The incidence of COVID-19-related hospitalisation in migrants in the UK: Findings from the Virus Watch prospective community cohort study.

Background: Migrants in the United Kingdom (UK) may be at higher risk of SARS-CoV-2 exposure; however, little is known about their risk of COVID-19-related hospitalisation during waves 1-3 of the pandemic. Methods: We analysed secondary care data linked to Virus Watch study data for adults and estimated COVID-19-related hospitalisation incidence rates by migration status. To estimate the total effect of migration status on COVID-19 hospitalisation rates, we ran mixed-effect Poisson regression for wave 1 (01/03/2020-31/08/2020; wildtype), and mixed-effect negative binomial regressions for waves 2 (01/09/2020-31/05/2021; Alpha) and 3 (01/06/2020-31/11/2021; Delta). Results of all models were then meta-analysed. Results: Of 30,276 adults in the analyses, 26,492 (87.5 %) were UK-born and 3,784 (12.5 %) were migrants. COVID-19-related hospitalisation incidence rates for UK-born and migrant individuals across waves 1-3 were 2.7 [95 % CI 2.2-3.2], and 4.6 [3.1-6.7] per 1,000 person-years, respectively. Pooled incidence rate ratios across waves suggested increased rate of COVID-19-related hospitalisation in migrants compared to UK-born individuals in unadjusted 1.68 [1.08-2.60] and adjusted analyses 1.35 [0.71-2.60]. Conclusion: Our findings suggest migration populations in the UK have excess risk of COVID-19-related hospitalisations and underscore the need for more equitable interventions particularly aimed at COVID-19 vaccination uptake among migrants.

The Failure to Recognize Continuing Harm: Post-Separation Domestic Abuse in Child Contact Cases.

This article presents findings from a case file review of post-separation parenting cases in England and Wales. It first outlines that jurisdiction's legal framework relevant to these cases, before providing an overview of the findings relating to the profile of the cases and their outcomes. It then describes the types of abuse most frequently encountered in these cases, and examines the attitude of the courts to post-separation abuse by looking at both interim and final court orders. The study finds that key legal provisions governing these cases are not being followed, with little understanding shown for the nature of post-separation abuse.

Geographical and socioeconomic disparities in post-transcatheter aortic valve replacement pacemaker placement.

INTRODUCTION: Pacemaker (PPM) implantation is indicated for conduction abnormalities which can develop post-transcatheter aortic valve replacement (TAVR). However, whether post-TAVR PPM risk is associated with the geographical location of the hospital and socioeconomic status of the patient is not well established. Our goal was to explore geographical and socioeconomic disparities in post-TAVR PPM implantation. METHODS: A retrospective cohort analysis was conducted using the National Inpatient Sample 2016-2020 with respective ICD-10 codes for TAVR and PPM implantation. A weighted multivariate logistic regression model was used to analyze prognostic outcomes. RESULTS: The number of patients hospitalized for undergoing TAVR was 296,740, out of which 28,265 patients had PPM implantation (prevalence 9.5 %). Patients' demographics including sex, ethnicity, household income, and insurance were not associated with risk of post-TAVR PPM except age (OR 1.01, CI 1.07-12.5, p < 0.001). Compared to rural hospitals, urban non-teaching hospitals were associated with a higher risk of post-TAVR PPM (OR 2.09, 1.3-3.43, p = 0.003). Compared to New England hospitals (ME, NH, VT, MA, RI, CT), middle Atlantic hospitals (NY, NJ, PA) were associated with highest post-TAVR PPM risk (OR 1.54, CI 1.2-1.98, p < 0.001), followed by Pacific (AK, WA, OR, CA, HI), mountain (ID, MT, WY, NV, UT, CO, AZ, NM) and east north central US. CONCLUSION: Patients' demographics including sex, ethnicity, household income, and insurance were not associated with the risk of post-TAVR PPM except for age. Compared to New England hospitals, Middle Atlantic hospitals were associated with the highest post-TAVR PPM risk followed by Pacific, Mountain, and East North Central US. Prospective studies with data on TAVR wait times, expertise of the interventional staff, and post-TAVR management and discharge planning are required to further explore the observed regional distribution of TAVR outcomes.

