Incidence and prevalence of eosinophilic oesophagitis across Europe: A systematic review and meta-analysis.

BACKGROUND: Several studies have reported large increases in the incidence of eosinophilic oesophagitis (EoE) in the last 20 years. We aimed to systematically review the incidence and prevalence of EoE, focused on all European countries. METHODS: Systematic review and meta-analysis up to 31 December 2022, based on PubMed, CINAHL and extensive hand searching of reference lists. Twenty-five eligible studies were identified and included. RESULTS: For both adults and children, the highest EoE incidence and prevalence have been reported from regional studies in Spain. EoE incidence for both adults and children was significantly lower (p < 0.001) in nationwide studies (meta-analysis = 3.64 per 100,000 person-years overall) compared with regional or centre-based studies (7.16). EoE incidence and prevalence were significantly higher (p < 0.001) in adults than children. All studies that reported on longitudinal trends in EoE incidence showed increases over time, more markedly during more recent years. Larger increases in incidence tend to refer to regional rather than nationwide studies; from Spain, Switzerland and Denmark, both for paediatric and adult age groups. Increases in EoE incidence 100,000 person-years were larger than for incidence per number of diagnostic endoscopies. The most frequently reported co-morbidities in adults were rhinitis, followed by asthma, food allergy and gastroesophageal reflux disease, and in children, erosive oesophagitis, asthma, food allergy and rhinitis. CONCLUSIONS: The incidence of EoE has increased in Europe over the last 30 years, exceeding increases in the volume of oesophago-gastro-duodenoscopies performed. The patchy and low incidence and prevalence of EoE generally in Europe and compared with North America, may reflect a lack of clinical awareness and research focus rather than a genuinely low incidence of EoE. A co-ordinated Europe-wide study that uses standardised methodology is urgently needed to provide a comprehensive picture of EoE incidence and prevalence across Europe.

Uptake of diabetes follow-up checks by minority community groups: a rapid review of the evidence for the CYMELL study.

BACKGROUND: Type 2 diabetes is a public health priority for the UK. A growing body of evidence has indicated ethnic and socioeconomic disparities in rates of diabetes prevalence and complications. Attendance at diabetes follow-up checks is key to ensuring complications are identified and managed at an early stage. The aim of this rapid review was to identify and summarise evidence of ways to improve diabetes management in ethnic minority groups. METHODS: In this rapid review, we searched PubMed, PsycInfo, and CINAHL for studies published in English between Jan 1, 2000, and Jan 31, 2023. Studies were included if the population was from ethnic minority groups and if the intervention was community-based and aimed to improve diabetes self-care. The comparisons were persuasion and behaviour change, and the outcomes were improved diabetes self-management including, glycaemic control, attending eye tests, kidney, and foot screening follow-up checks. This study is registered with PROSPERO 2023, CRD42023399283. FINDINGS: Nine studies were included, from Mexico (n=1), USA (n=7), and UK (n=1). Most studies reported on community engagement (n=8), and one focussed on peer support and diabetes self-management. Peer support and diabetes self-management education were found to significantly improve diabetes control in a Mayan community (n=29) in Mexico (p<0·0001) and in the Korean American (n=105), African American (n=107), and Latino American (n=56) communities in the USA. Another study showed that women from the Pakistani community in England also benefitted from a culturally appropriate and socially supportive environment when learning about diabetes self-management. Diabetic eye screening rates could be increased through education but not through incentive payments. INTERPRETATION: Culturally competent health-care policies and programmes have been shown to increase diabetes self-management including uptake of diabetes screening for people with diabetes from ethnic minority communities to avoid potential harmful and life limiting conditions. A strength of this review is that robust, recent, and relevant papers regarding self-management of diabetes were included. The main limitations were that none of the nine studies included any cost analyses, and only one UK-based study was included, indicating that further research is required to fill the evidence gap. FUNDING: Research for Patient and Public Benefit (RfPPB), Health and Care Research Wales.

What Aspects of Illness Influence Public Preferences for Healthcare Priority Setting? A Discrete Choice Experiment in the UK.

