Benchmark (United Kingdom)

(Abstracted from Br J Cancer 2022;127:844–854) Ovarian cancer (OC) is the gynecological malignancy with the highest mortality, partially attributable to the lack of effective screening for early-stage disease. Despite inadequate screening methods, there exists significant international variation in the proportion diagnosed at late stage and in OC survival across all stages.

Intraperitoneal (i.p.) injection vaccination is considered effective to protect European sea bass (Dicentrarchus labrax) from economically important diseases. Water-based as well as oil-adjuvanted vaccine formulations are being widely used. The oil adjuvants used to potentiate antigen effects lead to higher and more prolonged immune response but also to chronic peritoneal inflammatory reactions, regarded as adverse or side-effects. During a three-year field study conducted throughout Greek mariculture, the intra-abdominal lesions were assessed on fish sampled prior to, and at different times post i.p. injection with different oil-adjuvanted vaccine formulations. The scope was to create a macroscopic side-effect intensity scale for sea bass in line with those applicable to salmonids (Salmo salar, Oncorhynchus mykiss) and cod (Gadus morhua). The diversity of lesions observed ranged from none (presumably non-injected; score 0) to widespread, strong adhesions with granuloma, pigmented or not (score 6). The occurrence of small nodules apparently containing vaccine remains, encapsulated by layers of connective tissue is described. The proposed scoring system is described and illustrated, intended to guide farm staff to evaluate the intensity of post-injection vaccination side-effects by necropsy on site.

BackgroundBipolar disorder is the fourth most common mental health condition, affecting ~ 1% of UK adults. Lithium is an effective treatment for prevention of relapse and hospital admission, and is widely recommended as a first-line treatment. We previously showed in other areas that laboratory testing patterns are variable with sub-optimal conformity to guidance. We therefore examined lithium results and requesting patterns relative to monitoring recommendations.MethodsData on serum lithium levels and intervals between requests were extracted from Clinical Biochemistry laboratory information systems at the University Hospitals of North Midlands, Salford Royal Foundation Trust and Pennine Acute Hospitals from 2012 to 2018 (46,555 requests; 3371 individuals). Data were examined with respect to region/source of request, age and sex.ResultsAcross all sites, lithium levels on many requests were outside the recommended UK therapeutic range (0.4–0.99 mmol/L); 19.2% below the range and 6.1% above the range (median [Li]: 0.60 mmol/L). A small percentage were found at the extremes (3.2% at < 0.1 mmol/L, 1.0% at ≥1.4 mmol/L). Most requests were from general practice (56.3%) or mental health units (34.4%), though those in the toxic range (≥1.4 mmol/L) were more likely to be from secondary care (63.9%). For requesting intervals, there was a distinct peak at 12 weeks, consistent with guidance for those stabilised on lithium therapy. There was no peak at 6 months, as recommended for those aged < 65 years on unchanging therapy, though re-test intervals in this age group were more likely to be longer. There was a peak at 0–7 days, reflecting those requiring closer monitoring (e.g. treatment initiation, toxicity). However, for those with initial lithium concentrations within the BNF range (0.4–0.99 mmol/L), 69.4% of tests were requested outside expected testing frequencies.ConclusionsOur data showed: (a) lithium levels are often maintained at the lower end of the recommended therapeutic range, (b) patterns of lithium results and testing frequency were comparable across three UK sites with differing models of care and, (c) re-test intervals demonstrate a noticeable peak at the recommended 3-monthly, but not at 6-monthly intervals. Many tests were repeated outside expected frequencies, indicating the need for measures to minimise inappropriate testing.