COVID-19 inequalities in England: a mathematical modelling study of transmission risk and clinical vulnerability by socioeconomic status.

BACKGROUND: The COVID-19 pandemic resulted in major inequalities in infection and disease burden between areas of varying socioeconomic deprivation in many countries, including England. Areas of higher deprivation tend to have a different population structure-generally younger-which can increase viral transmission due to higher contact rates in school-going children and working-age adults. Higher deprivation is also associated with a higher presence of chronic comorbidities, which were convincingly demonstrated to be risk factors for severe COVID-19 disease. These two major factors need to be combined to better understand and quantify their relative importance in the observed COVID-19 inequalities. METHODS: We used UK Census data on health status and demography stratified by decile of the Index of Multiple Deprivation (IMD), which is a measure of socioeconomic deprivation. We calculated epidemiological impact using an age-stratified COVID-19 transmission model, which incorporated different contact patterns and clinical health profiles by decile. To separate the contribution of each factor, we considered a scenario where the clinical health profile of all deciles was at the level of the least deprived. We also considered the effectiveness of school closures and vaccination of over 65-year-olds in each decile. RESULTS: In the modelled epidemics in urban areas, the most deprived decile experienced 9% more infections, 13% more clinical cases, and a 97% larger peak clinical size than the least deprived; we found similar inequalities in rural areas. Twenty-one per cent of clinical cases and 16% of deaths in England observed under the model assumptions would not occur if all deciles experienced the clinical health profile of the least deprived decile. We found that more deaths were prevented in more affluent areas during school closures and vaccination rollouts. CONCLUSIONS: This study demonstrates that both clinical and demographic factors synergise to generate health inequalities in COVID-19, that improving the clinical health profile of populations would increase health equity, and that some interventions can increase health inequalities.

Assisted dying: principles, possibilities, and practicalities. An English physician's perspective.

It seems probable that some form of medically-assisted dying will become legal in England and Wales in the foreseeable future. Assisted dying Bills are at various stages of preparation in surrounding jurisdictions (Scotland, Republic of Ireland, Isle of Man, Jersey), and activists campaign unceasingly for a change in the law in England and Wales. There is generally uncritical supportive media coverage, and individual autonomy is seen as the unassailable trump card: 'my life, my death'.However, devising a law which is 'fit for purpose' is not an easy matter. The challenge is to achieve an appropriate balance between compassion and patient autonomy on the one hand, and respect for human life generally and medical autonomy on the other. More people should benefit from a change in the law than be harmed. In relation to medically-assisted dying, this may not be possible. Protecting the vulnerable is a key issue. Likewise, not impacting negatively on societal attitudes towards the disabled and frail elderly, particularly those with dementia.This paper compares three existing models of physician-assisted suicide: Switzerland, Oregon (USA), and Victoria (Australia). Vulnerability and autonomy are discussed, and concern expressed about the biased nature of much of the advocacy for assisted dying, tantamount to disinformation. A 'hidden' danger of assisted dying is noted, namely, increased suffering as more patients decline referral to palliative-hospice care because they fear they will be 'drugged to death'.Finally, suggestions are made for a possible 'least worse' way forward. One solution would seem to be for physician-assisted suicide to be the responsibility of a stand-alone Department for Assisted Dying overseen by lawyers or judges and operated by technicians. Doctors would be required only to confirm a patient's medical eligibility. Palliative-hospice care should definitely not be involved, and healthcare professionals must have an inviolable right to opt out of involvement. There is also an urgent need to improve the provision of care for all terminally ill patients.

The development and internal validation of a multivariable model predicting 6-month mortality for people with opioid use disorder presenting to community drug services in England: a protocol.