BACKGROUND: Decisions on funding new healthcare technologies assume that all health improvements are valued equally. However, public reaction to health technology assessment (HTA) decisions suggests there are health attributes that matter deeply to them but are not currently accounted for in the assessment process. We aimed to determine the relative importance of attributes of illness that influence the value placed on alleviating that illness. METHOD: We conducted a discrete choice experiment survey that presented general public respondents with 15 funding decisions between hypothetical health conditions. The conditions were defined by five attributes that characterise serious illnesses, plus the health gain from treatment. Respondent preferences were modelled using conditional logistic regression and latent class analysis. RESULTS: 905 members of the UK public completed the survey in November 2017. Respondents generally preferred to provide treatments for conditions with 'better' characteristics. The exception was treatment availability, where respondents preferred to provide treatments for conditions where there is no current treatment, and were prepared to accept lower overall health gain to do so. A subgroup of respondents preferred to prioritise 'worse' health states. CONCLUSION: This study suggests a preference among the UK public for treating an unmet need; however, it does not suggest a preference for prioritising other distressing aspects of health conditions, such as limited life expectancy, or where patients are reliant on care. Our results are not consistent with the features currently prioritised in UK HTA processes, and the preference heterogeneity we identify presents a major challenge for developing broadly acceptable policy.

Systematic review and meta-analysis: the incidence and prevalence of paediatric coeliac disease across Europe.

BACKGROUND: Coeliac disease is one of the most prevalent immune-mediated gastrointestinal disorders in children. AIM: To review the incidence and prevalence of paediatric coeliac disease, and their trends, regionally across Europe, overall and according to age at diagnosis. METHODS: Systematic review and meta-analysis from January 1, 1950 to December 31, 2019, based on PubMed, CINAHL and the Cochrane Library, searches of grey literature and websites and hand searching of reference lists. A total of 127 eligible studies were included. RESULTS: The prevalence of previously undiagnosed coeliac disease from screening surveys (histology based) ranged from 0.10% to 3.03% (median = 0.70%), with a significantly increasing annual trend (P = 0.029). Prevalence since 2000 was significantly higher in northern Europe (1.60%) than in eastern (0.98%), southern (0.69%) and western (0.60%) Europe. Large increases in the incidence of diagnosed coeliac disease across Europe have reached 50 per 100 000 person-years in Scandinavia, Finland and Spain. The median age at diagnosis increased from 1.9 years before 1990 to 7.6 since 2000. Larger increases in incidence were found in older age groups than in infants and ages <5 years. CONCLUSIONS: Paediatric coeliac disease incidence and prevalence have risen across Europe and appear highest in Scandinavia, Finland and Spain. The most recent evidence shows large increases in incidence in most regions, but stabilisation in some (notably Sweden and Finland). Sharp increases in the age at diagnosis may reflect increases in milder and asymptomatic cases diagnosed since reliable serology testing became widely used, through endomysial antibodies after 1990 and tissue transglutaminase antibodies around 2000.

Fishery reforms for the management of non-indigenous species.

Marine ecosystems are undergoing major transformations due to the establishment and spread of Non-Indigenous Species (NIS). Some of these organisms have adverse effects, for example by reducing biodiversity and causing ecosystem shifts. Others have upsides, such as benefits to fisheries or replacing lost ecological functions and strengthening biogenic complexity. Stopping the spread of NIS is virtually impossible and so the societal challenge is how to limit the socioeconomic, health, and ecological risks, and sustainably exploit the benefits provided by these organisms. We propose a move away from the notion that NIS have only negative effects, and suggest a turn towards an Ecosystem-Based Fishery Management approach for NIS (EBFM-NIS) in the Mediterranean Sea, the world's most invaded marine region. A structured, iterative, and adaptive framework that considers the range of costs and benefits to ecosystems, ecosystem services, and fisheries is set out to determine whether NIS stocks should be managed using sustainable or unsustainable exploitation. We propose fishery reforms such as multiannual plans, annual catch limits, technical measures for sustainable exploitation, and legitimization of unlimited fishing of selected NIS and introduction of a radical new license for NIS fishing for unsustainable exploitation. Depending on local conditions, investment strategies can be included within the EBFM-NIS framework to protect/enhance natural assets to improve ecosystem resilience against NIS, as well as fishery assets to improve the performance of NIS fisheries. Examples of the former include the enhancement of Marine Protected Areas, harvesting of invasive NIS within MPAs, and protection of overfished predators and key species. Examples of the latter include market promotion and valorisation of NIS products, development of novel NIS products, and innovative/alternative NIS fishing such as fishery-related tourism ('pescatourism'). The application of the suggested EBFM-NIS would create jobs, protect and enhance ecosystem services, and help to meet the United Nations Sustainable Development Goal 14: Conserve and sustainably use the oceans, seas, and marine resources for sustainable development.