With demand for endocrine tests steadily increasing year-on-year, review of requesting behaviour is very pertinent. A wealth of data now exists to suggest that there is a significant degree of unnecessary requesting of pathology tests,1-3 including endocrine tests, with commonly requested laboratory investigations imposing a major cost burden upon healthcare systems. We recently determined the re-testing intervals in patients treated with levothyroxine in two centres, in order to compare observed monitoring frequency (re-testing interval) to best practice and to assess the effect of the initial thyroid function test (TFT; TSH, thyroid-stimulating hormone and fT4, free thyroxine) results and the source of the request on the TFT re-testing interval. All TFTs performed by the Clinical Biochemistry Departments at the Salford Royal Hospital (2009–2012; 288 263 requests from 139 793 patients) and University Hospital of North Midlands (2011–2014; 579 156 requests from 193 035 patients) were extracted from the laboratory computer systems. Of these, 54 894 tests were on 13 297 patients confirmed to be on levothyroxine therapy in the test cohort (Salford) and 67 298 requests on 11 971 patients in the confirmatory cohort (North Midlands). In the test cohort, median TFT re-testing interval in the total group was 19.1 weeks (IQR 9.1–37.7 weeks), with clearly defined peaks in TFT re-testing evident at 6 and 12 months and a prominent broad peak at 1–3 months. Median re-test interval was much lower than recommended (52 weeks) for those with normal TFTs at 31.3 weeks (30.6 weeks for the confirmatory cohort). Where TSH was elevated and fT4 was below the reference range, re-test interval was much longer than is recommended (8 weeks) at 13.4–17.6 weeks (7.1–23.4 weeks in the confirmatory cohort), as was the interval when TSH was below and fT4 was above the normal range, at 16.7–25.6 weeks (27.5–31.9 weeks in the confirmatory cohort). There was no observable difference in the pattern of thyroid function testing by age band (<30 years, 30–65 years and >65 years of age). In those cases with initial normal range TFTs, 72.4% (North Midlands: 76.9%) of TFT tests were requested prior to 11 months after a normal TFT result (and 13.2% after 13 months; North Midlands: 11.6%). Overall, in those cases with initial TFT results outside the laboratory reference range, 60.3% (North Midlands: 58.0%) of tests were requested after 10 weeks and prior to 11 months (and 18.0% prior to 6 weeks; North Midlands: 9.1%). Only 21.1% (North Midlands: 11.7%) were requested at the recommended 8 weeks interval (± 2 weeks). There was significant within-practice variation in test-retest interval. For normal range TFTs, some practices showed re-test intervals ranging from <10 weeks to >80 weeks. In those cases with abnormal initial TSH and/or fT4, the median interval was above the recommended 8 weeks in most practices, with between-practice median intervals ranging 8–25 weeks (3.1-fold variation). Again, within-practice variation was considerable, ranging from <5 to >50 weeks in some cases. Relative to recommended monitoring intervals, testing frequency tended to be too short for those with normal initial TFTs and too long for those with TSH and/or fT4 outside the reference range. The finding that 72.4% of cases with initial TFT results within the laboratory reference ranges have repeat tests that are too frequent (<11 months) mirror our findings in patients with diabetes requiring regular HbA1c checks for glycaemic monitoring, that in those with a relatively well-controlled HbA1c (<7%; <53 mmol/mol) 21% of tests were repeated too soon and 30% too late.4 We observed significant within-practice variability in time interval to repeat TFTs in patients taking levothyroxine, with a tendency to repeat TFTs (over-test) in patients with normal initial TSH and fT4 levels, and under-test those with abnormal TFTs. We propose that direct requesting from the clinical laboratory (with a facility for clinician over-ride) may bring patients more quickly to target with their TSH levels and reduce costs in relation to unnecessary testing of TFTs when patients are already biochemically euthyroid. Such a change in practice, while requiring thorough evaluation, has the potential to save money and improve patient outcomes. None.

This chapter contains sections titled: General Emergency lighting Fire detection and alarm systems Petrol filling stations and liquid petroleum gas stations Installations in dusty environments Installations in underground and multistorey car parks, etc Installations in multi-occupancy blocks of flats Installations in ‘Section 20 buildings’ Installations in churches Installations in thatched properties Extra-low voltage lighting Outdoor lighting installations, highway power supplies and street furniture Security lighting Welding equipment Entertainers' equipment Generator sets

This chapter contains sections titled: General Loading, maximum demand and diversity Arrangement of live conductors and type of earthing Nature of supply Supplies for safety services and standby purposes Installation circuit arrangements External influences Compatibility Maintainability

This chapter contains sections titled: General Nature of protective devices Protection against overload Protection against fault current Determination of prospective fault current Characteristics of protective devices Overcurrent protection of conductors in parallel Coordination of overload and fault current protection Protection according to the nature of circuits and distribution systems Protection against undervoltage Protection against overvoltage

This chapter contains sections titled: Switchgear and protective devices: general Switchgear and controlgear Selection of devices for overload and fault current protection: general Overcurrent protective devices Residual current devices Identification of overcurrent protective devices Discrimination Other equipment

This chapter contains sections titled: General Locations containing a bath or shower Swimming pools and other basins Rooms and cabins containing sauna heaters Construction-site installations Agricultural and horticultural premises Conducting locations with restricted movement Electrical installations in caravan/camping parks and similar locations Marinas and similar locations Exhibition shows and stands Solar photovoltaic power supply systems Mobile or transportable units Electrical installations in caravans and motor caravans Temporary electrical installations for structures, amusement devices and booths at fairgrounds, amusement parks and circuses Floor and ceiling heating systems