BACKGROUND: People with opioid use disorder have substantially higher standardised mortality rates compared to the general population; however, lack of clear individual prognostic information presents challenges to prioritise or target interventions within drug treatment services. Previous prognostic models have been developed to estimate the risk of developing opioid use disorder and opioid-related overdose in people routinely prescribed opioids but, to our knowledge, none have been developed to estimate mortality risk in people accessing drug services with opioid use disorder. Initial presentation to drug services is a pragmatic time to evaluate mortality risk given the contemporaneous routine collection of prognostic indicators and as a decision point for appropriate service prioritisation and targeted intervention delivery. This study aims to develop and internally validate a model to estimate 6-month mortality risk for people with opioid use disorder from prognostic indicators recorded at initial assessment in drug services in England. METHODS: An English national dataset containing records from individuals presenting to drug services between 1 April 2013 and 1 April 2023 (n > 800,000) (the National Drug Treatment Monitoring System (NDTMS)) linked to their lifetime hospitalisation and death records (Hospital Episode Statistics-Office of National Statistics (HES-ONS)). Twelve candidate prognostic indicator variables were identified based on literature review of demographic and clinical features associated with increased mortality for people in treatment for opioid use disorder. Variables will be extracted at initial presentation to drug services with mortality measured at 6 months. Two multivariable Cox regression models will be developed one for 6-month all-cause mortality and one for 6-month drug-related mortality using backward elimination with a fractional polynomial approach for continuous variables. Internal validation will be undertaken using bootstrapping methods. Discrimination of both models will be reported using Harrel's c and d-statistics. Calibration curves and slopes will be presented comparing expected and observed event rates. DISCUSSION: The models developed and internally validated in this study aim to improve clinical assessment of mortality risk for people with opioid use disorder presenting to drug services in England. External validation in different populations will be required to develop the model into a tool to assist future clinical decision-making.

The illusion of treatment choice in abortion care: A qualitative study of comparative care experiences in England and Wales.

Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants' negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option.

A retrospective observational study on characteristics, treatment patterns, and healthcare resource use of patients with myasthenia gravis in England.

Background: There are limited data on the real-world healthcare resource use (HCRU) and management costs of myasthenia gravis (MG) in England. Objective: This study aims to assess the burden of disease for patients with MG in England. Design: A retrospective, observational cohort study of adult patients diagnosed with MG, using data from the Hospital Episode Statistics data warehouse. Methods: Patients with a first-ever recorded diagnosis of MG between 30 June 2015 and 30 June 2020 were followed up until 30 June 2021 or death, whichever occurred first. Post-diagnosis patient characteristics, treatment patterns, HCRU, and costs were described. Costs were evaluated using National Health Service reference costs. Results: A total of 9087 patients with a median follow-up time of 2.9 years (range, 1.7-4.3 years) were included. The mean age at diagnosis was 66.5 years and 53% of the patients were male. A large proportion of patients (72.8%) were admitted as inpatients during follow-up with a mean number of 1.3 admissions. Patients hospitalized for MG-related complications spent a mean of 9.7 days per patient-year in the hospital. During follow-up, 599 (6.6% of the total cohort) and 163 (1.8%) patients had a record of rescue therapy with intravenous immunoglobulin (IVIg) and plasma exchange (PLEX), respectively. Rituximab was administered to 81 (0.9%) patients and 268 (2.9%) patients underwent thymectomy. In those patients receiving rescue therapy or rituximab, >10% received at least three cycles of the same treatment. The average annual cost of hospital admissions across all patients treated with IVIg, PLEX, and rituximab were £907,072, £689,979, and £146,726, respectively. Conclusion: A majority of MG patients required hospitalization or accident and emergency attendance, resulting in high HCRU and costs. A subset of patients required rescue therapy (including IVIg and PLEX), rituximab administration, ventilation, or thymectomy.

Hurricanes pose a substantial risk to New England forest carbon stocks.