Correction to: Will the reformed Cancer Drugs Fund address the most common types of uncertainty? An analysis of NICE cancer drug appraisals.

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Patient and public involvement (PPI) in UK surgical trials: a survey and focus groups with stakeholders to identify practices, views, and experiences.

BACKGROUND AND AIMS: Historically, patient and public involvement (PPI) in the design and conduct of surgical trials has been absent or minimal, but it is now routinely recommended and even required by some research funders. We aimed to identify and describe current PPI practice in surgical trials in the United Kingdom, and to explore the views and experiences of surgical trial staff and patient or public contributors in relation to these practices. This was part of a larger study to inform development of a robust PPI intervention aimed at improving recruitment and retention in surgical trials. METHODS: Our study had two stages: 1) an online survey to identify current PPI practice in active UK-led, adult surgical trials; and 2) focus groups and interviews with key stakeholders (surgical trial investigators, administrators, and patient or public contributors) to explore their views and experiences of PPI. RESULTS: Of 129 eligible surgical trial teams identified, 71 (55%) took part in the survey. In addition, 54 stakeholders subsequently took part in focus groups or interviews. Sixty-five (92%) survey respondents reported some kind of PPI, most commonly at the design and dissemination stages and in oversight or advisory roles. The single most common PPI activity was developing participant information sheets (72%). Participants reported mixed practice and views on a variety of issues including the involvement of patients versus lay members of the public, recruitment methods, use of role descriptions and payment for the time of PPI contributors. They suggested some solutions, including the use of written role descriptions and databases of potential PPI contributors to aid recruitment. CONCLUSIONS: UK surgical trials involve patients and members of the public in a variety of different ways, most commonly at the beginning and end of the trial lifecycle and in oversight or advisory roles. These are not without challenges and there remain uncertainties about who best to involve, why, and how. Future research should aim to address these issues.

The Internet of Things in Health Care in Oxford: Protocol for Proof-of-Concept Projects.

BACKGROUND: Demands on health services across are increasing because of the combined challenges of an expanding and aging population, alongside complex comorbidities that transcend the classical boundaries of modern health care. Continuing to provide and coordinate care in the current manner is not a viable route to sustain the improvements in health outcomes observed in recent history. To ensure that there continues to be improvement in patient care, prevention of disease, and reduced burden on health systems, it is essential that we adapt our models of delivery. Providers of health and social care are evolving to face these pressures by changing the way they think about the care system and, importantly, how to involve patients in the planning and delivery of services. OBJECTIVE: The objective of this paper is to provide (1) an overview of the current state of Internet of Things (IoT) and key implementation considerations, (2) key use cases demonstrating technology capabilities, (3) an overview of the landscape for health care IoT use in Oxford, and (4) recommendations for promoting the IoT via collaborations between higher education institutions and industry proof-of-concept (PoC) projects. METHODS: This study describes the PoC projects that will be created to explore cost-effectiveness, clinical efficacy, and user adoption of Internet of Medical Things systems. The projects will focus on 3 areas: (1) bring your own device integration, (2) chronic disease management, and (3) personal health records. RESULTS: This study is funded by Research England's Connecting Capability Fund. The study started in March 2018, and results are expected by the end of 2019. CONCLUSIONS: Embracing digital solutions to support the evolution and transformation of health services is essential. Importantly, this should not simply be undertaken by providers in isolation. It must embrace and exploit the advances being seen in the consumer devices, national rollout of high-speed broadband services, and the rapidly expanding medical device industry centered on mobile and wearable technologies. Oxford University Hospitals and its partner providers, patients, and stakeholders are building on their leading position as an exemplar site for digital maturity in the National Health Service to implement and evaluate technologies and solutions that will capitalize on the IoT. Although early in the application to health, the IoT and the potential it provides to make the patient a partner at the center of decisions about care represent an exciting opportunity. If achieved, a fully connected and interoperable health care environment will enable continuous acquisition and real-time analysis of patient data, offering unprecedented ability to monitor patients, manage disease, and potentially deliver early diagnosis. The clinical benefit of this is clear, but additional patient benefit and value will be gained from being able to provide expert care at home or close to home. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12077.

