspective is described using the reflections of two current partners, highlighting improvements in the local healthcare system and demonstrating growth in local team members. The UK perspective is evaluated using two surveys sent to different groups of returned IGH participants. Leadership, global health and quality improvement skills improve, having a significant and long-lasting impact on career trajectory. The IGH programme is attracting women and black and minority ethnic groups into leadership. Through collaboration and reciprocity, the IGH programme is developing a new cadre of NHS leader that is diverse and inclusive. The use of long-standing healthcare partnerships ensures that learning is shared and growth is mutual, creating development within the overseas and UK partner alike.

• The decarbonisation of the cement industry using carbonate looping cycles. • Technical modelling of indirectly heated carbonate looping concepts. • The use of heat pipes to transfer thermal energy to the calcination process. • Economic assessment of tail-end and fully integrated CO 2 capture cycles. • The fully integrated option shows superior technical and economic performance. The concept of Carbonate Looping Cycle (CaL) offers many advantages compared to other CO 2 capture technologies within cement plants. The configurations currently discussed in the literature employ oxy-fuel combustion to supply the necessary heat for the calcination process in a single reactor. As a result, the process requires an air separation unit. The indirectly heated calcium looping (IHCaL) offers solutions to overcome the present limitations. Numerous heat pipes connecting a separate combustion unit to a calciner supply thermal energy for the calcination process. This study, based on the best available technology, recommends both full and tail-end IHCaL integrations within a commercial cement plant. Both systems provide over 1.3 million tonnes of cement per annum. The fully integrated option produces 309 GWh of electricity, compared to 875 GWh for the tail-end option. The CO 2 avoidance rates for fully integrated and tail-end options are 0.83 and 0.88 t CO 2 /t Clinker, respectively. The tail-end version has a notably high capital cost, resulting in a high CO 2 avoidance cost of €37.6/t CO 2 . On the other hand, the fully integrated version lowers the CO 2 avoidance cost to €29.8/t CO 2 because of a lower capital requirement and a smaller gap between the amount of CO 2 captured and avoided.

The European guidelines for diagnosing coeliac disease in children were revised in 2012. These recommend that in symptomatic children, a diagnosis of coeliac disease can be made without small-bowel biopsies provided their anti-tissue transglutaminase (anti-tTG) titre is >10 times of upper-limit-of-normal (>10×ULN) and anti-endomysial antibody is positive. In order to firm up the diagnosis in these children with very high anti-tTG titre, HLA-DQ2/DQ8 should be checked and be positive. Approximately 25-40% of white Caucasian population has HLA-DQ2/DQ8 haplotype. However, only 0.1-1% of the population will develop coeliac disease. Therefore, HLA-DQ2/DQ8 testing must not be done to 'screen' or 'diagnose' children with coeliac disease. Its use by paediatricians should be limited to children with anti-tTG>10×ULN, where the diagnosis of coeliac disease is being made on serology alone. A review of case referrals made to a tertiary paediatric gastroenterology centre in Southwest England demonstrated that HLA-DQ2/DQ8 testing is being requested inappropriately both in primary and secondary care suggesting a poor understanding of its role in diagnosis of coeliac disease. This article aims to clarify the role of HLA-DQ2/DQ8 testing for clinicians working in non-specialist settings.

When I was in school, I thought black people only wrote poetry.Call it ignorance or whitewashing – you’re right.And Asian too, now I think of it. Anyone whosits as a guilty afterthought on the lite...

With the publication of the Francis report, and last year's publication of the national nursing strategy, it is clear that change is needed. Impact analysis is key to recognising, quantifying and implementing essential changes to the nursing profession. By calculating the value of the services nurses provide, we can see what works and how we can do better. Nurses are committed to improving patient care and impact analysis helps us to do this more efficiently.

Premenstrual syndrome (PMS) is a common condition that affects women, most of whom will be managed in general practice. PMS should be distinguished from the physiological premenstrual symptoms experienced by many women, often not needing medical advice. PMS encompasses psychological, physical and behavioural symptoms that generally occur just before menses. This article aims to guide the assessment of women presenting with PMS, including a brief overview of the epidemiology, aetiology, diagnosis and management.