Nature-based climate solutions (NCS) are championed as a primary tool to mitigate climate change, especially in forested regions capable of storing and sequestering vast amounts of carbon. New England is one of the most heavily forested regions in the United States (>75% forested by land area), and forest carbon is a significant component of climate mitigation policies. Large infrequent disturbances, such as hurricanes, are a major source of uncertainty and risk for policies relying on forest carbon for climate mitigation, especially as climate change is projected to alter the intensity and extent of hurricanes. To date, most research into disturbance impacts on forest carbon stocks has focused on fire. Here, we show that a single hurricane in the region can down between 121 and 250 MMTCO2e or 4.6%-9.4% of the total aboveground forest carbon, much greater than the carbon sequestered annually by New England's forests (16 MMTCO2e year-1). However, emissions from hurricanes are not instantaneous; it takes approximately 19 years for downed carbon to become a net emission and 100 years for 90% of the downed carbon to be emitted. Reconstructing hurricanes with the HURRECON and EXPOS models across a range of historical and projected wind speeds, we find that an 8% and 16% increase in hurricane wind speeds leads to a 10.7- and 24.8-fold increase in the extent of high-severity damaged areas (widespread tree mortality). Increased wind speed also leads to unprecedented geographical shifts in damage, both inland and northward, into heavily forested regions traditionally less affected by hurricanes. Given that a single hurricane can emit the equivalent of 10+ years of carbon sequestered by forests in New England, the status of these forests as a durable carbon sink is uncertain. Understanding the risks to forest carbon stocks from disturbances is necessary for decision-makers relying on forests as a NCS.

Spread of avian influenza among poultry specialists in England during winter 2022/23: National poultry housing order and environmental drivers.

Purpose: To examine the impact of the national poultry housing order the UK government introduced on 7 November 2022 on the spreading of the avian influenza virus among poultry premises. Methods: A longitudinal design with 15 weeks of infected poultry specialist incidence rates per 100 poultry specialists during the 2022/23 winter for 8 English regions. A multilevel regression model was used to analyse repeated measurements. Time was level-1 unit and regions level-2 unit resulting in 120 observations. Random intercept models included interactions between housing order and weekly infected wild birds, poultry density, or weekly average temperatures divided into terciles. In models where these variables were not included as an interaction term they were introduced as confounders. Results: After the introduction of the housing order, it took 3 weeks for a considerable reduction in poultry specialist incidence rates. Reduction in incidence rates was strongest in regions with highest poultry density, from 1.27 (95%CI 0.99 to 1.56) to 0.30 (95%CI 0.09 to 0.52). Considerable reductions were also seen in regions with most detected infected wild birds. Conclusion: The housing order was successful in reducing infected poultry specialist incidence rates three weeks after its introduction. Strongest impact in regions with highest poultry density.

Cervical cancer incidence, mortality, and burden in China: a time-trend analysis and comparison with England and India based on the global burden of disease study 2019.

Background: Cervical cancer is the fourth highest incidence of malignancy in the world and a common cause of cancer death in women. We assessed the trends of incidence and mortality and disability-adjusted life year (DALY) in China, England and India from 1990 to 2030. Method: Data were obtained from the Global Burden of Disease (GBD) database. We collected the number and rate of incidence, death and DALY from 1990 to 2019 and calculated the estimated annual percentage change (EAPC). Further analysis was carried out by ages and years. We also collected attributable risk factors to cervical cancer. Finally, we utilized the Bayesian Age-Period-Cohort (BAPC) model to forecast trends in the rate of age-standardized incidence (ASIR) and age-standardized death (ASDR) the for the next decade. Result: Globally, the incidence of cervical cancer cases increased from 335,641.56 in 1990 to 565,540.89 in 2019. In 2019, the ASIR and ASDR of cervical cancer were higher than those of India but lower than those of England. Furthermore, unsafe sex and smoking emerge as prominent risk factors for cervical cancer. Over the next decade, ASIR and ASDR are expected to decline in China and England, while India's ASIR is still on an upward trend and ASDR is on a downward trend. Conclusion: The epidemiological data of cervical cancer in these three countries reflects the influence of different stages of development and healthcare systems. Trends over the next decade suggest that China and India still face a huge burden of cervical cancer. When England has made significant progress, China and India need to take more measures to improve the prevention and control of cervical cancer.

What remains after the money ends? Evidence on whether admission reductions continued following the largest health and social care integration programme in England.

We study the long-term effects on hospital activity of a three-year national integration programme. We use administrative data spanning from 24 months before to 22 months after the programme, to estimate the effect of programme discontinuation using difference-in-differences method. Our results show that after programme discontinuation, emergency admissions were slower to increase in Vanguard compared to non-Vanguard sites. These effects were heterogeneous across sites, with greater reductions in care home Vanguard sites and concentrated among the older population. Care home Vanguards showed significant reductions beginning early in the programme but falling away more rapidly after programme discontinuation. Moreover, there were greater reductions for sites performing poorly before the programme. Overall, this suggests the effects of the integration programme might have been lagged but transitory, and more reliant on continued programme support.