Impact of patient and public involvement on enrolment and retention in clinical trials: systematic review and meta-analysis.

OBJECTIVE: To investigate the impact of patient and public involvement (PPI) on rates of enrolment and retention in clinical trials and explore how this varies with the context and nature of PPI. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Ten electronic databases, including Medline, INVOLVE Evidence Library, and clinical trial registries. ELIGIBILITY CRITERIA: Experimental and observational studies quantitatively evaluating the impact of a PPI intervention, compared with no intervention or non-PPI intervention(s), on participant enrolment and/or retention rates in a clinical trial or trials. PPI interventions could include additional non-PPI components inseparable from the PPI (for example, other stakeholder involvement). DATA EXTRACTION AND ANALYSIS: Two independent reviewers extracted data on enrolment and retention rates, as well as on the context and characteristics of PPI intervention, and assessed risk of bias. Random effects meta-analyses were used to determine the average effect of PPI interventions on enrolment and retention in clinical trials: main analysis including randomised studies only, secondary analysis adding non-randomised studies, and several exploratory subgroup and sensitivity analyses. RESULTS: 26 studies were included in the review; 19 were eligible for enrolment meta-analysis and five for retention meta-analysis. Various PPI interventions were identified with different degrees of involvement, different numbers and types of people involved, and input at different stages of the trial process. On average, PPI interventions modestly but significantly increased the odds of participant enrolment in the main analysis (odds ratio 1.16, 95% confidence interval and prediction interval 1.01 to 1.34). Non-PPI components of interventions may have contributed to this effect. In exploratory subgroup analyses, the involvement of people with lived experience of the condition under study was significantly associated with improved enrolment (odds ratio 3.14 v 1.07; P=0.02). The findings for retention were inconclusive owing to the paucity of eligible studies (odds ratio 1.16, 95% confidence interval 0.33 to 4.14), for main analysis). CONCLUSIONS: These findings add weight to the case for PPI in clinical trials by indicating that it is likely to improve enrolment of participants, especially if it includes people with lived experience of the health condition under study. Further research is needed to assess which types of PPI work best in particular contexts, the cost effectiveness of PPI, the impact of PPI at earlier stages of trial design, and the impact of PPI interventions specifically targeting retention. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016043808.

Cancer as the "perfect storm"? A qualitative study of public attitudes to health conditions.

AIMS: Our aim is to identify important attributes of major diseases that shape how they are perceived by the public. METHODS AND RESULTS: Four focus groups among members of the public were recruited, in March and October 2016, and used semistructured discussion to explore important attributes of cancer, heart disease, stroke, dementia, mental illness, and infectious disease. Common themes were identified by using inductive thematic analysis.Five themes were identified: fear, impact on family and friends, hope, detection, and prevention. Fear of cancer includes not only fear of death but also of aggressive treatments. Loss of dignity is feared in dementia, while infectious disease raises fear of uncontrollable "plague"; in contrast, people with mental illness may themselves be seen as a potential threat. The impact of cancer and its treatment on family and friends was described as intense and all-consuming, even for those not involved directly in caring; with dementia and stroke, the family impact is taking on care, including funding, over the long term with little expectation of improvement. Hope is a major theme in cancer and stroke recovery, linked with the need to take action, often expressed in aggressive language of "fighting," but seen as futile in dementia. Detection difficulties for "silent" cancers mean that real treatment opportunities are missed; cardiovascular and infection risk, however, are seen as easy to identify and act on, whereas mental illness and dementia are seen as poorly diagnosed and with limited treatment options. Prevention awareness is high for cardiovascular disease and infection, lower for cancer, and limited for dementia and mental health. CONCLUSION: Although themes overlap across diseases, the specific concerns are different and each condition has a unique profile. Quantifying the relative importance of these themes could allow their incorporation in decision-making, not only when they occur as a named disease but also in any relevant condition.