What Are the Economic Arguments for Mandating LGBT+ Health Training for Healthcare Providers? An Economic Evaluation of the Impacts of LGBT+ Health Training on Cervical Screening.

Background: Equitable access to healthcare is a priority of many healthcare systems, aiming to ensure access is driven by need and not minority groups such as those defined by sexual orientation. However, there are healthcare areas where inequity in access across sexual orientation groups is found that are not justified based on need. Mandated LGBTQ+-specific training of the healthcare workforce may help address some barriers of access for these groups. The study aims to understand the potential economic implications for mandated LGBTQ+-specific healthcare training on the healthcare system in England, UK to inform commissioning of training provision. Methods: Cervical cancer screening was used as an exemplar case where there appears to be inequity in access for different sexual orientation groups. A decision model was developed and analysed that considered the impacts of greater uptake of screening for lesbian and bisexual women due to LGBTQ+ training. Costs took the perspective of the healthcare system and outcomes modelled were cancer cases averted in a timeframe of 5 years. Results: Based on cervical cancer screening alone, where training costs are fully attributed to this service, training would likely result in fewer cancer cases detected in the lesbian and bisexual populations, though this comes at a modest increase in healthcare sector costs, with this increase largely reflecting a greater volume of screens. Training costs do not appear to be a major component of the cost implications. Conclusions: In resource-constrained systems with increasing pressures for efficiency savings, the opportunity cost of delivering training is a realistic component of the commissioning decision. The findings in this paper provide a signal that mandated LGBTQ+ training in healthcare could lead to potentially greater outcomes and in breaking down barriers of access and could also enable the healthcare system to provide more equitable access to healthcare.

'A sad inheritance of misery': the cultural life of hereditary scrofula in eighteenth-century England.

This essay argues that scrofula was one of several disorders, including gout, rickets, and venereal disease, that were 'rebranded' as hereditary in response to broader cultural changes that took place during the Restoration and eighteenth century in England. While the purposes of scrofula's recategorisation were more political than medical, they resulted in this heretofore relatively obscure childhood ailment assuming a new prominence within both medical and popular discourses of the period. Scrofula became both emblem and proof of the links between sexual promiscuity, financial profligacy, and physiological degeneration, its symbolic status reinforced by the legal and moral language used to model processes of hereditary transmission. By likening the inheritance of scrofula to the inheritance of original sin-or, more commonly, to the inheritance of a 'docked entail' or damaged estate-eighteenth-century writers and artists not only made this non-inherited ailment into a sign of catastrophic hereditary decline; they also paved the way for scrofula to be identified as a disease of aristocratic vice, even though its association with crowded, unsanitary living conditions likely made it more common among the poor. By the same token, financial models of disease inheritance facilitated a bias toward paternal transmission, with scrofula often portrayed as passing, like a title or an estate, from father to son rather than from mother to daughter.

Supporting patient decision-making in non-invasive prenatal testing: a comparative study of professional values and practices in England and France.

BACKGROUND: Non-invasive prenatal testing (NIPT), which can screen for aneuploidies such as trisomy 21, is being implemented in several public healthcare systems across Europe. Comprehensive communication and information have been highlighted in the literature as important elements in supporting women's reproductive decision-making and addressing relevant ethical concerns such as routinisation. Countries such as England and France are adopting broadly similar implementation models, offering NIPT for pregnancies with high aneuploidy probability. However, we do not have a deeper understanding of how professionals' counselling values and practices may differ between these contexts. METHODS: In this paper, we explore how professionals in England and France support patient decision-making in the provision of NIPT and critically compare professional practices and values. We draw on data from semi-structured interviews with healthcare professionals. RESULTS: Both English and French professionals emphasised values relating to patient choice and consent. However, understandings and application of these values into the practice of NIPT provision differed. English interviewees placed a stronger emphasis on interpreting and describing the process of counselling patients and clinical care through a "principle" lens. Their focus was on non-directiveness, standardisation, and the healthcare professional as "decision-facilitator" for patients. French interviewees described their approach through a "procedural" lens. Their focus was on formal consent, information, and the healthcare professional as "information-giver". Both English and French professionals indicated that insufficient resources were a key barrier in effectively translating their values into practice. CONCLUSION: Our findings illustrate that supporting patient choice in the provision of NIPT may be held as an important value in common on a surface level, but can be understood and translated into practice in different ways. Our findings can guide further research and beneficially inform practice and policy around NIPT provision.

Economic evaluation of a water fluoridation scheme in Cumbria, UK.

OBJECTIVES: The addition of fluoride to community drinking water supplies has been a long-standing public health intervention to improve dental health. However, the evidence of cost-effectiveness in the UK currently lacks a contemporary focus, being limited to a period with higher incidence of caries. A water fluoridation scheme in West Cumbria, United Kingdom, provided a unique opportunity to study the contemporary impact of water fluoridation. This study evaluates the cost-effectiveness of water fluoridation over a 5-6 years follow-up period in two distinct cohorts: children exposed to water fluoridation in utero and those exposed from the age of 5. METHODS: Cost-effectiveness was summarized employing incremental cost-effectiveness ratios (ICER, cost per quality adjusted life year (QALY) gained). Costs included those from the National Health Service (NHS) and local authority perspective, encompassing capital and running costs of water fluoridation, as well as NHS dental activity. The measure of health benefit was the QALY, with utility determined using the Child Health Utility 9-Dimension questionnaire. To account for uncertainty, estimates of net cost and outcomes were bootstrapped (10 000 bootstraps) to generate cost-effectiveness acceptability curves and sensitivity analysis performed with alternative specifications. RESULTS: There were 306 participants in the birth cohort (189 and 117 in the non-fluoridated and fluoridated groups, respectively) and 271 in the older school cohort (159 and 112, respectively). In both cohorts, there was evidence of small gains in QALYs for the fluoridated group compared to the non-fluoridated group and reductions in NHS dental service cost that exceeded the cost of fluoridation. For both cohorts and across all sensitivity analyses, there were high probabilities (>62%) of water fluoridation being cost-effective with a willingness to pay threshold of £20 000 per QALY. CONCLUSIONS: This analysis provides current economic evidence that water fluoridation is likely to be cost-effective. The findings contribute valuable contemporary evidence in support of the economic viability of water fluoridation scheme.

Target Product Profile for a Machine Learning-Automated Retinal Imaging Analysis Software for Use in English Diabetic Eye Screening: Protocol for a Mixed Methods Study.

BACKGROUND: Diabetic eye screening (DES) represents a significant opportunity for the application of machine learning (ML) technologies, which may improve clinical and service outcomes. However, successful integration of ML into DES requires careful product development, evaluation, and implementation. Target product profiles (TPPs) summarize the requirements necessary for successful implementation so these can guide product development and evaluation. OBJECTIVE: This study aims to produce a TPP for an ML-automated retinal imaging analysis software (ML-ARIAS) system for use in DES in England. METHODS: This work will consist of 3 phases. Phase 1 will establish the characteristics to be addressed in the TPP. A list of candidate characteristics will be generated from the following sources: an overview of systematic reviews of diagnostic test TPPs; a systematic review of digital health TPPs; and the National Institute for Health and Care Excellence's Evidence Standards Framework for Digital Health Technologies. The list of characteristics will be refined and validated by a study advisory group (SAG) made up of representatives from key stakeholders in DES. This includes people with diabetes; health care professionals; health care managers and leaders; and regulators and policy makers. In phase 2, specifications for these characteristics will be drafted following a series of semistructured interviews with participants from these stakeholder groups. Data collected from these interviews will be analyzed using the shortlist of characteristics as a framework, after which specifications will be drafted to create a draft TPP. Following approval by the SAG, in phase 3, the draft will enter an internet-based Delphi consensus study with participants sought from the groups previously identified, as well as ML-ARIAS developers, to ensure feasibility. Participants will be invited to score characteristic and specification pairs on a scale from "definitely exclude" to "definitely include," and suggest edits. The document will be iterated between rounds based on participants' feedback. Feedback on the draft document will be sought from a group of ML-ARIAS developers before its final contents are agreed upon in an in-person consensus meeting. At this meeting, representatives from the stakeholder groups previously identified (minus ML-ARIAS developers, to avoid bias) will be presented with the Delphi results and feedback of the user group and asked to agree on the final contents by vote. RESULTS: Phase 1 was completed in November 2023. Phase 2 is underway and expected to finish in March 2024. Phase 3 is expected to be complete in July 2024. CONCLUSIONS: The multistakeholder development of a TPP for an ML-ARIAS for use in DES in England will help developers produce tools that serve the needs of patients, health care providers, and their staff. The TPP development process will also provide methods and a template to produce similar documents in other disease areas. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50568.