Will the reformed Cancer Drugs Fund address the most common types of uncertainty? An analysis of NICE cancer drug appraisals.

BACKGROUND: One of the functions of the reformed Cancer Drugs Fund in England is as a managed access fund, providing conditional funding for cancer drugs where there is uncertainty in the economic case, and where that uncertainty can be addressed by data collection during two years' use in the NHS. Our study characterises likely sources of such uncertainty, through a review of recent NICE Technology Appraisals. METHODS: Discussions of uncertainty in NICE Appraisal Committees were extracted from published Single Technology Appraisals of cancer drugs, 2014-2016, and categorised inductively. The location of the comments within the structured Appraisal document was used as a proxy for the degree of concern shown by the Committee. RESULTS: Twenty-nine appraisals were analysed, of which 23 (79%) were recommended for funding. Six main sources of uncertainty were identified. Immaturity of survival data, and issues relating to comparators, were common sources of uncertainty regardless of degree of concern. Uncertainties relating to quality of life, and the patient population in the trial, were discussed frequently but rarely occurred in the more uncertain appraisals. Concerns with trial design, and cost uncertainty, were less common, but a high proportion contributed to the most uncertain appraisals. Funding decisions were not driven by uncertainty in the evidence base, but by the expected cost per QALY relative to acceptance thresholds, and the resultant level of uncertainty in the decision. CONCLUSIONS: The reformed CDF is an improvement on its predecessor. However the main types of uncertainty seen in recent cancer appraisals will not readily be resolved solely by 2 years' RWD collection in the reformed CDF; where there are no ongoing trials to provide longer-term data, randomised trials rather than RWD may be needed to fully resolve questions of relative efficacy. Other types of uncertainty, and concerns with generalisability, may be more amenable to the RWD approach, and it is these that we expect to be the focus of data collection arrangements in the reformed CDF.

Cancer drug funding decisions in Scotland: impact of new end-of-life, orphan and ultra-orphan processes.

BACKGROUND: The Scottish Medicines Consortium evaluates new drugs for use in the National Health Service in Scotland. Reforms in 2014 to their evaluation process aimed to increase patient access to new drugs for end-of-life or rare conditions; the changes include additional steps in the process to gain further information from patients and clinicians, and for revised commercial agreements. This study examines the extent of any impact of the reforms on funding decisions. METHOD: Data on the Scottish Medicines Consortium's funding decisions during 24 months post-reform were extracted from published Advice, for descriptive statistics and thematic analysis. Comparison data were extracted for the 24 months pre-reform. Data on decisions for England by the National Institute for Clinical and Health Excellence for the same drugs were extracted from published Technology Appraisals. RESULTS: The new process was used by 90% (53/59) of cancer submissions. It is triggered if the initial advice is not to recommend, and this risk-of-rejection level is higher than in the pre-period. Thirty-eight cancer drugs obtained some level of funding through the new process, but there was no significant difference in the distribution of decision types compared to the pre-reform period. Thematic analysis of patient and clinician input showed no clear relationship between issues raised and funding decision. Differences between SMC's and NICE's definitions of End-of-Life did not fully explain differences in funding decisions. CONCLUSIONS: The Scottish Medicines Consortium's reforms have allowed funding of up to 38 cancer drugs that might previously have been rejected. However, the contribution of specific elements of the reforms to the final decision is unclear. The process could be improved by increased transparency in how the non-quantitative inputs influence decisions. Some disparities in funding decisions between England and Scotland are likely to remain despite recent process convergence.

Does the Public Prefer Health Gain for Cancer Patients? A Systematic Review of Public Views on Cancer and its Characteristics.

BACKGROUND: Policies such as the Cancer Drugs Fund in England assumed a societal preference to fund cancer care relative to other conditions, even if that resulted in lower health gain for the population overall. OBJECTIVE: The aim of this study was to investigate the evidence for such a preference among the UK public. METHODS: The MEDLINE, PubMed and Econlit electronic databases were searched for studies relating to preferences for prioritising cancer treatment, as well as studies relating to preferences for the characteristics of cancer (severity of disease, end-of-life). The searches were run in November 2015 and updated in March 2017. Empirical preference studies, studies of public views, and studies in English were included. RESULTS: We identified 24 studies relating to cancer preferences. Two directly addressed health trade-offs in the UK-one showed a preference for health gain in cancer, while the other found no such preference but provided results consistent with population health maximisation. Other studies mostly showed support for cancer but did not require a direct health trade-off. Severity and end-of-life searches identified 12 and 6 papers, respectively, which were additional to existing reviews. There is consistent evidence that people give priority to severe illness, while results for end-of-life are mixed. CONCLUSION: We did not find consistent support for a preference for health gains to cancer patients in the context of health maximisation. The evidence base is small and the results are highly sensitive to study design. There remains a contradiction between these findings and the popular view of cancer, and further work is required to determine the features of cancer which contribute to that view.

The incidence and aetiology of acute pancreatitis across Europe.

BACKGROUND: Acute pancreatitis is increasingly one of the most important acute gastrointestinal conditions throughout much of the world, although incidence and aetiology varies across countries and regions. This study investigated regional and national patterns in the incidence and aetiology of acute pancreatitis, demographic patterns in incidence and trends over time in incidence across Europe. METHODS: A structured review of acute pancreatitis incidence and aetiology from studies of hospitalised patient case series, cohort studies or other population based studies from 1989 to 2015 and a review of trends in incidence from 1970 to 2015 across all 51 European states. RESULTS: The incidence of acute pancreatitis was reported from 17 countries across Europe and ranged from 4.6 to 100 per 100 000 population. Incidence was usually highest in eastern or northern Europe, although reported rates often varied according to case ascertainment criteria. Of 20 studies that reported on trends in incidence, all but three show percentage increases over time (overall median increase = 3.4% per annum; range = -0.4%-73%). The highest ratios of gallstone to alcohol aetiologies were identified in southern Europe (Greece, Turkey, Italy and Croatia) with lowest ratios mainly in eastern Europe (Latvia, Finland, Romania, Hungary, Russia and Lithuania). CONCLUSIONS: The incidence of acute pancreatitis varies across Europe. Gallstone is the dominant aetiology in southern Europe and alcohol in eastern Europe with intermediate ratios in northern and western Europe. Acute pancreatitis continues to increase throughout most of Europe.

Colectomy rates in patients with ulcerative colitis following treatment with infliximab or ciclosporin: a systematic literature review.

This review aimed to compile all available published data on colectomy rates following treatment using infliximab or ciclosporin in adult ulcerative colitis patients and to analyse colectomy rates, timing to colectomy and postcolectomy mortality for each treatment. We systematically reviewed the literature after 1990 reporting colectomy rates in ulcerative colitis patients treated with infliximab or ciclosporin, excluding articles on paediatric patients, patients with indeterminate colitis or Crohn's disease and bowel surgery not related to ulcerative colitis. We presented weighted mean colectomy rates and mortality rates. Cox's regression was used to assess time to colectomy adjusting for colitis severity, patient age and sex. We tabulated 78 studies reporting on ciclosporin and/or infliximab and colectomy rates or postcolectomy mortality rates. Not all studies reported data in a standardized manner. Infliximab had a significantly lower colectomy rate than ciclosporin at 36 months when analysing all studies, studies directly comparing infliximab and ciclosporin and studies using severe colitis patients, but not at 3, 12 or 24 months. Severity and age were key indicators in the likelihood of undergoing colectomy after treatment. Postcolectomy mortality rates were less than 1.5% for both drugs. This review indicates that long-term colectomy rates following infliximab are significantly lower than ciclosporin in the longer term, and that postcolectomy mortality following infliximab and ciclosporin is very low. However, many key data items were missing from research articles, reducing our ability to establish with more confidence the actual impact of these two drugs on colectomy rates and postcolectomy mortality rates.

Six 'biases' against patients and carers in evidence-based medicine.