Adoption of C-reactive protein rapid tests for the management of acute childhood infections in hospitals in the Netherlands and England: a comparative health systems analysis.

BACKGROUND: The adoption of C-reactive protein point-of-care tests (CRP POCTs) in hospitals varies across Europe. We aimed to understand the factors that contribute to different levels of adoption of CRP POCTs for the management of acute childhood infections in two countries. METHODS: Comparative qualitative analysis of the implementation of CRP POCTs in the Netherlands and England. The study was informed by the non-adoption, abandonment, spread, scale-up, and sustainability (NASSS) framework. Data were collected through document analysis and qualitative interviews with stakeholders. Documents were identified by a scoping literature review, search of websites, and through the stakeholders. Stakeholders were sampled purposively initially, and then by snowballing. Data were analysed thematically. RESULTS: Forty-one documents resulted from the search and 46 interviews were conducted. Most hospital healthcare workers in the Netherlands were familiar with CRP POCTs as the tests were widely used and trusted in primary care. Moreover, although diagnostics were funded through similar Diagnosis Related Group reimbursement mechanisms in both countries, the actual funding for each hospital was more constrained in England. Compared to primary care, laboratory-based CRP tests were usually available in hospitals and their use was encouraged in both countries because they were cheaper. However, CRP POCTs were perceived as useful in some hospitals of the two countries in which the laboratory could not provide CRP measures 24/7 or within a short timeframe, and/or in emergency departments where expediting patient care was important. CONCLUSIONS: CRP POCTs are more available in hospitals in the Netherlands because of the greater familiarity of Dutch healthcare workers with the tests which are widely used in primary care in their country and because there are more funding constraints in England. However, most hospitals in the Netherlands and England have not adopted CRP POCTs because the alternative CRP measurements from the hospital laboratory are available in a few hours and at a lower cost.

The legal and medical consequences of child marriage.

The Marriage and Civil Partnership (Minimum Age) Act 2022 came into force in England on 27 February 2023 and made both registered and unregistered marriages involving people under 18 illegal in England and Wales. This means that such marriages which take place outside England and Wales will not be recognised and those who organised them, including parents, will have committed a criminal offence.This review considers issues related to families where such marriages have happened, including their impact on the health of the victim and any resulting children. It touches on religious and societal issues and the need for targeted and appropriate education.

Challenging NHS Corporate Mentality: Hospital-Management and Bureaucracy in London's Pandemic.

Whilst NHS Health Service management is usually characterized by hierarchized bureaucracy and profit-driven competitiveness, the COVID-19 pandemic drastically disrupted these ways of working and allowed London-based non-clinical management to experience their roles otherwise. This paper is based on 35 interviews with senior non-clinical management at a London-based NHS Trust during 'Alpha phase' of Britain's pandemic response (May-August 2020), an oft-overlooked group in the literature. I will draw upon Graeber's theory of "total bureaucratization" to argue that though the increasing neo-liberalization of the health-services has hitherto contributed toward a corporate mentality, the pandemic gave managers a chance to experience more collaboration and freedom than usual, which ultimately led to more effective realization of decision-making and change. The pandemic has shown NHS managers that there are alternatives to neoliberal logics of competition and hierarchy, and that those alternatives actually result in happier and effectively, more capable staff.