BACKGROUND: Evidence-based medicine (EBM) is maturing from its early focus on epidemiology to embrace a wider range of disciplines and methodologies. At the heart of EBM is the patient, whose informed choices have long been recognised as paramount. However, good evidence-based care is more than choices. DISCUSSION: We discuss six potential 'biases' in EBM that may inadvertently devalue the patient and carer agenda: limited patient input to research design, low status given to experience in the hierarchy of evidence, a tendency to conflate patient-centred consulting with use of decision tools; insufficient attention to power imbalances that suppress the patient's voice, over-emphasis on the clinical consultation, and focus on people who seek and obtain care (rather than the hidden denominator of those that do not seek or cannot access care). To reduce these 'biases', EBM should embrace patient involvement in research, make more systematic use of individual ('personally significant') evidence, take a more interdisciplinary and humanistic view of consultations, address unequal power dynamics in healthcare encounters, support patient communities, and address the inverse care law.

Use of a seagrass residency index to apportion commercial fishery landing values and recreation fisheries expenditure to seagrass habitat service.

Where they dominate coastlines, seagrass beds are thought to have a fundamental role in maintaining populations of exploited species. Thus, Mediterranean seagrass beds are afforded protection, yet no attempt to determine the contribution of these areas to both commercial fisheries landings and recreational fisheries expenditure has been made. There is evidence that seagrass extent continues to decline, but there is little understanding of the potential impacts of this decline. We used a seagrass residency index, that was trait and evidence based, to estimate the proportion of Mediterranean commercial fishery landings values and recreation fisheries total expenditure that can be attributed to seagrass during different life stages. The index was calculated as a weighted sum of the averages of the estimated residence time in seagrass (compared with other habitats) at each life stage of the fishery species found in seagrass. Seagrass-associated species were estimated to contribute 30%-40% to the value of commercial fisheries landings and approximately 29% to recreational fisheries expenditure. These species predominantly rely on seagrass to survive juvenile stages. Seagrass beds had an estimated direct annual contribution during residency of €58-91 million (4% of commercial landing values) and €112 million (6% of recreation expenditure) to commercial and recreational fisheries, respectively, despite covering <2% of the area. These results suggest there is a clear cost of seagrass degradation associated with ineffective management of seagrass beds and that policy to manage both fisheries and seagrass beds should take into account the socioeconomic implications of seagrass loss to recreational and commercial fisheries.

A legal and ecological perspective of 'site integrity' to inform policy development and management of Special Areas of Conservation in Europe.

The European Union Habitats Directive (92/43/EEC) provides for the designation and management of Special Areas of Conservation (SACs) and requires that impacting activities are subject to 'an appropriate assessment' of their implications for the 'integrity' of the site. We define the term 'site integrity' from a legal and an ecological perspective. We demonstrate that 'site integrity' is the maintenance of ecological processes and functions that support the wider delivery of ecosystem services. 'Site integrity' can be influenced by SAC management. Management that seeks to support 'site integrity' may include the use of buffer zones or connecting areas that extend beyond the SAC site's designated features. We conclude that 'site integrity' and 'favourable conservation status' are powerful legal terms that if fully transposed into the law and policy of Member States can enable the achievement of broader European and International goals for marine conservation.

A thematic cost-benefit analysis of a marine protected area.

The implementation of Marine Protected Areas (MPAs) is ultimately a social endeavour to sustain or improve human well-being via the conservation of marine ecosystems. The degree to which ecological gains are realised can depend upon how economic, ecological and social costs (negative impacts) and benefits (positive impacts) are included in the designation and management process. Without the support of key stakeholder groups whose user rights have been affected by the creation of an MPA, human impacts cannot be reduced. This study analyses a three year dataset to understand the themes associated with the economic, environmental and social costs and benefits of an MPA in Lyme Bay, United Kingdom (UK) following its establishment in 2008. Methodologically, the paper presents an ecosystem based management framework for analysing costs and benefits. Two hundred and forty one individuals were interviewed via questionnaire between 2008 and 2010 to determine perceptions and the level of support towards the MPA. Results reveal that despite the contentious manner in which this MPA was established, support for the MPA is strong amongst the majority of stakeholder groups. The level of support and the reasons given for support vary between stakeholder groups. Overall, the stakeholders perceive the social, economic and environmental benefits of the MPA to outweigh the perceived costs. There have been clear social costs of the MPA policy and these have been borne by mobile and static gear fishermen and charter boat operators. Local support for this MPA bodes well for the development of a network of MPAs around the UK coast under the United Kingdom Marine and Coastal Access Act 2009. However, this initial optimism is at risk if stakeholder expectation is not managed and the management vacuum is not filled.